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.  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. 
FOLLOW THIS WITH EACH VISIT

For any insurance process (auto, major health, Medicare, etc) 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 social security card to insure that they can bill for services that go unpaid.  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 10-15 minutes with you in her treatment room, she may well be performing more than one procedural code. 
The goal of insurance is to lower the subscribers use of the benefits available.  This is being accomplished presently.  It is sold with a typical marketing plan that promotes "features and benefits", but in reality, once sold, it will be increasing difficult to see the benefits.  High deductibles is the most effective way to guarantee its disuse.  Secondarily, making it impossible for the provider to stay in network with the carrier either by virtue of paperwork, claim denials, and after-market  conditions and limitations.  Next, as an added obstacle, copayments will go up.  By increasing the cost to use the policy, the subscriber stops going to the doctor and develops different habits and expectations over time.  The more that competition is reduced in the marketplace, the more likely the controlling agents can maintain the common expected result of a monopoly, prices go up and quality goes down.  Over time no one will remember the way it used to be. 

Since the third largest killer in the United States is a result of seeing medical doctors and following their protocols,  the result will be that a greater number of people will live longer.  Obviously, many will not get the care they used to get with treatments that helped them or was perceived as helping.  Overall, however, people will be healthier not going to medical doctors, of course, unless these medical doctors change what they are doing and earn their incomes from results not by monopolizing the marketplace and peddling poisons and unnecessary surgery.  If overall less people go to the medical doctor, less will die of doctor related treatments than will die of avoiding treatment for lack of resources.
Recently, Cigna insurance handled over 90% of their business to ASH, American Specialty Health.  This is a third party claims management company whose purpose is to save money on claims.  This is code for taking advantage of the provider and patient.  Cigna no longer makes decisions about claims; ASH is motivated to fulfill their contract and save money for Cigna.  One of their key personnel people told us that no matter what your contract says about coverage, ASH will automatically refuse any visit over 5.  Medicare does not even do this before 12 visits; BCBS seldom does this unless something seems excessive or suspicious.   In 2014, BCBS is doing this at 12 visits.   With Cigna (ASH) the provider would have to reestablish medical necessity after 5 and get approval from ASH's clinical physician before any more could be done.  You might have thought you had so much coverage; they failed to tell that it might not qualify.  Other limitations are also inherent in working with these third party managers; all of which we do not find out about until the claim is denied.   You will not find out the details until later but sign up now.  They stated this as though this was a good thing to work with ASH.  Cigna collects premiums and sells insurance, while ASH will cut and deny claims.  Welcome to the new order.  Sound familiar.
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.

Chiropractors are restricted in the number of codes that can be used.  The great body of codes are for medical purposes.  Chiropractic claims are most often repeated procedures using the same few codes.  If approved by one carrier, it would seem that the same coding would be approved by another carrier. 

Newer Medicare coding in 2013 and 2014  will be done only to keep record on the patient; more codes will be used but ironically, only one activity will be reimbursable.

Medicare has been paying incentive money out to physicians who comply with reporting additional information on Medicare patients using more expensive and intrusive software.  In 2014, the incentives will stop and penalties will be levied on physicians who still want to see Medicare patients but fail to provide additional coded information for each visit.  They tell us the information is necessary to improve services and research.  We believe that the information is to justify cutting costs and restricting services.  Some chiropractors have been told and believe that we will be allowed to participate with more equity in the services we can bill Medicare by showing our compliance and how effective we have been; we do not believe this.  Expect that all insurance will be finding ways to justify not having to provide perceived benefits.
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.
Just because they say it is covered 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.  It is a new world that neither of us have any control over.  It will not be the way it used to be.
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.
INSURANCE FRAUD ?

Recently Medicare has essentially "deputized" all Medicare patients encouraging them to watch out for fraud.  This sounds good on the surface, but people need to know what this really means.  Also Medicare knows that by doing this that physicians will back away from Medicare cases.  Few physicians willingly commit "fraud";  many can be found to make mistakes on paperwork, filing, etc., especially to Medicare's ever changing standards.   Now the physician is further worried that "unhappy" patients will see fraud where there is none.  This would turn into an audit and essentially an expensive shut down of their office.  The patient is given a financial incentive and the auditors are given incentives to find justifications.  Physicians are put into a scapegoat position just by being willing to see Medicare patients.   Since chiropractors receive so little from any case, it seems unclear why any see Medicare patients for the risks and extra expenses inherent in the system.

