Insurance and Chiropractic

Health insurance pays for chiropractic care if it is a benefit included in your policy. Each policy is negotiated by either yourself or the Human Relations person in your office. If you aren’t happy with the terms of your policy, you need to let the HR person know so they know what to negotiate the next time around. Policies are one year in length, usually from January to December, but not always. You need to find out. At the beginning of the “year”, you often will have to pay a “deductible”. This means that amount (as determined by your policy) is not payable by your policy provider and you will have to pay that amount out of pocket. However, you must make sure that whatever care you’ve gotten and have paid for is also billed to your policy holder so that they know about it and apply that amount to your deductible. If they don’t know about it, it won’t happen. Most of the time your health care provider will do that billing, but you should ask. You may have to get the information and provide it to your insurance company yourself.

Once the deductible has been met, there are more options. You may have no co-pay (you’re the lucky one), a set co-pay, or a percentage, or both a set co-pay and a percentage. You might read your policy, but this is often confusing. You can also call your provider at the phone number on your ID card, but you will hear a message telling you that any information you receive may be incorrect, so remember that later if payment seems incorrect. For instance, the benefits may say something like: you have a co-pay of $15 and chiropractic care pays in-network at 80%. Interpreted, this means that if your doctor is a preferred provider (they have a contract with your provider), at the time of service you should pay the $15 co-pay and you may also be asked for an additional estimated payment of 20% of the payment amount or you may receive a bill later.

It is highly unlikely that your insurance company will pay the amount that your doctor’s office bills, unless that amount is extremely low. So, the EOB (explanation of benefits) that you receive a copy of will show an “adjustment” or “contractual disallowment”. This is an amount that will not be paid by anyone. Healthcare providers are generally (as determined by your state‘s law) required to bill everyone that same amount. But they are paid according to your policy. The EOB shows the amount billed, the amount paid, and the co-payment due from you, the patient. Sometimes it shows the amount disallowed that the doctor’s office writes off. You may have been told by your policy provider that you only have a co-pay or that may have been what you understood (because it’s so confusing) and then not understand if you get an additional bill from your doctor’s office. If your insurance company shows on the EOB that you have an additional co-pay, you must pay it.

Often, your policy will pay for chiropractic care for a provider even if they don’t have a contract with your company. The payment is generally lower and your portion higher, but this is an option also. There are some chiropractic offices that will not bill insurance. You may choose to get the care, then bill the company yourself. Call them and ask if you need special forms. Some providers may have you pay your portion of the bill at the time of service and others may wait to hear from the insurance company and then send you a bill. There is no rule for this. Each office may handle this differently.

The only rule is that insurance companies have about one month to either pay the bill or deny payment from the time they receive the bill. This gets interesting. Most of the time it works great. But there are times when they will say they never received the bill, or they need more information before paying, or something that will delay payment. If you have any concerns about the way they are handling your claims, you have a couple of ways to handle it. First, try calling directly and request that they just pay the bill according to your policy. If that doesn’t work, try talking to the HR persona at work and see if they can help. If all else fails, contact your state’s insurance commissioner’s office. They are your advocate with your policy holder. Find them online or in the phone book under state services. They will be happy to help you. In Washington state, you must file any complaints on a form that you can download or have sent to you. Your ompany will be contacted and attempts will be made to resolve your situation.

When you and your spouse or partner both have separate plans, you may be covered on both policies. Then you have primary and secondary coverage. Your primary coverage is the one you have with your employer and your secondary is the coverage under your spouse or partner’s insurance. The primary policy will cover care under that plan, then the secondary will pick up at least part of whatever is left, including the co-pay. Most of the time, you will not pay anything to the doctor’s office, but it depends on the individual policies. When you give the doctor’s office your coverage information, tell them if you have more than one policy. They’ll know what to do.

Now for the biggie: MEDICARE. Yes, it pays for chiropractic care. You may have trouble finding a chiropractor who takes Medicare patients or who will bill for the care. But, if you can, get the care you need. Correctly used and correctly documented, there is no limit to the care. Please don’t suffer needlessly. You can get care any time you are in any pain. Health coverage of any kind does not pay for preventative (palliative) chiropractic care. Many Medicare patients also have secondary insurance that covers all or most of their co-pays

Depending on your state laws, work injuries may include chiropractic care. This varies widely, so check. Here in Washington state, your providers must have a contract with the Labor & Industry and your employer must have a policy with them in order for your care to be covered. If you hurt yourself at work, report it to your supervisor and check on your rights and benefits. Sometimes this may not be easy, like if your employer doesn’t understand the coverage or at least acts like they don’t. If your employer doesn’t help you, find the phone number online or in the phone book and call yourself and ask. Look for L&I (Labor & Industries) under the state government services.

Auto accident injuries are covered by your auto policy. This one is more complicated. You must have Personal Injury Protection (PIP) as part of your policy. If you have an accident that is your fault and you are injured, your policy will pay for your care. If you have an accident that is caused by someone else and you are injured, your PIP will pay for your care and later will be reimbursed by the other person’s insurance if their policy covers injury care. If your auto coverage doesn’t pay or underpays, you may need an attorney to help you. Their job is to make sure your injuries are treated and paid for. Hire an attorney that specializes in auto injury cases. The goal is to return you to the condition you were in before the accident. Small accidents can cause serious injuries. Watch for signs of head injury like: headaches, extreme fatigue, neck pain, short-term memory loss, anger, crying, mood swings, inability to concentrate. This last one is important in determining injuries in children that were in the car. Watch for it. Many times people don’t think their children are injured if they don’t make the same complaints as adults. They won’t. If you’re injured, your children are probably injured also. Have them checked by a chiropractor. Get care as soon after the accident as possible. You will have a quicker and more complete recovery.

From your chiropractor's (or any healthcare provider's office) point of view, billing your insurance is a free service to you, the patient. It takes time (sometimes a lot of time) and that means that it costs money in people-power. It is not an obligation, but so many providers do it, that we as patients often take it for granted. Sometimes there is so much run-around and it takes so many hours of paperwork, that it actually costs the doctor's office more than they receive as payment. So, it would be nice if you occasionally thanked them for this free service or at least don't be cranky about conflicts with the insurance about when or how little they pay or what they expect you to pay. When the provider does the billing, they end up taking the brunt of patients' unhappiness about their coverage. The conflict is with the insurance, not the provider. We're doing our best for you. The rules change constantly and we don't know about it until later. More and more providers are having their patients pay for service and then submitting the bill to their own insurance company for re-imbursement.

If you have pain or an injury, don’t let confusion stop you from getting the care you need. Ask the chiropractor’s office, call the insurance company yourself, ask the HR person at work. Don’t worry and don’t wait. Ask questions and get the care you need.

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