Insurance and Chiropractic

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If you are taking care of an individual for vertebral subluxation, it is lifetime care. But an insurance company expects that at some point they are going to stop paying for care. Therefore, their idea of vertebral subluxation is not the same as ours.Β  They see it (or its effects)Β as a condition that will one day respond to care and be alleviated.

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This article has 24 comments

  1. Richie Barone 07/03/2013, 5:43 pm:

    Insurance does not cover OSC and if u bill for it I can see Insurance fraud…..

  2. Tom 07/03/2013, 5:53 pm:

    You’re right Richie! It doesn’t cover OSC but it does cover OC!!! πŸ˜‰

    http://www.examdoc.com/articles/ACCRACPOSTERv3.pdf

  3. Bob 07/03/2013, 8:55 pm:

    Tom, you mean…it covers the practice of medicine, right?

  4. Michael Duncan 07/04/2013, 1:46 am:

    If you billing/submitting to insurance, regardless of reason said or listed on the form, in such a fashion that allows for actual reimbursement, then, yes, one is practicing medicine.

  5. Don 07/05/2013, 10:11 am:

    I haven’t thought of that but you’re right Dr. Strauss!
    Although, I am not sure about something, if the chiropractor bills/submits i can understand that but if THE PERSON RECEIVING THE SERVICE submits and there is reimbursement for the service, does that matter?

    Do all pm’s receive reimbursement for their services and does this mean the service in the chiropractors office was the practice of medicine because they were reimbursed?

    • Michael Duncan 07/05/2013, 6:11 pm:

      Don,

      There is a difference between submitting a bill/claim and doing what is required and necessary to actually result in getting it processed properly and funds paid for it. Things can be submitted anyway one wants, but if the don’t follow the “rules”, they’ll be rejected. So in order to actually get reimbursed, regardless of whether the office (medical, chiropractic, dental, etc.) or patient submits the bill/claim, a diagnosis code (ICD 9/10) AND a procedure code (CPT) must be used. That is the simplest answer.

      However, a few other things come into play. First, there are a small handful of ICD codes that are designed to be for “subluxation” that chiropractors (and any other mechanotherapists that might choose to use them) to use to “diagnose” subluxation for reimbursement purposes. Unfortunately, they dont adequately define VS as we do, so it is lacking, on definition alone.

      Second, we are non-therapeutic/non-diagnostic by nature of our objective, and ANY diagnosis (even VS), is reached by virtue of “differential diagnosis”, which we don’t do. Third, there is something called “medical necessity”, that must be attested to when submitting a claim for reimbursement. This means that the provide must verify and provide evidence (if asked) as to the procedure and its use for said “diagnosis”. Well, a couple of problems with that. It is impossible to rule out medical conditions and solely rule IN subluxation without all of the tools and scope of practice consistent with medical diagnosis. Next is the fact that a chiropractic adjustment for a VS is NEVER “medically necessary”. Chiropractically necessary or not, yes…but never medically necessary.

      Third, the small handful of CPT codes describing the adjustment procedure would actually be fine, except the fact that they only describe a procedure, which cannot be performed without a justifiable “reason” (diagnosis), therefore rendering it incomplete.

      Many chiros will justify insurance saying they only put “subluxation” codes down, but that is weak justification based on the above. But it happens extremely frequently, even in “straight” offices and, even though viewed in light of our objective and our philosophy, it is incongruent and practicing the medical objective because it is the ONLY way to get it paid. That is undeniable. And to do so is ignoring the truth.

      Now, insurance is NOT the bad guy. They can pay for what they want, when they want…its their coverage and anyone that wants money from the must agree and follow the rule of their game. If the things I listed above were not part of the picture, then it would be a moot point. Personally, I contend that it would make extremely good health and economic sense to include regular, lifetime REAL chiropracTIC care to the whole family. It makes sense to everyone but the insurance companies. They don’t want folks to be healthy. Healthy people rarely need insurance. Healthy people don’t purchase high priced “health” insurance premiums. Healthy people don’t live in fear of being “sick and “needing” insurance to cover every little sniffle. The insurance companies are betting someone WON’T need the insurance and the public is betting that they WILL. Who do you think is right most of the time?