All physicians are essentially trying to avoid working with angry, bitter, and unforgiving people, because of the problems that can be created by them.  No matter how well you communicate or how well you try to avoid making mistakes, problems will still happen.  Most all problems occur with patient claims because of complaints from patients who are asked to pay their  bill or from jealous doctors.  

Significant real  insurance fraud occurs by those who are not even physicians or by those who have no facility, employees, or services.  No one wants to fault Medicare itself because they paid out millions of dollars to a completely phony business for services never performed by physicians of record-- all because of stolen information.  If they just identified the large repeated claims, and checked out their location and/or called the doctor who supposedly performed these activities, they would know way ahead of time and saved millions.  Maybe they might even catch the people.  The real crooks are gone by the time Medicare discovers them.  The money is gone also.  Instead, Medicare sets up a system to intimidate real doctor by fining them out  of existence for what anyone would consider to be minor management issues.  This is because they are legitimate and can be found; its easy to turn these real doctors into a revenue source with Medicare enforcers culling the herd to get everyone's attention.  Medicare and the government know this and, of course, want it to be just the way it is.  In the long run, it saves them more money with easier management.  Create a big problem by paying out millions upon millions to real crooks, and act like you are solving it by making real physicians seem to be the cause of concern.  And if asked by the patient/client, Medicare is quick to tell them that it's covered.  More money is saved and made by fining those easy targets and by having providers backing out of the system or filing fewer claims.  Unfortunately they make it easier to be a crook and difficult to be a legitimate provider.  If something is hot, you quickly learn not to touch it.
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.
Do not expect to see a Single Payor health care system cover chiropractic services.  It does not matter to them that it saves money and that it helps people.  Any Single Payor 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 payor system similar to the European model will be no better chiropractic coverage than Medicare and/or will have nothing whatsoever.
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 dedudtible 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. 
When one goes to the ER, there are two lines--one for the "haves" and one for the "have nots".  The "haves" have Blue Cross with an established group with a low deductible.  The hospital knows it is going to get paid with the least amount of management and harassment.  They move the "haves" through the system.  We hope that we do not do this, but the "haves" really pay for our clinic and its services also.  For the medical community, the "haves" are not the people with money, but they are the people with insurance coverage that will be used and will pay out.
The government's interest in controlling all financial resources is looking at Medicare as a revenue source.  This is why they want more and more information on this population.  I predict that seniors with resources such as pensions, assets, equity, savings, etc. will have to sacrifice these resources for mandated coverage.  Of course, it will only be managed sickness care up to only a point.   The new Medicare program will be fighting it out with the assisted management care facilities for the last few resources before you go to hospice and check out.   The poor will be left alone, primarily because they have nothing to take, while the more affluence, not the wealthy or the politically connected, will continue to pay for it.
OBAMA CARE UPDATE:  Most individual plans have been eliminated.  These are to be replaced with new plans that meet Federal guidelines.  These plans will be far more expensive. BCBS allows some transitional time to a new plan, and one must call BCBS or the federal phone line to see what is available.  Regarding chiropractic, no individual plan through 2013, provided adequate chiropractic coverage.  All individual plans had only from $400-$600 per year.

All individual plans for BCBS are ranked from Platinum--Gold--Silver--Bronze.  Only two of these plans provide for a reasonable deductible where one could expect to receive some benefit from their investment. The Gold Plans are similarly priced and have three different deductibles (500-600-1500).  The Silver and Bronze plans may have nice coverage, but it does mean much when the deductible go from $1500 to $6500 a year.  They are expensive catastrophic plans.  All of these plans from Platinum to Bronze have the same chiropractic benefits.  They have 15  visits a year.  From past experience, we consider this to be good coverage.    It essentially means that only Platinum and Gold plans will have some ability to benefit from this better coverage.

