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. It is still true, however, that at any time the carrier could demand more 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 have 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 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. We no longer complete requests for additional services beyond your contract limitations. If it is not viewed as an emergency, chiropractors try to help. If it's an real emergency, we ask that you see a medical doctor.
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. It is not so even with the other physical medicine providers such as a PT, OT, or ST. They're not even clinical doctors but have far greater participation in the MedIcare system.
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 patients choose to Self Pay, and sign the Medicare Option 2 form as confirmation that Medicare or any supplemental carrier is not to be filed. Chiropractors have little to no representation in government programs even though we are represented by most all private health plans.
PATIENT STATUS CHANGE REQUIRED
You are given a patient status when you are accepted as a patient. This is done by completing all intake papers and signing all pages. Your financial situation is determined by this status. This may involve a formal meeting with our Case Manager. We also must agree to a financial understanding regarding this status change. Whenever your status changes we will restart with the necessary intake forms. We may have to issue a new patient number and folder. Examples of status change are a new carrier, new insurance plan, seeking disability, auto claim, workman's comp, and any liability claim. Many of these changes may lead to being released. You may be a Self Pay non-insurance patient who files an auto claim; we most likely refuse to take this auto claim. You may be an active BCBS patient and you changed to Medicare.
FEES AND INSURANCE CLAIM
We provide Self Pay for the uninsured and an opportunity to make a Minimum Contribution for the BCBS insured, but they are only given on conditions. Please understand that you cannot be given a Self Pay 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 only insurers determine what is to be paid. They do not expect to see different fees from one insurance company to another anymore than different fees within ones office. On any Full Care visit we rarely provide only one procedure per visit, but a series of procedures as needed. If we file a claim, we are expected 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 for each procedure received after filing; however, we found that all out of network carrier often make the same demand before they release funds. Our CMT procedures are severely adjusted when filed. 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 necessarily required with a Self Pay patient. Self pay is not performed unless we feel that it is Medically Necessary; however, we must defer to the insurer. We file only if it complies with the insurer's guidelines; too many self pay patients fail to meet insurer's guidelines and reasonable compliance but pressure us to release a diagnostic code. 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 for what we call Basic Care, the visit that includes only one CMT procedure which imitates the limitation to chiropractic to what is given by Advantage programs or Medicare.. It is clerically easier to recognize that it equals the average CMT costs on our fee schedule. Consider any Self Pay fee to be given only upon an agreement that the patient will not want to use their insurance and agrees not to do so. Self Pay has no insurance to utilize; therefore there is no deductible, coinsurance or copay, nor any adjustment of fees. Self Pay status is subject to our mutual agreement to how you pay for services on the same day of your appointment.
Any required payment for BCBS services is viewed by us as a "Minimum Contribution" to be used to contribute to procedures that when filed pay down the deductible. A patient could pay more than the minimum to more rapidly influence the deductible, but without showing up to file procedures, we have no influence over a deductible. Most of time chiropractic services require that you meet a deductible, and often only with the addition of outside greater medical provider costs. We never know what a patient may elect to do: follow up with a plan of care or elect to see medical doctors for whatever may happen. Some insurance programs cost you as much to use them as it would to be a Self Pay patient with its restricted procedures paying cash, check, personal 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 CMT, especially after chiropractic adjustments.
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 "free care from the provider", special rates below our published fees and below the insurer's network fees, and then be able to collect personally 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 any 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. Too often these patients required and expected more services than Medicare reimbursed and refused diagnostic procedures. If you require Medicare, you must pay all your retail costs that Medicare or a supplement will not cover for "full chiropractic care" that is safe and necessary.
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 Self Pay that can be strictly an in-house exchange.
We gave you a paper receipt. This is not a claim. 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 all our published retail fees by procedure and meet the requirements for our "plan of care" as an "active patient" and meeting "medical necessity", or we cannot see you. Whenever we are asked by an out of network carrier, disability claim or auto insurer to release records to pay you for services or satisfy conditions to which we were not informed, or agreed upon at a Self Pay fee, we will do it once only if required, and then immediately release you. Please just ask yourself what it is that you want and go to the provider that will conform to your needs initially.
IF YOUR STATUS IS ACTIVE AND WE CAN FILE FULL CARE, WE CAN MORE EASILY WORK WITH ATTORNEYS, AUTO CLAIMS, DISABILITY, ETC.
SELF PAY CURRENT AMOUNT
This was determined by the minimal time performed by the doctor (5-10 minutes) in a 15 minute slot. It also approximates the amount we receive by BCBS for only CMT procedures less any bookkeeping discount we are entitled to give by paying on the day of service. We are more demanding about collecting more from you if you haven't been here in 6 Months to a year, because we must do more. You could be asked to restart as a New Patient. We hope that this encourages you to return for timely and regular follow up visits; if it is perceived as high and prohibitive, please don't (re)start the process. We do not want to take your funds. If it takes longer than the 15 minutes with the doctor, we can back up on others, and we have to make some decisions about being able to service your perceived needs.
MANY PATIENTS REQUIRE MORE TIME AND SPECIALIZED PROCEDURES THAN THEY WISH TO PAY FOR. WE CANNOT DO THIS BY CONTRACT; THE BEST INTENTIONS HAVE SEEN KIND AND GENEROUS PROFESSIONALS FINED BEYOND YOUR WILDEST NIGHTMARES. DOCTORS HAVE NO CONTROL OVER THEIR BUSINESSES, ESPECIALLY WHEN TRYING TO HELP YOU WITH YOUR INSURERS.
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 a full care visit, as best as possible. 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. This contribution 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 by us as an Active patient or an Activated patient. Only "activated" patients pay either a copay or coinsurance, or both; this can be formally known only from the remittance and resolved in a Claim Status check on Provider Access..
