Yay! You finally got health insurance or you’ve been paying premiums for quite some time and you’re ready to use it. You went to your primary care physician (PCP) and your co-pay was just $10. Great! If that’s all it costs to see a doctor, why not finally see a chiropractor?
We regularly run into the same problems dealing with what patients believe their health insurance should/does cover and what it actually covers. To make matters worse, the answers patients are often given by their health insurance is confusing and can contradict what actually happens when the bills are submitted to your particular plan.
Insurance takes up a lot of our staff time, so it’s no surprise that so many chiropractors have decided to stop taking some insurance plans. Some chiropractors have just stopped accepting insurance altogether. I’ll try to clear up some common terms, problems, and explain why it’s really not that bad. (But, yes, it’s still a lot of work.)
Issue #1 – Assuming that “everything is covered 100%”
Wouldn’t that be nice? Less than 1% of the insurance plans we encounter cover 100% of all services. Even if they do cover everything without you paying any additional fees, some services in our office (PEMF therapy, spinal decompression therapy, knee decompression therapy) are not covered by any insurance plan as “investigational.” While we see great results with these therapies, we understand and explain to all patients that they will not be covered by their insurance plan.
Almost everyone has some type of portion they will have to pay. You may have a deductible (which means we bill your insurance company but they don’t pay the first portion – usually $500 or more), a co-pay (a set amount you pay each visit based on your provider type), or a percentage (a set percentage you pay for each service performed that’s covered by your insurance).
Chiropractors are considered “specialists” by the insurance companies too. That means you may see your PCP for $10 and a specialist visit is $45 (or something different).
Issue # 2 – Believing that all plans from your insurance company cover chiropractic care
What your insurance pays and what they expect you to pay is often on your insurance card, but if not, it’s just a phone call away to your insurance company. Some patients believe they only way they can access their health insurance benefits is by us calling, but that’s just not the case. You have access to information on your health insurance company’s website or by phone that should give you enough to go on.
We can look up some benefits online with our provider access, but we often have to make a call to the insurance company to know exactly what your plan covers. This phone call is around 30 minutes for us, and cannot always take place immediately. Giving us at least 24 hours prior to your initial appointment is enough time, but walking in with your card means we won’t have time to check your benefits.
Every insurance company has many plans with varying amounts of benefits. Your plan may have chiropractic coverage, while other plans with the same company do not. Your co-worker may have selected a different plan than you did, or they are on their spouse’s plan and it’s completely different. Each person’s insurance coverage has to be confirmed by your insurance plan to know what is covered for you.
(Unfortunately, the insurance company may still choose to process the claim differently and we don’t know 100% what your coverage is until the claim is processed and payment is received. Thankfully, we’re usually correct.)
Issue #3 – Your insurance said you get 20 visits a year, therefore you think you get 20 visits a year
Your insurance plan will pay for “medically necessary treatment” for your condition. They have their own formula on how many visits that will take based on the seriousness of your condition. You also have to see results from your chiropractic care, but not yet have reached resolution of your problem in order to continue with visits. If your problem isn’t improving after a few weeks, they could argue that the treatment isn’t helping. If you feel great after a few weeks, they could argue that you don’t need any further treatment for this problem.
Some chiropractors and patients have tried to game the system in the past, by changing their listed problem every so often. However, it’s not difficult to see through this tactic and it just means your insurance company will deny the claims. The bigger issue is when your insurance plan says you have a large number of visits, like 60 visits a year. That doesn’t mean you can come in every week and insurance will cover it.
It means you come in for a particular problem, like neck pain, and then get that treated. At some point, that problem should resolve and then you’re released from care. If a few months later you hurt your back working out, then you could start treatment again for the new problem. Most patients never hit the 60 visits, so they don’t worry about that number.
However, if you’re treated for a neck issue this year and then just keep coming, then continue to show up every few weeks next year… well, they may decide that’s long enough to be treated for that problem. That’s regardless of how many visits you’ve used in any particular year. It’s about having a problem, having the problem treated, improving under the treatment provided, and then being released for that condition. It’s a normal process that’s expected with healthcare, even if you just love to come in and get adjusted. If you want your insurance company to pay for care, it has to be for a problem.
Issue #4 – Thinking we don’t want your health insurance to cover our services
Of course we want your insurance company to cover chiropractic care and all services in our office! There’s absolutely no reason why we wouldn’t want your insurance company to pay for every part of what your plan states they should cover. If a patient only has to pay $10 for their treatment, they tend to follow our treatment plans and they aren’t stressed about our fees. If a patient has to pay everything out of their own pocket, they may not financially be able to follow everything we recommend. It’s in everyone’s best interest for the services to be covered and make it easy on the patient.
However, when the insurance company doesn’t pay for something, patients immediately get upset with us. “Why won’t they pay? You said they would pay!” They told us they would pay, which is why we told you that. We are on your side and we’re your advocates to help your insurance company know that all services were medically necessary and should be covered. We speak with them on your behalf, send in any notes, even write letters saying that the care was needed.
If your insurance company denies a claim and you want them to cover it, you can contact your insurance company and let them know the situation. We will do our part as well, but remember we are on the same team. If you are planning a visit to our office, send us your health insurance as soon as possible so we can have it ready for you when you arrive.