For example:  My 27 year old son had a plan with BCBS for $138/mo.  This was cancelled for 2014.  He can get coverage in the Gold plan from $212-$260/mo.
He will receive a deductible of $500.00 where with the 2013 plan he had a $750 deductible.  He had $600 in chiro/coverage in 2013 and in 2014 for the extra $1200/yr he would have 15 visits ($1500 value) rather than the $600.  He makes less than $10,000 for the year and failed to qualify for any reduction in fees.  He may well qualify for Medicaid where he would receive no chiropractic benefits.  He received medical benefits from the 2013 plan for a condition that was troubling him.  He would not  have received any better coverage for the same condition under the new, more expensive 2014 plan.

Most of the celebrated activity on individual plans put more people on the state Medicaid program, because of the high  costs and the large amount of unemployed and underemployed people.  If you are without resources and healthy, you will more likely opt out of Obamacare and receive less money back from income taxes equal to the new fines for being unable to document having health coverage.

No one knows what will happen with Group plans in 2014.  It appears that the benefits continue to go down and premiums will go up, but no one will tell you what to expect with Obamacare. 
Group plans are the mainstay of our business, and can well determine what the future will be for chiropractic care delivered through insurance coverage for the majority of chiropractors.  If it appears that people are unhappy with the changes to individual plans, there will be far more upheaval when these group plans are dropped and/or the costs changed whereby these good plans also change into merely catastrophic plans.

If the group plan is dropped, it forces the client to go to the marketplace and purchase from a market that has been  tainted by Obamacare with the prices and deductibles much higher.
ANNOUNCEMENTt:  BCBS of Alabama for educators has changed their chiropractic coverage for 2014.  It reflects some of the new trends that threaten the integrity and equity of the program.  They had 18 visits a year, but now have only 12 visits a year.  Not only has Medicare of Alabama automatically stopping payment at 12 visits, but 12 seems to be the magic number..  Federal BCBS has only 12 visits for the year.  This is purely arbitrary.  They no longer have their small deductible for the  year.  The deductible for chiropractic is for the  time being is even better now at zero.  To extend the 12 visits one must get pre-approval that must be approved by a MEDICAL DOCTOR.   They are now forcing us to refer to a medical doctor as though we are part of THEIR SYSTEM.

We have seen some plans that require Medical approval to use the chiropractic coverage.  They dole out the adjustments a few at a time making the patient return to the medical doctor.  If patients do not protest and demand equity and choice in their health care, chirpractic coverage will be in name only. Why would anyone demand medical approval when medical doctors know absolutely nothing about chiropractic.  Our patients know more about chiropractic care than most all medical doctors.  They see us as competition, and most resent that we can help patients when they cannot.   They are eliminating ones choice to avoid drugs and surgery by controlling where the money goes.
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INSURANCE

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 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.  

Medicare only covers the chiropractic adjustment.  A chiropractor is restricted from any other benefits even if it fits into their scope of practice, such as therapies, examination, diagnosis, and imaging.  It is purely political to restrict them from a fair access to the marketplace.  One day they have 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 to be not medically necessary, or fraud.  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 Federal overseers; 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 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 cash 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.

CASH FEE AND INSURANCE CLAIM


Please understand that you cannot be given a cash fee for services and then be expected to file with your insurance.  You cannot have it both ways.  All insurance companies are given the same retail published fee by procedure.  They do not expect to see different fees from one insurance company to another.  You will get a reduced fee only if we are in-network with this company.  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 cash patient.  You cannot make a claim if we have considered the transaction a reduced cash fee or where this transaction was considered maintenance care and then have this filed with insurance.

 All of our office cash patients pay a reduced fee by the visit that may include many procedures; there is no way to itemize this fee by procedure.  It cannot be done after the fact.  Consider any cash 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 condition of this reduction.  In many cases, some insurance programs cost you as much to use them as it would to just pay with cash (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.  Even Medicare patients could elect cash services with reductions in x-rays and therapies by signing off on Option 2, electing services but not wanting the transaction sent to Medicare.  Medicare patients are only entitled to a lesser fee for the one adjustment procedure only, and only when it meets medical necessity, or qualifies for reimbursement.  All of the other fees are retail fees if the Medicare patient elects to use this insurance--the same as for all insurance patients.

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 poor, 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.

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.

Covered: This is a very misleading term.  It means that the procedural code 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.  If they choose not to pay for it later, they 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 copayments. 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.