Self Pay: This means the requested funds received by the patient for CMT services on that day. This is when the patient has no insurance (listed) 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 fee equal to our published fee for CMT services (1-2) 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. We will always tell you regarding BSBC and chiropractic, but this horribly misleading when it comes to medical services in Advantage and Medical services.
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 CMT codes 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. In our state, we can use some physical medicine codes CPT shared with PT and medical doctors to include examinations, testing, x-rays, and therapies. Of course, when added to the treatment, the time increases along with the costs. Since the main reason to see a chiropractor is to receive CMT, self pay patients choose this whenever they can receive no other benefit.
CPT CODES: These are therapies that can be performed by chiropractors during a visitation. These are the same as with a PT; however, we are restricted. CPT codes are usually performed with CMT codes. Unlike CMT codes, they are timed treatments that can be assisted or not. They may not be given by the doctor. The doctor must be present, however. As chiropractors, we view these treatments as essential to "full care chiropractic" coverage. We view restricted CMT only coverage as restricted "basic care chiropractic". We use the word "treatment" because it in the CPT, "Chiropractic Physical Treatment,"and is billable. Non-billable or general health activities are called "sessions" and require Self Pay. Since CPT is combined with CMT and examinations, we restrict the timed units so it can reasonably be included in the limited visits provided within the schedule.
These are primarily to compliment the CMT by providing much more passive treatment, exercises, and range of motion. We feel we are never given enough visits to perform rehabilitation. We have essentially seeded this area of "physical medicine" to the PT or OT who gain most all patients from orthopedic doctors pre or post surgery or from internal medicine following a significant medical event.
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 your 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.
UNLESS BUILT INTO THE BCBS CLAIM PROCESS, IF IT IS TO HAPPEN TO YOUR SATISFACTION WITH A SECONDARY INSURANCE OR HSA ACCOUNTS, IT HAPPENS ONLY BY FILING REGULARLY; WE HAVE NO INFLUENCE CHANGING THIS. CALL YOUR BCBS INSURER. ONLY THEY CAN MAKE THINGS HAPPEN AS EXPECTED.
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. Very few primary policies for non Medicare patients operate as supplementary to offset deductibles and coinsurances, but these are built in automatically to the filing process. We must file with the Primary to find out, so we will require a minimum contribution as we proceed until it clears, if at all. Otherwise, stated deductibles, coinsurance, and/or copays will apply.
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. We do not file for supplemental carriers and Medicare. SUPPLEMENTS ARE FOR SENIORS WHO USE BIG TICKET MEDICAL SERVICES AND DO NOT HAVE RETIREMENT/PENSIONIZED MAJOR CARRIERS any longer. Today most all full Secondary plans changed to supplementary plans as either being Medicare primary or ADVANTAGE plans exclusively.
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. They have increased in use for seniors, often being forced on them by their group. They are exclusively private insurers with their own deductibles, etc; often they have lesser services than Medicare and Medicare/Medigap. 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 these patients, We refuse any Advantage policy requiring that we file a 1500 form and wait months for it to clear, or put it another way, we take only Blue Advantage where file E-Claim with BCBS.
On a New Patient we take $100 to start their plan. They pay for an examination and basic CMT care. Afterwards on follow ups, they pay only $15 copay for the same basic care. No one pays less for a visitation and few give on visits yearly, but these are basic chiropractic care only.
All Blue Advantage (MBG) plans state "NOTE: Diagnostic tests, including x-rays, are non-covered when furnished by a chiropractor. Coverage of chiropractic services is specifically limited to treatment by means of manual manipulation." This means in application that BCBS does not pay for an examination, x-rays, therapies (called a CPT, not "manipulation), and even an extremity manipulation (98943), so all they pay for is one CMT procedure at $25-$35 after adjustments.
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 65 YO+ WHO OVER THE YEARS HAVE NEGOTIATED AWAY THEIR RETIRED POPULATION OF TEACHERS OVER 65.
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 business tax ID #. Dr. Crafton has these and uses them in filing claims. You must be a doctor with a NPI # to file a claim.
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 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/coinsurance 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 and staying within limits.
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. We are no longer even training our staff to print off on these forms.
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 financially 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." on your "Subjective" portion of your daily visitation sheet. If you don't improve for the same incident, we must release you. Chronic patients may go through multiple incidents aggravating their "chronic" status. Tell us why you are in pain today; don't tell us that you are always in pain no matter what.
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. TYPOS, number and letters errors, will not even be accepted into the eclaim, electronic system. If the eclaim accepted them, they were done correctly.
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 can only refile again. This will not change the obstacle.
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 eventually negotiable; BCBS demands you pay us for procedures used toward the deductible and the coinsurance/co-payment. If not paid up front, even if owed, we have found it nearly impossible to collect after the visit; patients view the transaction as complete for the exchange but with insurers many important considerations may not be known on the visitation day, ie. exact coinsurance amount, the amount the insurer deems applicable to ones deductible, the exact adjustments, procedural denials, and even agreements required between your insurer and you. The whole claim may be rejected because the patient was required to identify a primary medical doctor and did not. You may not have responded to a request, and you did not, so again the claim was rejected. As a responsible patient, your carrier expects to review the remittance. All doctors can only estimate; most medical doctors collect nothing from the insured, but you know a bil(s) will eventually arrive.
SUMMARY OR OVERVIEW: AN OPINION
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, 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, nano particles, pacemakers, 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. Ironically, nearly every grocery store sells drugs. Near to one corner in Mobile within view, I can see four places where one could fill a prescription. The future is in the large medical community, the drug industry, vaccines, experimental gene-therapy "vaccines", nanotechnology, 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, if existent, 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 and the politicians who work for them.