Most large clinics and hospitals use a third party biller to process their claims.  They know that if they delay sending in claims that it is more likely that the claims will pay out directly from the insurer, because it is more likely that the earlier claims would not clear.  Earlier claims  received would require that some other provider would have the task to collect money from the patient to meet the deduction.  This is more alienating and more difficult to do.  One way or another, it takes time for another provider's claims to clear with BCBS so they can go against the deductible.  We cannot know this nor can we determine what amount is going to be applied.  When we suspect a claim will clear, we file immediately.  When it doesn't clear, we stop filing.
FOLLOW THIS WITH EACH VISIT

For any insurance process to work for you, please follow our office procedures.  Sign in and complete the subjective portion of the form on the clipboard.  When you leave, pay as agreed, and look at the paper bill showing codes and amounts, and sign this at the bottom agreeing that this information is correct.  Ask questions if you do not understand.  Ask for a copy of this billing; it is used to process all claims.  Few, if any doctors, do this. It insures better communications and fewer errors.  We should be asking you to sign in, sign out, and asking if you need a copy, but we cannot guarantee that we will always.  It is your claim.  Also, we cannot process any claim if we do not have your identification number with the insurer and your personal information.  We must know who is the primary insurer, so the claim goes to the right carrier.  Only you can give us this information--we often cannot find this out.  If you do not get this information to  us or it is inaccurate, we cannot process the claim.   If challenged by the patient or insurer, these are our documents showing that we took appropriate action to insure accuracy.  The information on the paper claim is transferred to the office software that manages all transactions associated with your patient number.   If any personal information changes, you are obligated to update us since billings could be forthcoming in our reconciliation of your account.

All physicians are asking to view and copy your drivers license and your insurance ID card.  We no longer ask for SS #.  Also it protects against someone using your identity for services.

If you are using insurance and you are leaving our office with an established balance, it is important to our business that we have accurate personal information to process claims and bill you in the future.  Your receipt of a remittance or failure to get a remittance is enough to know whether you owe our office.  In Alabama, there is no statute of limitations on a debt.

SAVE RECEIPTS AND REMITTANCES SENT TO YOUR ATTENTION.  WE WANT OUR BILLING, THE DOCTOR'S RECORDS, AND THE INSURER'S RECORDS TO AGREE WITH WHAT OCCURRED.

As with most practices, no one is going to announce to you which procedure is being performed and when it changes to another.  It could at times not be as clear as it would be with others.   If Dr. Katherine is spending over 5 minutes with you in her treatment room, she is performing more than one CMT procedural code. 
Doctor Patient Relationship should be one of trust and confidentiality.

Insurance companies purposely create protocols and procedures to strain the doctor/patient relationship.  The insurer is only a voice on the phone, while the doctor/office personnel are seen regularly and are there to help you.  The insurer will tell you what you want to hear, while the truth is left to be delivered by our office personnel.  When they have to deliver this bad news about coverage, the patients want to "shoot the messager."  Humana once told our Medicare patient that he could see a chiropractor for as many times as he wished.  This is what he wanted to hear.  The truth is that he can be seen for as many times as are medically necessary and are supported by a plan of care with a date of incident.  He only wanted to come occasionally as he saw fit.  He  still believes that we lied to him about these limitations.  Humana told him what he wanted hear;  he heard "Free Care".  Medicare tells us that we must make this patient a cash patient since they are not compliant with a plan of care and that even if they were, they must be released after a short plan of care to eventually being placed on maintenance care (cash patient).  The patient does not have a blank check.  They know that when you tell them it is now cash only, the patient will be angry, doubt you, and call to see.  Care is interrupted if not stopped completely.  They save money--you lose patients--patients cannot get better.  This is why patients can only talk with "marketing/sales people" from customer service, while providers can only talk with accountants and the people who release the money.  Medicare was always problematic and terribly risky for the provider, so we dropped it.

The doctor is being forced to define care as maintenance, elective, or preventative care.  You may have been used to having these services paid for, but they will not be paid for in the future.  The doctor has become the gatekeeper, and he/she will be held accountable if he/she sends in a claim that the carrier and/or federal government view as not "medically necessary." The chiropractor's opinion as to "medical necessity" has been and will continue to be devalued.  Essentially either the insurer or the government will be determining all necessity for the delivery of care.
  YOUNG CHILD CARE

Any covered claim does not mean that they will pay for it. Just because they paid for it does not mean they will not ask for the money back.  

 In 2018, we were rejected on a claim by Blue Cross because they sited that no 3 years of age benefited from chiropractic.

Dr. Katherine was trained in infant and child chiropractic care.  We have found it very effective.

One was a two years toddler and other was over four years, but both were rejected twice even after we submitted Medical Records.  There was nothing we could do about it.  The parents never paid for services and did not bring back the children.  On others they paid for the younger children. Just because you have coverage, does not mean they will pay for it.  

Now young children must pay in advance no matter their coverage until it pays out.

My experience is its a waste of time to try to establish "medical necessity" unless you personally have a patient advocate.
All physicians have their patients sign an agreement that the patient is obligated for the unpaid portions of their services.  Insurance is a contract between the patient and the carrier. 

Remember, it always costs you money if you use insurance.  In the future it will be costing you more out of pocket and more for the premiums.
High deductibles will essentially render major health insurance into catastrophic health care only.  The Affordable Health Care movement has transformed most policies into high deductible policies with higher premiums.  Before high deductibles as an option meant lower premiums.  Now we have a system that collects money from the client and delivers no benefits.  It truly is becoming the tax that the Supreme Court said it was.
MEDICARE FOR ALL

Do not expect to see a Single Payer health care system to cover chiropractic services.  It does not matter to them that it saves money and that it helps people.  Any Single Payer system will work just like government coverage that we have right now.  Chiropractic essentially does not exist in Medicare.  It is not at all included in Tri-Care for retired servicemen/women.  It is not in Medicaid.    Samba coverage for many government employees does not have chiropractic.  People have always been forced into only a one treatment only program, conventional drug based medicine.  Obamacare individual "Medal" plans are still sponsored by private companies, so they offer chiropractic coverage.  The single payer system similar to the European model will be no better for chiropractic coverage than Medicare and/or will have nothing whatsoever. Universal government care is called "Medicare for All" which means no chiropractic for anyone.
Younger people seldom see physicians and have traditionally not been well represented by major health insurance.  People not in a group plan have to consider the individual plans.  They were given less options and paid more money.  They often elected less expensive high deductible plans.  These people will be avoiding the Affordable Care Act dictates.  If these people do not pay for the new expensive plans, they will be hounded for fines by collectors and the IRS.  They will join the hordes of college graduates that cannot afford to pay back or even on the interest for their student loans.  It looks very ugly.