Deductible:  This is the yearly amount that must be spent by the client before their benefits become active.  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 $100.00.   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 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 biller 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.

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.

Co-insurance/Co-payment: This amount is subtracted from the money received from insurer.  It is assumed that this is collected 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 without any reduction in fees.  These co-insurance amounts are determined to the penny, and are recorded as such on the ledger only after the receipt of the remittance.

Adjustment:  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 applies only to in-network status, while no provider is responsible to reduce fees to "out of network" status.

Medical Necessity:  This can be as little as a new procedural or diagnostic code 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.  This has been more common with open ended benefits  Services must stop to avoid unpaid claims, and the parties wait for the carrier's rullings on this documentation.  Documentation to support medical necessity can be billed to the carrier and the patient.  It seldom covers costs and often it is paid by either the patient or the carrier.

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 descriptorrs and require a phone call for explanation.  Seldom are they so clear as to say, "Deductible not met."

Procedural Codes:  These are numbers assigned to activities performed by the doctor or therapist.  Chiropractors used 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 viable treatment.

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 findings on images. 

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 and patient information.  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.  In 2014, a new 1500 will be required by Medicare which increases the data required.

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 the preventative care means that the health care giver gives you treatment, 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 creative more intrusive money streams.

Wellness Care:  This overused term has many meaning with numerous misleadiing implications.  When a chiropractor says that they provide wellness care, understand they are trying to talk you into a care 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. 

Maintenance Care: This is 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 visits as "maintenance care"--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 the 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.  This is "enticement" and it is considered unethical and in violation of the doctor's contract with the carrier.  No physician can guarantee the patient how their insurance will respond to a claim; no carrier will tell you ahead of time whether a claim will be paid out.  You always run this risk just by using your insurance.

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 the 1500 form.  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. 

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 or email 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 monies owed by the patient to the provider (denied procedures, copayment 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 codes on the remittance, but they are seldom specific in natural and most often  require your contact with the insurer to understand why they did not pay out.  Denials are most often for not meeting the deductible and for going over the limitations of coverage.   All claims are processed prepared manually based on the paper bill, so it is possible that errors could be made.  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 isyour 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 the information so they can responds 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.

ICP 9 and 10 Codes
:  These are the coding systems for insurance work performed by all  providers.  They are usually seen as 5 digit numbers with or without 2 digit modifiers.  New Codes are forthcoming.  This was initiated by Medicare and big government, Obamacare, and, of course, influences all private insurance companies.  Medical codes dominate these classifications, but even chiropractic is being overwhelmed.   Prior to October of 2014,  the ICP9 codes are being used. IPC10 codes will follow.  Most all providers are going to be overwhelmed in this transition.  We can hope for delays, but the government states that they will not delay this transition.  It will be chaos!!!  The ICP10 codes are  many times more complicated and everyone's software has to be changed.  Occasionally you will see this in the news, but no patient understands what this means.   Estimates to the overall cost increase for these changes will be in the billions of dollars, along with problems and delays in any huge transition like this.  All codes will be longer and will tell the government and/or private insurer more information about you, your history, and the specifics of the diagnosis and  treatment.   It will be the biggest reason why providers will drop taking insurance, because the smaller establishments cannot handle the costs of adding "manpower".  They will also be seeing less patients.  Some physicians estimate that patients visits per day will go down as much as 50%.  Imagine what happens when you make less per visit, your visits per day go down, and you are not getting money for the work that  you decided to perform because the system is down all the time.


SUMMARY

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.  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 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 Practicianers, Physical therapists,  Medical doctors via off coast programs, and other caregivers who are more favored by the current system.

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. 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.  They are called bureaucrats and IRS agents.  There is no end to those who will be willing to enforce tomorrow's "health care."

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 2013 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 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.  2014 does not look good, so take advantage early on whatever benefits remain before they disappear or are dropped.  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.

Right now many hospitals advertise that they will accept 60% of 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 pre-pay 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.  Downtown Detroit is ravaged, but the hospital networks are thriving right next to the abandoned intercity vacated multilevel housing.  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, gold standard care, may be allowed to exist  privately for those with enough resources and the right political connections.  The general public without resources is just fodder for these huge megalithic enterprises.