    • Don 07/05/2013, 11:03 pm:

      Dr. Duncan,
      That made great sense to me.
      If a receipt contains an ICD 9/10 code and the chiropractor has a no diagnostic approach that definitely doesn’t make sense. Especially considering ICD stands for International Classification of Diseases. Lol.

      Now if the requirement was a CPT only without the medical necessity attestation then we may be approaching something resembling a workable situation.

      Question: Does all this render every type of receipt for OSC services unnecessary or only those with codes (ICD and CPT)?

      I mean do all straight offices leave out the codes? If not, why not? Maybe I already know the answer to this but please make it explicit for me. πŸ˜‰
      Thanks.

      • Michael Duncan 07/05/2013, 11:57 pm:

        Don,

        Let me restate that the ONLY way to receive INSURANCE reimbursement, is to have the 2 elements I described before, AND submitted on a standardized form known as a HCFA. #1. Is a diagnostic code (of which you can use up to 4 separate codes). #2. Is a procedural code (CPT stands for “Current Procedural Terminology”). Without those, insurance will NOT pay.

        The ONLY way to derive a a diagnostic code to put on the form is to ddx/dx, even IF that is justified as only a “subluxation”, which is really termed by the actual code as “segmental dysfunction”. That is NOT OSC, by definition OR objective.

        Now, other “reimbursement entities”, such as a flexible spending account or health savings account or even for a tax deduction, that doesn’t require ANY diagnostic or procedure codes, but rather a description of service (ie. Spinal Adjustment).

        I am not sure what you mean by “unnecessary”, but if someone desires a “receipt”, you are likely required to give one, but you are not required to render that receipt “insurance reimburseable”, when in fact it is not. That would be unethical in the least and fraud in the most. Many chiros skate the questionably “unethical” side of the line quite close and justify why they do it as part of the game and cost of doing business.

        OSC’ors will not cross the lines, and engage in the practice of medicine, and therefore it is a moot point. Other types of “straights” will and either don’t see the incongruency (which I personally think is rare) or simply ignore it and use semantics to rationalize doing it (much more common).

        • Don 07/06/2013, 11:31 am:

          Dr. Duncan,
          If I read this correctly then OSC’ors can cross the line and engage in the practice of medicine, consciously or not even in the manner in which they provide receipts!
          As I now understand this, presently HCFA form needs a ICD 9/10 for diagnosis (which OSC does not do). It also needs a CPT (Current Procedural Terminology) code. Is using this CPT codes system NOT OSC, by definition OR objective also?
          It seems the use of the code IMPLIES a diagnosis but not explicitly. This may be the open gray area of semantics you suggested. Doesn’t the CPT explicitly state somewhere that a diagnosis MUST be made before the use of a CPT?

          From what you have written, other “reimbursement entities” such as the health savings account, flexible spending account, tax deduction (and I would add OVERLY demanding wife or husband πŸ˜‰ ) situations seem different. I am not familiar with the first two. Do these also require receipts? Do they require ANY codes?

          Lastly, to explain what I meant about “unnecessary”. Through your excellent tutelage I know understand a heck of alot about receipts and insurance. I appreciate it.
          What I used to think was that if a receipt was requested, it was for insurance. period. And OSC’ors didn’t have any reason to provide receipts most especially with diagnostic codes because that is not the practice of an OSC.
          So there were no situations that would require a receipt thus deeming all receipts “unnecessary”.
          I know know that my thinkgin was correct with the exception of the other “reimbursement entities” we listed above.
          Hope that helps and please let me know about the 2 or 3 questions buried in this response somewhere πŸ˜‰
          Thanks.

          • Michael Duncan 07/06/2013, 1:26 pm:

            Don,

            Before I forget, let me ask you a couple of things real quick. Are you a student or D.C.? If a D.C., how long in practice? If a D.C., do you have a website I can visit? Thanks!