Any group major health care plan that has been offering reasonable chiropractic coverage may not be available in the future.  It all depends upon that group's political affiliations and its ability to lobby for special interests.  It will be difficult if not impossible to offer chiropractic services only to these groups, but for the last twenty years, federal employees, county employees, state workers and teachers have maintained good chiropractic coverage while others have declined. 

 Unfortunately, Mississippi teachers have good chiropractic coverage, but they have a very high deductible of $1000 that must be met before it helps them.  Alabama teachers in contrast have a similar good group insurance, but have no deductible for their chiropractic and can be seen right away on January 1,  Most often by the time MS teachers meet their deductible, they have no time left in the year to use their 30 visits. 
If in any way you prepaid a provider for services, this money cannot be used toward a deductible.  It can only be used toward the deductible when and after the day of service for only those procedures filed on that day.  Any prepaid funds received over $500 for future services are held in a special account.  Upon receipt of a claim, no matter what the day of service, BCBS determines the cost of the procedures filed to be applied for any required deductible. Any amount exchanged for services is strictly between the provider and patient, until the claim is officially filed, or the provider can "accept assignment", if ever.
ONLY YOU CAN INFLUENCE YOUR INSURER

If your claim is filed by us, we would have expected it to clear either paying us for our services or to pay toward your deductible. We would not have filed it otherwise.  If we were to be paid but were issued a denial, you will also know this on your remittance.  We will ask that you call BCBS at the number on the back of your card and resolve the issue.  Often BCBS indiscriminately requires information from you about your status by letter;  they will hold up all claims if you don't respond.  They also occasionally just hold up a claim for weeks or months with no clarification. We have no influence over the claim; very very rarely is a claim held up because of a clerical error.  If this effects your claims, you must "pester" them; otherwise we must eventually charge you what we expected to receive.
OBVIOUS INEQUITIES IN INSURANCE TO CHIROPRACTORS

Most or all chiropractors:

1. are forced to collect "coinsurance" rather than a set "copay."

2. have limited visits or a set limited financial amount granted per year.

3. have reduced visits even when the visit did not pay out to the provider but toward meeting the deductible.  Visits are exhausted before a deductible can be met.

4. are granted no exception for special circumstances.

5. are given far less visitations than an OT or PT.

6. are not given free wellness visits  to encourage patients to have check-ups but the insurer still pays the physicians.  This is the same as a paid promotion to benefit only a select benefactor.

7. are given only one special coded examination for a new patient, but are not given any reexamination as with medical no matter the circumstances.

8. have included a small token examination with the CMT treatment code.  This is the only code of all physical medicine codes to do this, and, of course, this is an exclusive chiropractic procedure.  Medical doctors are paid separately each time they examine.

9. are excluded or severely restricted from federal programs, many of which by virtue of age and past participation in the military service.  Each representing very large populations and forcing them into only medical options.

10. are restricted from all media advertisements as an option from regular health care, yet all diverse populations are represented as well as all types of medical doctors. Chiropractic is never positively promoted by insurers in television, websites, and literature.

11. are told to send frequent patients to medical doctors, but medical doctors are never told to sent out their frequent patients to "alternative" doctors.  It's an important distinction; only medical doctors are specifically entitled to paid access to patients from "cradle to grave" regardless of a patient's choice.


"We pay as we go.  If you do not get a bill from us, we do not believe we are owed anything.  But, if you paid your coinsurance only and we did not get paid by your insurance, we should at least receive our minimum fee"

                             Dr. Katherine Crafton
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INSURANCE

WE NOW ONLY ACCEPT BLUE CROSS AND BLUE SHIELD INSURANCE.  ALL OTHERS OVER THE YEARS  PROVED IMPOSSIBLE TO  PREDICT.   THE FINANCIAL TURNOVER WAS LENGTHY AND UNPREDICTABLE.  WE DECIDED TO MAINTAIN PREFERRED PROVIDER STATUS WITH BCBS AS AN IN-NETWORK PROVIDER.

WE ONLY BILL ECLAIM IN ALABAMA AND MISSISSIPPI'S ELECTRONIC FILING.  ALL OUT-OF-NETWORK CARRIERS ARE REFUSED.  THIS KEEPS OUR OFFICE BUSY.  WE ARE VERY FAMILIAR WITH MOST LOCAL BCBS PLANS AND WISH TO TELL YOU UPFRONT HOW THEY CAN HELP YOU AT THE TIME YOU REQUIRE CARE.

MEDICAL NECESSITY

It has always been the case that insurance pays only for "medically necessary" procedures.  There is no good standardized definition of what this means.  The insurance company becomes the final word on whether something qualifies or not, and they have a vested interest in this determination.  All insurance companies only pay for a plan of care to treat a diagnostic finding defined by codes which often have only a very generalized definition. 

If you have active insurance benefits without any limitations, such as medical coverage, the carrier will more likely require proof of continuing care beyond a certain point; otherwise, from their point of view it could be indefinite and abused.  Care can only be delivered as long as it is controlled and focused; it cannot be given if it is not expected to produce results.  To continue to treat a patient beyond the plan of care, by request of the carrier,  the doctor must get permission through report and documentation to continue treatment or change that treatment.   Unsanctioned care is management care, preventative care, or elective care.  No insurance company pays for this care.  This includes Medicare, Blue Cross, United Health Care, Cigna, Aetna, or any other brand name carrier.

