Chiropractic + Health Insurance = ????

The number one question chiropractors are asked is, “Do you take insurance?”  I will admit to you, fewer and fewer Chiropractors are accepting insurance these days.  This can be a very good thing, or not.  Let me explain.

First, Chiropractors are considered “Specialists” in the insurance world, so when you look at your insurance card, make sure you are looking at the co-payment for a Specialist.  Now here’s the kicker – unless it is specifically written otherwise, you MUST have depleted your DEDUCTIBLE before the co-pay price kicks in for chiropractic.  That means, if you have a $4,500 deductible, you have to pay your Specialist the full negotiated price at time of service, assuming your doctor is in network.  If your doctor is out of network, or does not file insurance at all, you end up paying the full price of the doctor’s usual and customary care price.

As an example for chiropractic care, a regular office visit would end up costing approximately $75.00 for the spinal adjustment, extremity adjustment and 15 minutes of physio-therapeutics, which includes massage, trigger point therapy, ultrasound, therapeutic exercises, traction, etc.  This price is increased if it is your first visit (usually $100) when the chiropractor takes a comprehensive health history, or a re-examination (usually $75) which should be done about every 3 months or after 10 – 12 visits.

If the doctor is in network, there is a negotiated price for doing business with the insurance company.  What is considered a usual and customary fee of $75 is now negotiated down to approximately $28 for an adjustment and nothing more is included.  This negotiated price is subtracted from your deductible.

For the person who has insurance benefits for chiropractic care, co-payments are applied once you have met your deductible.  So now, according to the fictitious insurance card pictured above, the specialist co-payment is $25 for each visit.  That means the chiropractor now submits a claim to the insurance company, and hopefully will be reimbursed for the remaining $50, but may only receive $3.00.  This could take 2 – 5 hours for the chiropractor to justify to the insurance company that treatment was medically necessary and took place in the office as described.  Here is where insurance companies like to play games with us which drives that hourly commitment skyward for both the insured and the doctor.  Suddenly, the doctor is no longer listed as being in-network, even though the insurance company has already paid for the same services with another patient, or even the same patient; or the insurance company states the member ID number is illegible, despite the fact the form is filled out electronically; and finally, the insurance company will only allow 20 visits per year for chiropractic and this is the 21st visit in this calendar year.  With this last case, the patient may end up paying full price for the rest of the year, knowing that chiropractic care is helping you feel better and be more functional in your daily activities.

Now, the chiropractor has only received $3 – 25 for their services which usually costs $75.00 and they end up spending extra time themselves or hiring someone to chase down the insurance payment for the remainder.  The chiropractor ends up spending more time with insurance companies than she does seeing patients.  This equates to a DOCTOR (with $300,000 worth of student loan debt) now ends up making $10 per hour.  This is what ends up driving prices up higher, or ultimately, chiropractors making the decision to be a cash only practice where no insurance is taken.

There is an alternative for chiropractors who are able to offer a Time of Service – TOS discount, which caps the dollar amount on the office visit despite insurance.  As an example, United Healthcare has a co-payment of $60 for an office visit, but your chiropractor may offer a TOS discount of $50 without filing insurance for you and/or handing you the forms to file yourself.  This TOS discount may include the adjustment, physio-therapeutics and no limit on how many visits.  Be sure to ask your chiropractor about this, don’t just assume everyone has this.  This has an advantage to the doctor and the patient when they are able to give/receive the care needed without limitation from the insurance company.

Always check with your own insurance policy for an explanation of chiropractic care benefits.

Coming up – Medicare coverage for Chiropractic

Posted in The Empowered Patient Series.