            Now, back to business…

            Perhaps I am not following you, or you me as some of this is seeming more complicated than it needs to be. But I will start from the top and go down your post.

            If a chiropractor, or any provider, peforms diagnosis, then they are now in the practice of medicine, whether they recognize it or not, agrer with it or not or accept it or not. Mixers actually embrace it. TSC’ors claim not to diagnose, but do, if only diagnosing “subluxation” by justification because diagnosing is the only way insurance will pay.

            I am not really understanding your question regarding CPT codes and your use of them in the absence of a diagnosis code. First, I have no reason to consider it OSC or NOT OSC. I guess to completely answer that, I would need to review a CPT manual. From my former understanding, and still assuming its true, only a small handful of codes (ie. 98940-98943) are chiropractic specific as they are “spinal adjustment” procedural codes, and excluding 98943 as being applicable to OSC, because it is an extremity adjustment code. But the bigger question is what is the point of using it, when it is unable to function or serve a purpose without an ICD 9/10 code to accompany it? It becomes useless and unnecessary. And it what situation would one need to do so?

            The “gray area” I was referring to is above, but I’ll also directly say this. If a chiropractor puts diagnosis code on an insurance form and justifies it as being “well, I ONLY use subluxation codes”, they are practicing medicine for reasons I stated above and elsewhere. The issue is diagnosis.

            Yes, FSA’s and HSA’s (and I guess demanding spouses) are a different entity. And you have never heard of either of those? They are ways people can put “pre-tax” dollars into account to use toward health care expenditures. They are governed by IRS rule and regulations. And no, no ICD/CPT codes required, but a “description of the service” is. Certain types of goods and services that are included as reimburseable are called “covered entities”. This is NOT insurance. Many of these accounts now have a debit card attached so the money is instantly accessed, whereas it used to be the client paid and then submitted a receipt to get “reimbursed” in a few weeks. Now, many of the companies that administer these accounts may request a single receipt or multiple as they are needing the receipt to verify the good/service is on the “covered” list should the IRS ask.

            Generally speaking, there is no reason other than I have outlined for an OSC to need to provide a receipt, and especially not one for insurance purposes. In my office, I do mostly autodebit/recurring payments, so most everyone gets an email receipt, which usually suffices. But if someone asks for a different receipt, I first ask what it is for. If they want it for insurance, we explain we don’t give receipts for that purpose. I then explain, we’ll give them a generic receipt, but it will do no good for insurance reimbursement. I have numerous folks that have submitted my receipts for use with FSA/HSA accounts with no problems.

  6. Don 07/06/2013, 5:43 pm:

    Dr. Duncan,
    To answer some of your questions.
    I am in practice. Licensed 8 years now. Whew! Didn’t realize how fast the time passes. No website sorry.
    I am in the office right now and will hopefully get a chance to respond to the rest of your post later today.

    • Michael Duncan 07/06/2013, 8:08 pm:

      Don, I forgot to ask with the other questions, what kind of practice do you currently have? Are you seeking to learn OSC and converting from how you now practice?

      I look forward to the rest of your other answers…

      • Don 07/06/2013, 10:12 pm:

        Dr. Duncan,
        I’ll answer your most recent questions first, then return to any I have missed.
        I currently have a practice that is/was VS focused but as I learned heavily symptom oriented. I am moving away from that model more and more as time passes. Everything is a process I guess.
        Focus is now correction of VS regardless of symptomatic picture.

        Yes, I agree that diagnosis is the central issue.
        I have heard of HSA’s, not FSA’s. I am not familiar with them.
        In fact I never heard of a FSA. Shows how much I know. LOL!!
        I was wondering if the HSA and FSA’s changed and required all only CPT codes (not ICD codes) for reimbursement would an OSCor produce a reimbursable receipt?