Chiropractic care is almost always very limited.  This means that the carriers have placed a yearly limitation on  the use of the coverage.  It is either by a set amount and a set number of visits.  Chiropractors are always adjustly filed patients having established "medical necessity; however they are often not  bothered by proving "medical necessity", since  the benefits will run out quickly anyway.  If Chiropractors had equality in benefits, they would have the same challenge as the medical doctor.  This is to keep going back to the carrier for permission via documentation and delay.  It is still true, however, that at any time the carrier could demand proof of medical necessity even when it appears that the patient is guaranteed a certain amount of care by visit or amount.  There is no guarantee unless the insurer accepts the provider's claim of "medical necessity" and all terms are been established in the contract.

For the last several years BCBS has refused all our requests to extend the limitations no matter how we prepare the necessary documentation.  They will tell you to ask us to make the request as though it's easy and a matter of fact; this is not true.  They are telling you what you want to hear.  They tell us that if any chronic condition does not get better after the limit is exhausted, you must be referred out to a medical doctor for an MRI, drugs, or surgery.  If it's acute, they tell us to send you to ER or medical doctor with "formal referral" from them to see us.  We do not appreciate this when we have to do a lot of work and get refused anyway by trying to make it seem to be our fault.  We will no longer complete these "medical necessity" forms along with SOAP notes and tests.  If you require this, we must release you and refer you to another doctor.

We no longer maintain Medicare as a carrier. Medicare only covers the one chiropractic adjustment to the spine.  A chiropractor is restricted from any other benefits even if it fits into their scope of practice, such as therapies, extremity adjustments, examination, diagnosis, and imaging.  It is purely political to restrict them from a fair access to the marketplace. 

One day a patient has full chiropractic coverage, and the next day after 65 they do not.  Even so, Medicare places no limit on the number of visits or adjustments, or so it says in the literature and when you ask.  They may well pay out for random adjustments over an extended period of time, but the doctor can be called on these visits at any time.  They are looking for claims that were paid out, but were found by only Medicare reviewers at a much later date to have been not medically necessary now.  This is how they can at any time raise money, cull and intimidate the providers.  At one time, Alabama Medicare was telling the patients that they had 12 visits a year to a chiropractor; they were stopped by the Feds; however, they are now back to doing this again.  They could not set a limit on a service that someone was forced into having just by virtue of age.  It is somewhere probably around 12 visits; however, they can audit some cases to make sure that treatment stops or that the physician went about the task of turning the case into either a Self Pay patient or into a new case with a new incident.  

Medicare is not a blank check but really is only a large trap easy to fall into when one least expects it.  We have shared many negative experiences with Medicare patients about the risks and limitations, but they do not want to believe us.  Providers are hurt, not necessarily the patients.  Ironically, we now have more Medicare aged patients then we did when we were with Medicare.  


These patients choose to pay our discounted fee, and sign the Medicare Option 2 form as confirmation that Medicare or any supplemental carrier is not to be filed.  Regardless, we are no longer a provider listed by Medicare and this is by our choice. They do not recognize any claim by us nor send it to Secondary or Supplement carriers.  Our P-Tan number was relinquished;  when asked again by Medicare to join in late 2019, we again refused.

FEES AND INSURANCE CLAIM

We provide Self Pay for the uninsured and a Minimum Contribution for the BCBS insured, but they are only given on conditions.  Please understand that you cannot be given a reduced cash fee for services and then be expected to file with your insurance or that we can.  You cannot have it both ways.  All insurance companies are given the same retail published fee by total of procedures and insurers determine what is to be paid.  They do not expect to see different fees from one insurance company to another.  On any visit we rarely provide only one procedure per visit, but a series of procedures as needed.  If we file a claim, we must collect from you the patient portion which includes all retail monies for all procedures to include coinsurance, copay, and any monies paid toward the deductible.

You will get a fee adjustment only if we are in-network with this company by each procedure received.  In-network does not exist for auto insurance; all auto injury claims have the same fee per procedure as those billed to the major health insurance carrier.  All cases have to be reconciled to the penny, and there is no way of knowing ahead of time how insurance will settle a claim until it is settled and a remittance is issued. Also all insurance claims are considered procedures performed meeting "medical necessity"; this is not required with a Self Pay patient.  You cannot make a claim if we have considered the transaction as a Self Pay patient and/or where this transaction was considered "maintenance care" and then have this filed with insurance.

All New Patients are informed of the benefits and limitations of Self Pay fees.


 Many of our Self Pay patients pay a fee by the visit that may include many procedures; there is no way to itemize this fee by procedure.  Consider any Self Pay fee to be given only upon an agreement that the patient does not want to use their insurance and agrees not to do so on either of being released or having to pay as an insurance patient.  This Self Pay could be viewed as a small contribution toward the deductible, but it must approximate the balance shown. Most of time chiropractic services require that you meet  a deductible, and often only outside medical provider costs can do this.  Some insurance programs cost you as much to use them as it would to just as Self Pay (cash, check, credit card).  This is often discovered when the patient has a very high deductible that could never be met using the lesser expenses seen with chiropractic services.  

PERSONALLY FILING WITH AN INSURER

To receive a Self Pay fee, you agreed that this would not be sent to an insurer.  If you are over 65, you signed an Medicare Option 2 form stating that we would not be filing with any insurer.  Some patients can be very stubborn where they want our lowest fee, below our published fees and below the insurer's network fees, and then be able to collect from the insurer.  This is much like having a discount coupon and trying to use it on a clearance item; we can admire your creativity, but please don't ask us to file for you, use our doctor status to establish "medical necessity", and submit records.  When we file claims for ourselves, we are releasing codes for the establishment of "medical necessity"; this is a very big deal in our relationship with the insurer.  It requires specialized legal forms. This is one of the reasons that we gave you an option for Self Pay.  

