Do I Accept Health Insurance?

I get asked this question on a regular basis, because a good portion of my patient population is looking for more of a holistic approach when it comes to their chiropractic care. In addition to chiropractic care, I offer a wide array of nutritional and soft tissue therapies to help get my patients better, quicker because not all chiropractors are the same. For instance: often times for a regular office visit, I incorporate 3 procedures that can be billed into one visit. How this relates to insurance gets a little complicated, so that is why I am writing this blog to help explain the entire situation. Don’t be afraid to ask me questions, because this is confusing (even for me, and I’m in the healthcare industry for a living).

What it boils down to, though, is quality of care. Long story short: in order to maintain high-quality care at affordable rates for the patients, I don’t accept traditional insurance plans, including Medicare. However, I do accept money from flex accounts (FSA) or health savings accounts (HSA) since insurance isn’t involved in determining my prices for services. “Letters of Medical Necessity” could be written by me (providing doctor) to explain the medical situation a patient is going through, and how my services would help that patient out. In that case (most likely), the insurance company will then reimburse the patient a certain percentage of the visit, as long as they pay everything themselves initially. The patient would then get reimbursed at a later date once the patient submits the Letter of Medical Necessity and their receipt that has the appropriate billing codes on them (superbill). That’s my situation in a nutshell, however, if you want to understand more of my situation, and insurance for chiropractors in general, then I would recommend continuing to read the rest of this blog.

To start out, I am going to describe how chiropractors provide their services, and place them on two ends of the spectrum. On one end of the spectrum, there are chiropractors who spend two minutes with patients, have minimal (if any) patient interaction, doesn’t try to figure out the root cause of any pain/dysfunction, and typically adjusts the spine only. Those chiropractors have their purpose, however, if someone is looking to figure what the root cause of any pain and/or dysfunction, then I would suggest a chiropractor on the opposite side of the spectrum (like what I do). On the opposite side of the spectrum, there’s chiropractors who spend more time with patients (typically 10 minutes or more), have a lot of patient interaction and questions, tries to figure out the root cause of any pain/dysfunction, and adjusts more than just the spine (and often incorporates other therapies).

To make my point about insurance, I am going describe how chiropractors get reimbursed from insurance and tie some ideas together. Chiropractors get reimbursed by insurance companies from the number of “regions” adjusted. For spinal adjustments, the maximum amount a chiropractor can bill and get compensated for is 5 different regions. To relate it back to back to the previous paragraph, chiropractors that spend two minutes may tend to adjust and bill for the maximum number of regions (5). From a business standpoint, that is much more enticing and lucrative compared to other chiropractic clinics that spend 15 minutes with patients for a regular office visit and may only adjust two segments for a patient, because that may be all that they need for a particular visit. My clinic spends the 15 minutes with patients for a regular office visit, so from a business standpoint my clinic is at a competitive disadvantage if we were to accept insurance.

There’s another layer this whole situation, in that accepting insurance means that you are in network with an insurance company, and being in network means that there’s an “automatic write-off” for the chiropractor’s services. What that means is that since the insurance company is “referring” patients to the chiropractor for being in network, the chiropractor has to accept the patient’s copay, which is a discounted price of their services. The difference between that copay and what the chiropractor charges is kept by the insurance company. A certain percentage of that difference is supposed to be paid to the chiropractor from the insurance company, but quite often the insurance companies don’t pay those reimbursements to the chiropractor. If my clinic were to accept insurance and maintain the high-quality of care, then I would charge 3 times the amount (or more) I charge now for my services to get compensated from the insurance company so that I can keep my doors open and help patients. The reason why I would charge 3 times the amount or more is going back to what I previously said, in that I incorporate usually 3 procedures that can be billed into one session. However, no one would come and see me because my prices would be very expensive in regards to their healthcare policy.

Essentially, insurance companies try not to pay the chiropractor anything, even though the patient is paying their premiums. That premise sets up chiropractors giving lower-quality care in order to keep their doors open, because there is no incentive from the insurance companies to give higher-quality care. That ultimately ends up hurting the patients in the end, and is why our healthcare system can definitely be improved on. It’s a lose-lose scenario for both my clinic and the patients if my clinic accepted insurance.

Medicare is worse, because they will only compensate chiropractors for adjusting the spine only. Adjusting the spine only is just a bad model, because the chiropractor is limiting the amount of people that they can help get over certain conditions. For instance, if someone is having shoulder pain, adjusting the spine may not get rid of the shoulder pain. There are some cases where that may happen because the nerves that innervate the shoulder come from the neck, however, often times there needs to be other therapies involved to help resolve shoulder pain (in particular some soft tissue therapies).

Younger people who have high deductibles with minor health issues really benefit from my care and services because they often have HSA’s or FSA’s. For instance, this very day as I am typing this blog, I helped a 27-year-old female with neck pain in two visits. That is even after going to two other chiropractors, going to a massage therapist, and being prescribed muscle relaxers. I gave her a couple of exercises and stretches to help prevent what she had going on with her from coming back. As long as she continues to do those exercises/stretches, I shouldn’t see her again. But if something does happen, then she is going to contact me. I didn’t have her on some elaborate treatment plan where she came in three times a week for six weeks. I just addressed the root cause of her neck pain, and now she’s feeling 100%. All that was around $200 from her HSA account.

Lastly, I am going to talk about letters of medical necessity (LMN). Letters of medical necessity is a difficult subject, because insurance companies are difficult because they try not to pay for therapies out of network (which I would be considered). Ideally, if a patient was to come to me and I write them a letter of medical necessity, they should be able to submit that to their insurance company and have my services covered (at least a portion of it). That letter of medical necessity needs therapies that are going to be utilized, the reason why those therapies are used, and the duration those therapies will be used. Anything performed outside those parameters will not be covered.

If there are any questions or items in this blog that needs some clarification, don’t hesitate to reach out and contact me!

About the Author

Dr. Eric Johnson, Doctor of Chiropractic and Diplomate of the American Clinical Board of Nutrition as well as owner of Functional Wellness and Chiropractic Center in Madison, WI, is a functional medicine doctor that identifies root causes of pain and/or dysfunction. His systems-based, not symptoms-based, approach is a comprehensive, holistic approach that helps identify mental, chemical, and physical stressors that are underlying numerous health conditions. If you are in the Madison, Middleton, Verona, Waunakee area and looking to not only feel better, but live better, contact Dr. Eric at (608) 203-9272.