CHIROPRACTIC
AND INSURANCE
The
first thing that patients need to be aware of is that ultimately,
the patient is responsible for the doctor's bill. A doctor's office
will typically have the patient sign an Assignment of Benefits
statement which authorizes the patient's insurance company to
issue payment in the doctor's name. However, in most cases it
is not known how much of the billed charges the insurance company
will cover. Copays, deductibles, allowed charges and not allowed
charges come into play. Only after the bill has been processed
do both parties know for sure how much the insurance plan covers.
There
is also the issue of out of network vs. in network provider. Many
PPO (Preferred Provider Organizations) plans allow the policy
holder to seek both in and out of network doctors; in most cases
the in network coverage is more attractive to the patient as it
offers a lower (or no) deductible and/or a higher percent coverage.
However, from the doctor's standpoint, the reimbursement is much
lower than the doctor's "usual and customary" fees.
Many chiropractors refuse to join certain networks because of
this fact.
A
typical group health plan (offered by an employer with many employees)
that covers some chiropractic treatment will have one or several
limitations:
1)
the maximum amount paid per visit (a flat payment
per visit)
2) the percent coverage (for example, insurance
pays 70% of bill and the policy holder pays the other 30%).
3) the maximum annual benefit (the most the plan
will pay in a calendar month). Usually between $500 and $2,000.
There
is usually a deductible, which in most cases
starts January 1st of each year (some go by fiscal year and start
July 1st). The deductible is the amount of medical expenses that
the patient is responsible for before the insurance plan starts
coverage. The higher the deductible, the lower the premium.
Some
policies have coverage restrictions. For example, massage therapy
can be listed as a non-covered procedure. Some policies have special
limits on the modalities a chiropractor can bill; for example,
only two modalities per visit. Many plans do not cover ice or
heat; many do not cover heat/ice therapy.
Before
you start treatment, make sure you know how much you will be billed
by the doctor, in order to avoid misunderstandings.