At one time, we had "non-participatory" status with Medicare where the patient paid us and we filed to have Medicare pay the patient back.  This was a nightmare, work intensive, and problematic just to collect for only one procedure.  These Medicare patients were not following the guidelines which only put the provider at risk.  Often these patients required and expected more services than Medicare reimbursed.  It was much easier to drop Medicare and avoid any conflict.  Our staff has been much happier.

We recorded your visit by date, time, amount, and receipt as any commercial business.  If asked by an insurer who paid us, a state regulator, or any legal representative cleared by HIPAA, we would release procedural and diagnostic codes, file records, and daily notes along with enough to establish "medical necessity".  It may be fully acceptable for us to adjust someone and not feel that it was "medical necessary" according to insurer's guidelines on having a plan of care.  A great percentage of patients come when they want, are not compliant, avoid follow up visits, and resent following a doctor's plan.  You can do this; however,  insurers view this as something they need not pay for.  We have been providing adjustments for many patients who want the freedom to have occasional or maintenance care at a Self Pay that can only be strictly an in-house exchange.

We gave you a paper receipt.  We have no control how you choose to use this.  Most all insurers will not pay directly to the member without a 1500 form and medical records; if you are going to demand our involvement for your attempt to recover funds that you feel you are entitled, you will either be required to pay our retail fees by procedure and meet the requirements for "medical necessity, or we cannot see you.  Whenever we are asked by an insurer to release records to pay you for services at only a Self Pay fee, we will do it once with required, and then release you.  Please just ask yourself what it is that you want and go to the provider that will conform to your needs.


ESSAY ON HEALTHCARE AND GOVERNMENT

Whenever you let government into your life, you lose some freedom; if they are to pay the bill, they will have total control over you.

 For example, if your child has Medicaid, food stamps,or WIC, the state believes that they are in control over that child and are responsible now for his/her welfare, and what can be done in their interests and beliefs toward his/her health and welfare.  This may even come to more forced vaccinations, etc.  They truly believe that they need to take over, because you have essentially told them that you cannot do it without the state's help.  If they elect to help you and you let them, they can take control.  Some people like this, but few understand its scope and the negative effect it has on our freedoms, especially our ability to choose treatment, vaccines, and sincerely held traditions and religious beliefs, etc,  You might find that the state and their bureaucrats do not have or respect your values and beliefs. When a senior uses Medicare, paid for by everyone, they are saying the same thing about what can or cannot be done for them or to them.  Getting into Medicare is made to seem as though it is a choice that you make to let government into your life.  The process, however, forces most into compliance.  Essentially, just by virtue of getting older or disabled, their freedoms and choices are gone as it relates to the nation's greatest expense, healthcare, and the longevity and quality of life it should deliver.  Not that we believe it should be that way, but consider, younger people do not spend money on healthcare.  The vast majority of costs are for servicing seniors.  Any government sponsored healthcare system for everyone is even more obtrusive and limiting to everyone.  This is essentially saying that the democratic system imposed upon all citizens has created a totalitarian system with its  full and complete government control over most people's welfare.  At least with Medicaid, one can use it when they need it, and hopefully, improve their circumstances, get out of it before any damage is done. With Medicare it is with them to the grave even if they thought they earned a pension and healthcare by their investment into a career package with retirement benefits.  Their bargaining unit, the private healthcare carrier, and employer all benefit by forcing older people into a government controlled exiting plan.

OFFICE TERMS


Minimum Contribution
: This means monies paid by the BCBS patient that are intended to be a payment toward or a contribution toward the required chiropractic deductible.  This must exceed the patient's estimated coinsurance or copay were it to be filed with BCBS but not filed until it equals, as best as possible, the procedures received to date.  This process is less likely in itself to reach a significant deductible. This contribution requested made by the provider for services whenever insurance has been unsure of paying out to satisfaction based on the past with these particular circumstances.  These can be called "reduced or discounted" funds, but it must be enough to reduce a deductible during their plan of care.  "Minimum Contribution" is the best descriptor and accurately distinguishes them from self pay.

Copay or Coinsurance
: This is an estimated amount paid by the patient when it is anticipated that no chiropractic deductible exists or that has been reached.  This estimate has been determined by a review of the Provider Access and past experience.  This is referred to us as an Active patient or an Activated patient.

Self Pay
:  This means the requested funds received by the patient for chiropractic services on that day.  This is when the patient has no insurance that we accept.  This includes patients over 65.  or anyone having Medicare.  Self Pay patients have limitations.  The amount requested is most often a standardized approximating the in-network BCBS fee for CMT services only which take as little as 5 minutes to perform.



THE LANGUAGE OF HEALTH CARE

In-Network: Providers can make application through lengthy paperwork for a special status with a carrier.   The benefits are considered better for the patient; the provider supposedly is listed with the carrier and this could attract more patients.  It is not unlike using credit cards that give benefits to the card user at the expense of the merchant.  Most in-network agreements require that the provider agree to arbitrarily reduced rates.  Usually with in-network, the insurance would pay 80-100% of the reduced rate after the deductible is met.  Providers in-network find that many rules change for them without warning.  A procedure that was once covered is no longer covered.  This would become another condition of this in-network contract.

In-network status with an insurer most always has lower deductibles and less contribution for the member.  In-network and out-of-network status are managed independently of each other.  Using an out-of-network provider does not contribute to an in-network deductible, and reverse.

Covered: This is a very misleading term.  "Covered" procedures are conditional, and BCBS will not tell unless you ask the right questions. It means that the procedural codes for the service could be reimbursed according to the health care plan, but only if it qualifies.  Most insurers will only tell you that it is covered which is encouraging, positive, and implies that it will be paid for. "Covered" does not mean that the deductible is met or that certain procedures are paid for. If they choose not to pay for it later, the parties then like to blame the physician.  