        I had an interesting discussion once with a chiropractor that stated his fees are NOT affected by insurance reimbursement and that it was the LAW (emphasis was theirs not mine) to provide a receipt for services. I stated that that may be true however a reimbursable receipt hinges on what is written by them on the receipts. I did not get into the finer details that we had here. (Admittedly, I didn’t know them all, like I do now. Thanks Dr. Duncan)
        So, this chiropractor went on to say that he provides a receipts with codes and whatever the client wants to do with that is their issue. I challenged that idea, respectfully of course :), that if the person is reimbursed fully the for the amount being paid, what was the true cost or value personally? This didn’t elicit a very direct response. πŸ™
        Thanks for clearing up all my confusion about receipts and HSA/FSA’s. If I missed any of your questions, my apologies. Please repost and I will try again.
        Have I stated that this blog is a great resource!
        And so are you Dr. Duncan. Much thanks!

        • Michael Duncan 07/07/2013, 2:43 am:

          Don,

          Good to see you moving yourself and your practice in the right direction. And yes, it is a process.

          And FSA is a “Flexible Spending Account” that is available to employees through the employer, if available. It is similar to an HSA, although it is a lower cap and is also a “use it or lose it” basis each year. So, it while it allows a pretax savings, it behooves the employee to be diligent in their estimation for contribution, as if it is underfunded, too bad and if it is over funded, too bad because they loose the excess. Say you want to put $2400 in (there is an annual cap of like $3K set by the IRS), then your employer takes out $200/mo. (divided out over equal pay periods). An HSA is an account that an individual sets up at a bank on their own. It is a special type of account and the individual must have a “qualifying high deductible insurance”, such as a policy with a $5K deductible. The account is yours, you can contribute up to an annual max for individuals or couples (also set by the IRS) . But, it doesn’t expire or renew annually, and isn’t a “use or lose” deal.

          Now, I am not sure why the regs for HSA/FSA would change to include a CPT code. They are ONLY used to make sure a “procedure” was done, and or adequate/proper for a given diagnosis, when not only doesn’t it now, but because it is not necessary to “know” a diagnosis or require the need to have one in order to use your own money to pay for a health care service. That would inherently limit the function and purpose of the HSA/FSA altogether. For example, say you get a medical, dental, optical or chiropractic checkup and they run up a bill for $500, yet find nothing to diagnose or treat. Other than the actual exam, which is a unique procedure compared to other ACTUAL procedures, the client still gets a service but can’t use the money to pay for it. It would also take away additional freedom as a consumer of health care services more than it already does based on the “covered” list. It would function like insurance, which already exists and it remove the incentive for people to use the tax break for which it is designed.

          Your arguement with that guy was incomplete. Yes, it is true that many states explicitly state that you must offer/provide a receipt if requested, pehaps even WITH a diagnosis. However, I have never seen any law for any state that requires you to provide ICD and/or CPT codes. Those are specifically to create a standardized “launguage” for insurance reibursement. There is nothing that I am aware of that states you MUST say “XXX.XX” (ICD) instead of Emphysema or 98941 instead of 3-4 region spinal adjustment. Codes would make a receipt potentially reimbursable and put you as the responsible party for it in the eyes of both the patient and the insurance company. So, chiros usually either don’t care or don’t want to ruffle feathers and just do what the patient wants, so long as theg get paid. With regard to the amount reimbursed, only the amount ACTUALLY paid (by the patient) or charged by the clinic can be submitted. However, what gets reimbursed is up to the insurance company and what they have agreed to cover, the patient’s particular policy, medical necessity and how deductibles and co-insurance/co-pays factor in. The amount of the actual reimbursement is figured and approved the same, regardless of who submits it.

          • Don 07/07/2013, 6:56 pm:

            Dr. Duncan,
            Great info. I agree that a change in HSA/FSA’s to require CPT codes would take away additional freedom as a consumer of health care services more than it already does based on the β€œcovered” list. However, I have come to learn that insurance companies do some interesting things and not all with the freedom of the consumer in mind. The “covered” list is an example of just that sort of restriction.

