If I have so many visits on my plan, why isn’t my insurance covering wellness visits? And other super confusing insurance issues.

Insurance.  It’s a blessing and a curse.   Over the last 13 years or so I have seen numerous changes to the insurance world and have fought many battles with them.  I would say that I’ve come out about even in the win/loss category.  While I try very hard to keep treatment and financials separate, as the owner, it’s also my duty to be well versed in all aspects of running the office.

Each year we are seeing deductibles go up, out of pocket maximums go up and coverage go down.  Trust me, the added money that the insurance companies are collecting isn’t coming to our office either.  Our reimbursements have a downward trend overall.  One challenge with insurance is that it’s very complicated and changes often.  So, many patients don’t have a full grasp of the ins and outs of their plans.  This is something that we deal with every day and it can still be a challenge!

Add on top of all of this, we are seeing a lot of incorrect information being given to us when we call with zero recourse.  We ALWAYS urge you to call your own insurance and find out what they tell you your coverage is.  If there is a discrepancy between what you are told and what AHC is told, it’s much easier to address it at the beginning of a treatment plan as opposed to a couple of weeks in.  It can take up to 90 days for us to have the information of how your insurance is processing and in a treatment plan, that could mean a lot of visits are coming out differently than you (or we) expected.  Where you are ultimately responsible, it behooves you to also make that call.

One major confusing question that we often get that I would like to address is “If I have 40 visits a year, why is my insurance not covering my maintenance/wellness care?”  This is a tough and super frustrating situation.  Here is an excerpt from a popular insurance plan on what will NOT cover:

 

Not Medically Necessary

  1. Chiropractic services are considered not medically necessary if any of the following is determined;

Chiropractic services are considered maintenance/preventive:

Maintenance/Preventive care is defined as elective healthcare that is typically long-term, by definition not therapeutically necessary, but provided at intervals (preferably regular) to prevent disease, promote health and enhance the quality of life.

Ongoing preventive/maintenance care may include patient education, screening procedures to identify risk, a home exercise program, and lifestyle modifications in the hope of promoting optimal health.

The service is not aimed at diagnosis, and/or treatment of disorders of the musculoskeletal system, and the effects of these disorders on the nervous system and general health.

The service is for conditions for which therapy would be considered routine educational, training, conditioning, or fitness. This includes treatments or activities that require only routine supervision.

The service are not expected to result in practical improvement in the level of functioning within a reasonable and predictable period of time.

 

 

Our goal when you are coming in monthly or so for wellness visits is that you feel awesome when you walk through that door and even better when you leave.  Wellness care typically happens in our office after your second reexam and we space your visits out at regular intervals to keep you feeling great and maintain all of the amazing progress that you’ve made.  Unfortunately, insurance companies don’t see the value of this and they exclude it from coverage.  In the past, we tried having patients call their insurance companies, explain that they are coming in for maintenance and they are getting verbal confirmation (including a reference number) that it will be covered, however, we are still seeing that it’s being denied, putting the cost back on the patient.

 

While you are under your treatment plan (coming more frequently), the adjustment is billed out as 98941 which is defined by:  chiropractic manipulative treatment involving 3 to 4 regions.  When you are coming at regularly scheduled intervals, with no major complaints, the adjustment must be billed out as S8990.  This is defined as: physical or manipulative therapy performed for maintenance rather than restoration.  Most, if not all insurances will not cover that code and thus it will be denied.  When calling to have this discussion with your insurance company, should you choose to, we highly recommend giving them the actual S8990 code to check on coverage.  Unfortunately, an insurance employee stating that they will cover it doesn’t seem to be enough.

 

There is a caveat to all of this.  If you come in and you have had a flare up, or a fall or otherwise a change in your health, this will be covered by insurance.  However, if you end up having a flare up “once a month”, this will get flagged by their system and they more than likely will take back their payment causing you to be responsible for the cost of treatment.

 

Trust me, this is equally as frustrating to you as it is to us.  We never want to see finances stand in the way of you feeling amazing.  It can be frustrating to go from a $15 copay to $65 a visit, however, that $65 a month is key to maintaining all of the amazing progress that you’ve made.  And, that $65 a month is a whole heck of a lot less than you were paying when you were coming in multiple times a week in the beginning of care.

 

At Absolute Health Chiropractic, we do everything that we can to be as upfront as possible about your finances.  We try our best to navigate the gauntlet of insurance rules to make sure that we are keeping everything above board.  If you have any questions at all about this or about your insurance, please don’t hesitate to ask.  We are here to help and to give you the exceptional care and customer service that you deserve!

  • Dr. Cait
2019-11-19T19:31:12+00:00November 19th, 2019|