Out of Network: The provider may not have been given special status with a carrier to gain supposed greater access to patients.  Aetna, for example, refuses every request of any chiropractor to become in-network.  There are only two chiropractors who got this status locally in Mobile county; they got this some time ago. The obvious benefit for Aetna would be that fewer clients will use chiropractic services. The clients who do use chiropractic pay more out of pocket because Aetna pays less.  Providers are not obligated to lower fees for out of network patients.  Out of Network usually means high deductible, but most often means greater out of pocket for the patient in co-insurance or copay. Many carriers and plans have out of network benefits but nearly all of them make it less favorable for the patient to elect to see them.  With chiropractic,  Aetna purposely does not let you use the physician of your choice just by not opening up in network status to the marketplace.  Many carriers provide no electronic, E-claim filing for their providers requiring 3rd party biller costs to the provider which only fit a larger medical complex.  Also these carriers use out of the country services staffs or only prerecorded messages.  If required we must refuse service; otherwise, you must pay at least our minimum fee on the day of service.

For our small business, only BCBS provides personal local Alabama assistance of high quality and a prompt E-Claim system to file on all nationwide BCBS contracts, along with reasonable access to most BCBS contracts, allowing us reasonable predetermination of your immediate chiropractic coverage.  The Alabama BCBS website is unparalleled nationwide.

CMT CODES
: These procedural codes are exclusively used by a chiropractor.  Chiropractic Manipulation Treatment (CMT) is directly performed by the chiropractor in a very short time frame (5-10 min.) depending on the code. They are the "chiropractic adjustment" codes. They may represent 2 of 4 codes used during the visit.  These codes always are used and have the same diagnostic codes to define areas.  Chiropractors use far less codes restricting us to our limited scope of practice or specialty, so these seem very repetitive.


Deductible:  This is the yearly amount that must be spent by the client before their benefits are reimbursed.  Even Medicare has a deductible.  These amounts vary.  Usually corporate insurance offers packages with lower deductibles; individuals in 2013 are not given the option to purchase plans with lower deductibles.  In 2013, the lowest individual plan deductible with BCBS was $750.00, while the educational BCBS plan's deductible was as low as $0.   Insurers have no idea what the patient paid the doctor.  They only record the reduced value of the procedure and subtract that amount from the deductible  as they receive it from the provider in the claim.  First claims into their system (regardless of the visit date) go unpaid until the deductible is met; they assume that the provider collected the deductible balance from the patient.  The patient receives a remittance stating that the patient owes  the provider.  If a medical doctor was seen before they saw chiropractor, but the medical doctor bills through a slower service, the chiropractor will not be paid on the claim even though you might have paid out of pocket to the medical doctor for the deductible.  The slow billing often gets your cash and gets paid by the insurance company while the fast billing chiropractors get to pay for your deductible and has trouble trying to convince the patient that they were not paid, and the patient owes them money.   The remittance is the last word;  BCBS is rarely mistaken in the processing of their claims.  Ultimately, as the client of the insurer, you are in the end responsible for keeping track of who owes you and who you owe.  Part of the in-network agreement requires the provider to collect the deductible from the patient.  We have been given different responses to questions about the status of individual and family deductibles when we had knowledge that made them seem satisfied; apparently, different BCBS contracts have different logic.  Bottomline, if it does not state that the deductible has been met, then it is not going to pay out no matter what we think. 
You cannot escape the required stated deductible. 

Primary/Secondary Insurance: 
This term has a very specify meaning.  This is a full policy that a patient may have, but this same patient has another full policy in a primary position.  These policies may be with different carriers or the same carrier, as well as different PPO's within the same carrier but at different independent group processing locations.  These companies do not have any internal communication system that automatically moves from any one policy to another.  By being a full policy, it operates independently to its own terms and conditions.  It also has been determined that the provider must be informed that any claim must be filed initially with only the primary insurance.  The primary insurance must first respond to any claim; any claims sent to the secondary insurance require a receipt on how the primary responded to the claim.  We are being asked to file two separate claims with some lag time before a secondary insurer will legitimize the claim.  We have had the process take a full year before a secondary will pay after having first being denied by the primary.  Insurance companies do not coordinate with claims of different companies, and, ironically, they do not coordinate well internally within their own company.  We certainly are not set up to micromanage your claims. 

Another fallacy regarding having several insurers is that your secondary will pay for you coinsurance or copayment.  Any insurance policy pays for the procedures performed by the provider in accordance to its terms of the contract.  If the primary pays out in full for these procedures and sets out its conditions of either a copayment or coinsurance, then that's it, no more is paid and one visit is subtracted from your limit.  The provider is paid as agreed and no one expects them to file again for the same procedures on the same day with a secondary carrier.  Certainly there is no ability to file for anything other than a procedure with its diagnostic code. 

It is impossible to file for a copayment or coinsurance (it's not coded) from a secondary insurer.  They are independent policies with different deductibles, copayments, and limits; the secondary could respond to an unpaid procedure on the Primary  but only for an unpaid deductible, partially paid procedure, or denial for having met your limited number of visits, but this secondary must be self standing at the time of the claim to be able to grant the claim according to its terms and it will not do this until they receive proof that the primary denied the claim, in part or in whole. 

Only private Primary/Secondary carriers have full chiropractic coverage. We also only represent Blue Cross Blue Shield.  Supplemental insurance do not.

 It is possible that patient can have two primary carriers.  This can happen when people change jobs or having been placed on the spouse's insurance without secondary status being determined.  Spouses can have different polices and carriers.  One can have several full polices, while the spouse and children have only one.  Think about it,  you can have many life insurance policies also if you are willing to pay for them or you are given them as a condition of employment.  Please make it clear where you want your claim to be sent; if you do not want it sent, do not give us this information, otherwise we may sent it as the terms of our financial agreement.

Supplement Insurance:  This has nothing to do with a primary or secondary carrier.  This term is only used along with Medicare and it means that it will pay only a smaller percentage of what is paid for by Medicare.  If Medicare does not pay for it, then the supplement is useless.  It is useless for chiropractic services for two reasons.  First, it pays only 20% of one procedure equal to a few dollars.  Second,  we do not take any Medicare primary.  Medicare pays for no therapies, examination, x-rays, or extremity adjustments, so neither does any supplement.  These supplements policies are sold and pushed at seniors in December and include AARP, C Plus, Humana, and many others. Some BCBS supplement plans along with a primary BCBS plan may help with one CMT procedure in our BCBS E-claim, but we cannot anticipate this until it clears. We do not file for supplemental carriers and Medicare.

