Updated: May 28, 2021
I am sorry to say this is not the most fun post because, let's be honest, health insurance isn't the most fun topic. However, I do feel like this will be useful so I will try to keep it short and sweet.
Health insurance is TRICKY (both for the patients and the providers). We all know the baseline that if we have insurance we should have healthcare at a discounted or covered price but then there are all these rules that make things far from black and white. As a provider, these are things I wish every patient knew.
(Please know everything I have written is from the prospective of how things work in a chiropractic office.)
1. Your doctor doesn't choose his or her prices- they are regulated.
True story folks. Many patients believe costs at the doctor's office are chosen by the physician but this isn't true. Costs are set by federal regulations, state regulations, and fee schedules decided by health insurance companies. Furthermore, a doctor may not change the price without a contract (such as with Medicare, BCBS, or other insurance companies). If we do charge some patients different prices than others we face a huge penalty (I'm talking THOUSANDS of dollars PER patient visit) for having what is called a "double fee schedule".
This was put in place to protect insurance companies from being overcharged and to ensure patients are treated equally. However, it also created a barrier so that physicians cannot just give free or reduced pricing for services even if we want to try and help someone who maybe could not afford care. In order to do so legally, there are forms and documentation that must be completed and the patient must meet certain requirements. So please know, there is truly very little we can do about pricing and that's why we must be so picky with billing.
2. Health insurance does not pay for actual "health" visits.
No, really. This one causes many uncomfortable interactions in practice. In the insurance world we actually call them "wellness" visits. Basically, if you go in and see the doctor just because you want to and not because you have a complaint- they are deemed "unnecessary" and your insurance policy will not pay for them. Some examples of a complaint can be pain, decreased mobility, or something that may interfere with your daily activities. However, many chiropractic patients come in because they want to. Whether it be because they are athletes and it helps with their performance, they were once in pain but aren't anymore and would like to continue coming to prevent it from coming back, or they notice they're in a better mood/have more energy/etc. when adjusted - these visits are not covered by ANY insurance. If your complaint is not considered "active" the cost is on you- not your insurance.
3. Health insurance does not pay for "maintenance" visits.
If you are a patient that has a chronic condition or pain (a complaint that has been going on a long time) your insurance will likely stop paying for care. Let me explain:
At your very first visit, your doctor makes an assessment that tells the insurance company how well you will recover and how quickly. Once this condition has recovered as much as it most likely ever will, your insurance will stop paying for the visit making your liable for the cost. This is because insurance only covers visits that are improving the pain/complaint. So even if visits are helping the pain not get worse, this is still considered "maintenance" therefore they will not pay for the visit.
Something I hear all the time is: "but it was covered at the other office..".
This is where it gets tricky. Not all providers play by the rules and will find a way for something to always be covered (essentially making up a reason). Because of that, it makes the ones that do follow the rulebook look like the bad guys. Now, I know no harm is meant by this. Providers know insurance so expensive and they want you to be able to use it. As much as I wish these regulations didn't exist- that is out of my control and I must follow their rules. Even though it is done in the best interest of the patient, this is insurance fraud and once again, we face huge penalties such as major fines and even jail time.
This is an extremely frustrating rule for both the patient and the provider because let's face it, insurance is so expensive. The last thing we want to do is says you can't use it. I'm with you, believe me. Regardless, rules are rules.
5. Even if a provider is not in network with your insurance, there may still be a way for you to get the service paid for.
If your insurance policy covers a service but the doctor you would like to see is not in network, many offices are willing to give you what is referred to as a "superbill". Basically, this is a print out that says what was done, the medical billing codes for the service, how much was charged, and when, where, and by whom the service took place with as well as patient information. Once you have this sheet you can send it into your insurance company and they will reimburse you for the cost of the service. The rules on this can change based on your insurance company and policy so it is always best to contact your insurance company first to ensure this is a possibility.
6. Medicare plays by it's own set of rules.
So, long story short, Medicare has many rules and can be very tricky to work with. I don't believe that is the intent but nonetheless that is what happened. For starters, there are very specific rules about who a doctor can see. If the doctor is not a provider that is enrolled with Medicare, there are many circumstances in which you ARE NOT allowed to treat that patient even if they are willing pay cash. This is not always the case but the rules get fuzzy which is why a non-par provider (a doctor not enrolled) may be hesitant.
Additionally, Medicare does not pay for the majority of chiropractic services. I have never seen them pay for exams, imaging, adjustments of anything but the spine (no extremities) and no soft tissue work (muscle treatments, massage, e-stim, etc) in a chiropractic office. They, like other insurances, also do not pay for wellness or maintenance visits. However, doctors still must charge the patient for these services. Going back to not setting our own prices- there is a huge fine if we do not charge the patient for the cost of this service.
This was by no way meant to sound like me whining about insurance companies. I chose to be in network because I believe it is an awesome thing to offer to my patients. I simply wrote this to hopefully help people understand where some of these rules come from and help lower the amount of frustration for patients.
If you ever have a question about the fees you are charged at an office, check with your doctor (or their office staff). They should be more than happy to help you!
Have a beautiful day,
(PS promise the next post will be way more fun!).