Health Insurance

We accept most major medical health insurance plans and will also take individual cases for auto accidents and workers compensation claims. We will contact your insurance company and/or attorneys and attempt to make all necessary arrangements to assist with your medical claims. We will check your benefits, review the information we have received and will work with your individual needs for your insurance.

Just to name a few:

• Aetna
• BCBS
• Cigna
• Empire
• First Health
• GHI
• Greatwest
• Humana
• Medicare & Medicaid
• Multiplan
• United Healthcare

And many more…

We run into a lot of questions and confusion when it comes to what insurance covers in our office.  We hope this section can help clear up how insurance covers you.

You can think of your insurance as “medical care” insurance, and not “health insurance”. Medical insurance only covers “Medically Necessary” treatment. “Active care” that is prescribed under a treatment plan, for dysfunction, pain or deficit in ADL’s that you are experiencing.  We must have one of these components identified to create an objective treatment goals, to help guide us in creating a treatment plan just for you.  These treatment plans typically run 2, 4 to 8 weeks at a time, and you must continue to improve, with goals set forth before you can continue to the next phase of care.  It is typical for our patients to go through 1 to 2 phases of treatment plans, and only severe cases go a 3rd phase.

Medical Insurance, will NOT pay for your chronic issues that are constant or recurring.  This is because once you have reached a “plateau” of improvement and your pain is not expected to improve any further, they will not pay for your care anymore.  They will NOT pay for you to keep you at your improved state (at a 0 or mild level of pain), even if we know for a fact if you stop care, that your pain will come back.  This is called “supportive” or “preventative care”, that is NOT covered medical policies. Maintenance, Wellness, Preventative, Supportive or Stabilization care (all synonyms) are common in our office, but again are NOT covered by insurance policies.  Maintenance care is typically done 1 time per month, 2x per month, or sometimes every 6 weeks depending on your condition and level of participation.

These rules have been in place for many years and are still not understood well by patients.  If we as doctors do not follow these rules, insurance companies will demand or force a refund of the money we receive for non-medically necessary care.

Please read these FAQ’s to further your understanding some of these rules:

What is Active Care?

Active care is care that is rendered with a specific treatment plan in place. Care is typically more frequent in the beginning of care and less frequent as the patient becomes more stable and has less complaints and dysfunction. Periodic examinations are required and treatment goals need to be monitored, updated, and documented.

What is Maintenance/Stabilization/Wellness Care?

Maintenance care is care that follows active care once the patient’s health status has become stable. The goal is to maintain the improvement that was achieved with active treatment. Even though the patient may still have some degree of pain or discomfort, once their improvement has leveled off they must be released from active care . Maintenance care typically exceeds a 2-week gap between visits.

What is “Medical Necessity”?

Medical Necessity is a term the insurance industry uses to define what services are covered by insurance and what services are not covered by insurance. Health insurance companies provide coverage only for health-related services that they define or determine to be medically necessary.

“I just want to come in whenever I feel I need to and I don’t want to be on a treatment schedule.”

That is completely acceptable. However, you need to understand that chiropractic treatment provided on an “as-needed” basis is determined by the insurance industry to be “not-medically necessary” and is therefore NOT covered by insurance. Patients that are seen on an “as-needed” basis and are not on a specific treatment plan are required to pay for the services out-of-pocket since insurance will determine the care to be maintenance.

“But I’m still in pain. Why won’t insurance cover my care anymore?”

Insurance will only pay for services that it determines to be medically necessary. Once a treatment plan has been completed (or not followed by the patient) and long-term improvements are not expected, called “Maximum Therapeutic Benefit” or “MTB”, then the patient must be released from active care without regard of any remaining symptoms.

“But my insurance says that I have 30 visits per year covered.”

Insurance will only pay for services that it determines to be “Medically Necessary. Insurance will not pay for any visits that are not deemed medically necessary no matter how many visits they say you have.

“My insurance says that the doctor just needs to change the code and then they will pay.”

For a doctor to bill insurance using a code that is different than the service that was provided would be insurance fraud and our office would never participate in that practice.

“Can I go back on active care once I’ve been on maintenance care?”

Absolutely. There just needs to be documented legitimate new condition or injury, exacerbation or relapse of a past condition. A new examination must be performed ( which may or may not be covered by insurance) in order to determine a new active treatment plan. Active care could require therapies and rehab procedures in addition to the chiropractic adjustments.  If the treatment plan is not followed for any reason then the patient would need to be discharged again to a maintenance status.

“If my insurance won’t pay, then I can’t afford it.”

A large percentage of our patients have no insurance benefits for chiropractic care . A large portion of our patients are under Wellness/Maintenance care at this time.  Chiropractic care is very affordable for most people. We make care affordable so that anyone can get the care they need. An entire year of chiropractic care usually costs less than what most people spend on oil changes thru the year. Our visit for maintenance can be as low at $29.75 . It is much cheaper (and healthier) to invest a small amount in prevention instead of waiting for a health problem to get more serious which will be far more expensive.