Advantage carriers:  Many years ago, these plans covered seniors for full chiropractic services.  We have, however, watched them decline to where they are no better for chiropractic services than Medicare along with a Supplement plan.  Humana, Blue, and United Health Care Advantage plans will pay for only one chiropractic procedure without having to file with Medicare.  It may help the patient, but the chiropractic provider has no advantage but a lot of paperwork.  Some chiropractors may accept these patients, but they can only offer very limited services and spend very limited time with their patients,  We refuse any Advantage policy requiring that we file a 1500 form and wait months for it to clear.

IN 2020, WE NO LONGER WILL FILE 1500 FORMS FOR OUT OF NETWORK ADVANTAGE PROVIDERS; THIS INCLUDES UNITED HEALTH CARE AND HUMANA. THIS WILL EFFECT RETIRED ALABAMA TEACHERS 65YO+.

Carrier/Insurer:  These are the terms used to refer to a company that insurers the patient.

Provider:This refers to the physician who makes the claim for services performed. All eligible providers are granted a National Provider Identification  (NPI) number along with a tax ID #.

Co-insurance/Co-payment: This amount is subtracted from the money received from insurer.  It is assumed that this is collected directly by the provider.  The remittance spells out this amount.  Co-insurance is the the percentage paid by the patient on each visit amount.  Co-payment is a set figure out of pocket per visit.  Co-payments vary from $20-$35 per visit.  Co-insurance varies from 0%-50% of the amount.  Most BCBS co-insurance amounts are at 20%.  Co-insurance can only be estimated since the claim must be filed and processed before the actual amount can be determined.  Many out of network contracts pay only 60/40 while in-network contracts are 80/20..  These co-insurance amounts are determined to the penny, and are recorded as such on the ledger only after the receipt of the remittance.  Co-insurance is unique to chiropractors, because it is thought that it will influence the patient's contribution.  Medical doctors would be very unpopular if they were required to collect a co-insurance, 20% of big medical bill rather than just $25.00.

Out of Pocket
:  By contract year, this category refers to the total qualifying amount spent by the family or individual. When this amount exceeds the contractually given amount, the patient no longer has out of pocket obligations of a co-payment and/or coinsurance.  We never know in advance when or if this occurs; it can only be determined by BCBS.  The patient may still have a balance from previous under-estimated coinsurances as determined by BCBS as shown on remittances.

Adjustment of Fee:  This is simply the amount that our fees are reduced per procedure to meet the in-network carrier's fee for that procedure.  This is recorded on the remittance and is subtracted from our fee on the ledger.  This varies per company, state, and plan so it cannot be known prior to the claim being reconciled.  Our bill has a disclaimer that makes this clear when we collect copayments and deductibles based on the best available online information.  Even though we are in-network with BCBS, some BCBS contractual plans do not reduce our fees. There is no way of identifying these plans ahead of time.  "Write Off" is often used on the remittance which means the same as "Adjustment."  It should only apply to in-network status, while no provider is responsible to reduce fees to "out of network" status, unless made conditional to "accepting assignment".

Medical Necessity:  This can be as little as a diagnostic code for a procedure as the reasoning behind the justification to pay for services received or to be received.  It could mean a report with rationale, measurements, findings, and observations to support those codes.  It is the documentation to support the services.  All claims must be able to be supported by this rationale to be considered for payment.  There is no standardization for this; it is left open and vague so it can more easily be denied by the carrier. 

Medical necessity always comes with an understanding that services can only be filed and paid out if the provider affirms medical necessity as well as providing medical records if required.  Services must stop to avoid any future unpaid claims, unless full payments are made by the patient, as the parties wait for the carrier's rulings on continuation.  Documentation to support medical necessity can be billed to the carrier and the patient who are ultimately financially responsible for any unpaid past services.  Carriers almost never grant a continuation of services, so you may want to avoid having a growing balance.

Denial Codes:  These are numbers used by insurers whenever they deny a claim or part of a claim.  These codes are very generalized and seldom accurately reflect the reason for the denial.  These codes are specific only to that carrier and/or the third party company that they use to find some reason to save money and justify their existence.  They always require a phone call for more information and no one seems to be able to explain the use of the code and the reason for the denial.  They are not consistent when these are applied.  Even the codes used by BCBS are poor descriptors and require a phone call for explanation.  Seldom are they so clear as to say, "Deductible not met, Patient did not respond to mailed request, No primary care doctor selected. Limit has been reached.."  These are usual reasons are denials.

Procedural Codes:  These are numbers assigned to activities performed by the doctor or therapist.  Chiropractors use physical medical codes; many of these codes are the same that can be used by physical therapists and medical doctors.  The descriptors for these activities are very general and are easily subject to interpretation as what could be included and what could be denied.  No codes refer to the use of any specific piece of equipment.  It is essentially the doctor's intention that determines the selection of a code to be used for the activity.  Carriers like this because at any time they can determine that something does not qualify.  The standard joke is that insurance continually self-publishes information stating that there is not enough research yet to justify the use of ________________.  The joke is that there will never be enough research, and only they can be the bottom line on what is considered as a viable treatment.  Many delivery systems identified are now antiquated, ineffective, and outdated while many effective newer systems may have to wait another 20 years for identification such as "cold laser" treatments.

Diagnostic Codes:  These are the findings of the doctor to justify treatment.  These are also very generalized.  They almost always refer to regions of the body.  They essentially attest to observations of pain and dysfunction, and/or on findings on images.  Chiropractors generally refuse to use disease and pathology codes, and restrict themselves to muscle/skeletal and joint observations to avoid thought of "diagnosing and treating disease."

State Insurance Commission:  All states have a regulatory and governing body that protects the consumer in any given claim regarding insurance either auto or general health.  They exist only to protect the consumer, not the provider.  Without such a body, an insurer could well refuse to satisfy any claim for any reason within their own rules and protocols.  Some body must exist that would be considered fair and unbiased. In Alabama, however, BCBS was able to be classified differently, so they are not subject to the Alabama State Insurance Commission.  Filing a complaint is the only unbiased way a patient can go to resolve a claim without ligation. 

1500 Form:  This single page form has been the accepted means of filing a paper claim with most insurance companies, including Medicare.  Codes, date of service, and date of incident are recorded along with pertinent identification numbers of the doctor and patient information.   We call its use the "slow walk."  A claim does not require that this is used, but many carriers act like it is necessary.  Auto carriers sometimes like to require it, because they use a third party software program that automatically makes deductions and denials based on the format.  Auto claims are regularly processed without 1500 forms however.  All health carriers except BCBS require a 1500 taking over a month or more to process.

Preventative Care
:  The medical trade uses this term to mean testing to see if you qualify for treatment.  They believe that if they discover something and treat it that they prevented something.  Most of us believe preventative care means that the health care giver gives you activities, education, and recommendations that will prevent you from getting a disease.  It implies savings and the prevention of more costly and toxic treatments by providing wellness.  If a policy says they paid for preventative care, they do not mean nutrition, chiropractic, or any alternative natural health protocol.  It means costly testing that they want to deliver to more and more people as early as possible.  It would also include the continued assault on our immune systems by a battery of immunizations for everything imaginable from the flu, shingles, common cold, etc.  Preventive care only sounds logical; it really is just an excuse to market new products and create more intrusive money streams.  Preventative Care on health insurance means testing.

Wellness Care:  This overused term has many meanings with numerous implications.  When a chiropractor says that they provide wellness care, understand they are trying to talk you into a care prepaid package where insurance is not used.   Do not fault them for this, as chiropractors are severely restricted from the marketplace.  Also understand that chiropractic care along with nutritional care is important in the long run to being healthy and well.  But really, they use it to make it seem that they are unique as chiropractors because they provide "wellness care."  They really do not want to use your insurance and want you to commit to their plan to make you healthier. 

Just because a chiropractor or medical doctor is a doctor does not mean that they know anything about nutrition, natural health, or wellness. Wellness is also used by a managing group that manages and advises chiropractors on increasing income by teaching them closing protocols.  Some of these marketing companies also provide the products that they want the physician to retail.  

Wellness medical visitation is encouraged by the health plan by not requiring the deductible; this is so the medical doctor can perform very costly tests that will however require this deductible and start a more expensive process.  You need to decide on the outcome you desire, but don't think its free care or anything to do with "wellness".

Maintenance Care: This is also considered occasional care.  It is like saying you need to service your equipment, car, etc. A warranty might cover a procedure to repair a faulty part, but traditionally it does not cover oil changes, wiper fluid, air in your tires, or service related "maintenance" issues.  More and more health insurance is viewing doctor "maintenance care" as something that does not qualify for coverage.  Accepted proof of medical necessity and adherence to a prescribed plan of care is the only way to better insure that covered  procedures will pay out.  Chiropractic is governed under the same way of thinking.  At any time they can challenge a claim by demanding proof of the viability of the claim.  If a claim is filed and they believe that it is only "maintenance care", the provider risks paying back the insurer, fines, or quite possibly claims of "insurance fraud."  If the insurer makes the provider pay back a claim and determines it to be maintenance care, the provider can require the patient to pay for the services. 

Remember that at any time, providers have the patient sign an agreement before accepting the patient that if the insurance does not pay for the procedure that they are obligated to do so.  There is no situation that exists, nor can there be, that if insurance does not pay that it is to be written off.   It is like saying if you see me, I will not obligate you to pay if the insurance does not.  It is considered unethical.  No physician can guarantee how any insurance will response.  You always run this risk by using you insurance

Your best bet to avoid this is show that you have been compliant in your plan of care; simply put, you showed up enough to get better.and that we updated your "date of incident."

INSURANCE VALUES YOUR CARE BY YOUR TIMELY PARTICIPATION EQUAL TO ITS JUSTIFICATION.  THEY, HOWEVER, ARE THE FINAL JUDGE.

Accept Assignment
:  This is the term used to refer to the provider making a claim with the insurer and having the payment go to this provider.  Assignment of Benefits is a statement  signed by the patient where the patient essentially borrows money from the provider for their services to be paid out of a claim to be filed.  If the claim is not paid out to any extent, the patient owes the balance.  The provider identifies to the insurer that the money is to be paid to them on either 1500 form or electronic filing/E claims.  Most states protect the assignment of benefits so the funds go to the provider, since the bill is unpaid; however, it requires the provider to go to court to recover funds if the carrier or attorney violates this agreement.  All hospitals, medical and chiropractic offices have the person sign a statement to this effect before taking the case.  The contract for coverage is between the carrier and you.  The provider must have some guarantee that they are to be paid directly by the insurer.  By our agreeing to "accept assignment" we are filing the full retail fees for all procedures performed on the day of service and that to our best knowledge we have been led to believe that the deductible for chiropractic services has been met and the visit is within the contract limitations.

Active Care: This term is overused and can mean different things in insurance. "Active" means that one's plan is in effect, but deductibles may not have been met.  This is used directly in BCBS website language as only that the plan is in effect as of the date of inquiry.  "Active Care" also means that the patient is still in their "plan of care"; AT means "Active Treatment" regarding Medicare only requiring  justification for reimbursement, recent " date of incident" as if to say the treating doctor only endorses it's justification by using this modifier.  Any carrier can challenge this active status for any reason which requires satisfactorily "medical necessity" or the carrier can require back payment.

In this office, we refer internally to an "Active Patient" as a patient whose chiropractic deductible has been met or is not required, and, therefore we can now file a claim.  Informally, an active patient can be someone seen in the last 6 months which reasonably justifies their status as "active" in a "plan of care."  It depends on the context.

Inactive means that the BCBS contract per identification number has expired, closed giving an ending date.  The patient stopped premiums or changed carriers.

Remittance:  This is the receipt from the insurer that resolves the claim.  Once resolved by the insurer, no other activity will be performed on this claim unless initiated by the client.  Both the provider and the patient receive the remittance in the mail as soon as the claim is processed. It identifies how the monies are dispersed per procedural code.  The amount of the claim, the adjusted or reduction in fees, and Patient Responsibility, monies owed by the patient to the provider (denied procedures, monies paid toward the deductible, copay and/or coinsurance %). 

This is not a bill from the provider, but it does reflect the balance that is maintained in our office regarding this claim.  Denials of claims are coded on the remittance, but they are seldom specific in nature and most often  require your contact with the insurer to understand why they did not pay out.  Denials are most often for an unresolved deductible, for going over the limitations of coverage, and your failure to respond to requests from BCBS.   Read your remittances and if you do not understand the terms or disbursements, we could help.  If we made an error, we can correct this.  It is your insurance company, and the insurance company is only responsible to you by contract and they are only responding to the information we gave them;  if you are displeased about the settlement, you are the only one who can change this settlement; we are the only one who can correct errors in this information so they can respond accordingly. 

You are asked to sign an agreement with our office that you are responsible for reviewing your remittances and taking care of the balance owed this office whether you receive a bill or not from our office.  Any monies owed to the Provider is negotiable, except BCBS demands you pay us for monies toward the deductible and the coinsurance/co-payment.


SUMMARY OR OVERVIEW

We do not know for sure how insurance will change for patients, but it has always been changing.  It appears that these are the trends and the most reasonable expectation.  Government programs have traditionally excluded chiropractic (Veterans, retired military, secret service, FBI, Medicare, Medicaid), so it seems unreasonable to expect this to change. If we are ever forced into a "medicare for all" or a government controlled "single payer" system, chiropractic services are at risk or will no longer be available.

 Chiropractic may become more involved in prescriptions and other medical activities which could change some things.  In New Mexico, chiropractors can take coursework to prescribe medications related to their scope of practice. Of course, as with other things, just because you are qualified to do something does not mean that insurance will reimburse a chiropractor for the same thing as they would reimburse a medical doctor.  They may have equal status, They may be able to do it, but insurance may not pay for it.  Osteopaths used to be independent physicians but now are no different than medical doctors.  In the near future, however, expect that chiropractic services will be more and more excluded from insurance.  More and more chiropractic services will only be for the people with their own resources and with government protected private health plans because of exemptions and special privileges for certain bargaining units.  We expect more chiropractors looking to integrate more and more with therapists and medical doctors; some will go the other way lowering their overhead and becoming cash based working with nutrition.  Some chiropractors have taken coursework into being Nurse Practitioners or Physical Therapists as to participate in the medical community. 

Insurance and the government are not involved in healthcare because they care. Private insurance want only a bottom line profit by increasing fees and lowering services.  The government is only involved in healthcare so it can control the masses and serve the demands of special interest corporations, political control and globalists, because they do not believe that Americans make good decisions, and the government requires another taxable money source.  Insurance is primarily a "talking point" for politicians. The state can employ people to watch over people to make sure that any choice meets their humanistic vision of man's role on the planet, requiring and enforcing insurance.  These people are called bureaucrats, NIH, FDA, FBI, IRS agents, etc..  There is no end to those who will be willing to enforce tomorrow's "health care" and the specialized interests of a NGO.

In the long run, learn how to take care of yourself naturally and inexpensively.  Most problems can be controlled short of real emergency care.

We expect that through the year 2020 patients will still have coverage and should not expect to see much changing especially regarding Blue Cross.  Like most small business, it is impossible to know how to plan and know where tomorrow's funds will come from for chiropractors to continue to help patients.  In 2014, the individual insurance plans have been somewhat destroyed with little to expect from the Obama options.  Later in the year the Group plans will pay the price for what was not made from the Individual Plans and the low enrollments with the added drain from the increase in Medicaid enrollments.  Every year benefits gradually diminish as you adjust accordingly; eventually, you will be forced to pay very high premiums for essentially no coverage whatsoever, unless it is catastrophic damages, and even that will be a huge hassle with you probably owing as much as it would be if you negotiated your own cash settlement or paid out your savings that you were allowed to accrue with a possibility to increase in value..

Right now many hospitals un-advertise that they might accept less for their fees if you pay cash for your bill.  Before they used to act as though you had no choice but to pay full retail without the benefit of having a reduced in network fee.  It was always open to negotiations, but people did not know it.  They were hounded by collectors as the costs continued to increase with interest.  Right now, physicians and even some chiropractors are grouping together to offer yearly affordable plans, calling it a concierge's practice for the few who can prepay for being a member having patient privileges.  Providers are going to get more creative to be able to see patients.  No one doctor can see everyone, so some see to it that they solicit for those able and willing to have some privacy and choice. Doctors lower the costs by eliminating the insurance company.  It will be more difficult for many, since they are being forced into expensive health care programs that they cannot afford to use.  These resources could go elsewhere.  They would be better to direct what resources they have toward their choices and the doctors they want to see regularly.

You know where the future will be taking us just by observing where people are employing, building and investing.  Hospitals are still a significant employer making huge purchases in equipment and property.  Medical doctors are being sold all kinds of devices to install in you from stints, coils, metal joints, cheap plastic mesh, wires, and electric stimulating devices.  Downtown Detroit is ravaged, but the hospital networks are thriving right next to the abandoned intercity vacated multilevel housing.  During the biggest plight in the "rust belt" they were able to build a huge hospital facility alongside I-75 south just outside of the older city urban hospitals in Flint, MI.  Why? 

Drug stores are all over the country with two to three on each corner of most major intersections.  Sam's and Walmart sell drugs.  Nearly every grocery store sells drugs.  Near to one corner in Mobile within view,  I can see four places where I could fill a prescription.  The future is in the large medical community, the drug industry, legitimizing the elicit drug industry, public schools, and the state university educational systems, all of which are government subsidized.  Your privacy, financial condition, health and welfare, however, generally you are not going to see benefits.  Premium care, gold standard, may be allowed to exist  privately for those with enough resources and the right political connections.  The general public with middle class  resources is just fodder for these huge megalithic enterprises.