            I also agree that my “discussion” (I wasn’t argueing πŸ˜‰ ) with the chiropractor wasn’t complete. As you and I have said codes would make a receipt potentially reimbursable.
            Unfortunately, not everyone agrees that doing that puts the chiropractor as the responsible party for it. I don’t know if “not caring” is an adequate excuse since caring about it or not, the insurance and the patient can hold them responsible for it and as you have said it isn’t OSC.

            IMO, the red tape of insurance policies copays, deductibles and the need to prove medical necessity seems excessively burdensome for an office.
            Still there are those in the public who insist they “have insurance for chiropractic” and want to use it. I guess ruffling feather happens here for the OSCor. A solid orientation since TOITMITWD is fundamental. Learning is a process though so, I welcome anything you can share to help with these situations Dr. Duncan.
            πŸ™‚

  7. Michael Duncan 07/07/2013, 8:02 pm:

    Don,

    I honestly rarely have people ask if we take insurance. And if they do (we’ve had only a handful ask in the last 20 months), we explain we don’t and why. During that same time, only 2 didn’t start because of it.

    My office structure and fee make it unnecessary and I explain in detail why when needed. It is EASY to explain it until it becomes moot. And by then, they are agreeing and it never comes up again. I do an orientation first BEFORE they ever get on the table. All things are explained and questions answered up front, so there are no surprises.

    TOITMITWD is absolutely correct!

    I am not sure what specific help you might be looking for, so maybe just ask some questions and I’ll answer.

    Also, out of respect for Joe and this blog, in an effort to not hijack this thread or his site, you can always email your questions to me at chiromichael@gmail.com. If he doesn’t mind it here, then here is fine and I am happy to answer/discuss in an open forum.

  8. Don 07/07/2013, 11:47 pm:

    Dr, Duncan,
    Yours sounds like an excellent practice to be in. I agree that I should email you if there re any further questions. None for now though. Maybe in the future.
    If I high jacked this thread, I apologize to Dr. Strauss…and everyone else.

    • Claude Lessard 07/08/2013, 11:03 am:

      Michael and Don,

      It’s about inquiring, together without condemnation, into the nature of chiropractic philosophy and practice… No one is highjacking anything… it’s about going deeper and breaking through… in order to be transformed into… πŸ˜‰

      • Tom 07/08/2013, 1:18 pm:

        Claude beat me to it! Chances are excellent that any question that you come up with, someone else also has, or at the very least the answers will benefit others too. Unless it is of a very personal nature, please continue to post questions and dialogue here to benefit all! Thanks! πŸ™‚

    • JoeStrauss 07/08/2013, 1:16 pm:

      Don, I for one am glad to have you and Michael interacting. I’m sure there are others who are benefitting from your dialogue.

      • Michael Duncan 07/08/2013, 1:59 pm:

        Fair enough! I suspected this would be the responses, but just wanted to check. Thank you!

        Let us carry on! πŸ™‚

        • Don 07/08/2013, 10:01 pm:

          Thank you Dr. Strauss. I will continue to contribute as often as I can.
          Also a big thanks to Dr. Duncan as well as Dr. Lessard and Tom. It is great to have someone to ask questions or inquire together with.

    • Michael Duncan 07/08/2013, 1:58 pm:

      Don,

      Well, I personally love my style of practice. And while it is growing, and needs to, I have a lot yet to serve. But the philosophy, style and methods of my practice come from implementing thngs taught and practiced by Reggie and Joe Strauss and Joe D. for roughly 46 years now. These guys are phenomenal teachers and mentors, as is my good friend Tom, and now Claude. It is possible to create an extremely low stress, objective straight, non-insurance-dependent (cash), happy, fun and loving practice of WHO you choose to be. Just listen and follow those before you.

      I love these guys and can never imagine practicing any other way!

  9. Kirk McAnsh 08/02/2013, 4:09 pm:

    As chiropractors we are LEGALLY required BY FEDERAL LAW to bill MEDICARE any time we take care of a Medicare “patient”.

    Now, since Medicare does not pay for care that “…seeks to enhance the quality of life” (sounds a little like OSC), we bill (as required by law) but use the modifier “GA” which indicates the Medicare will not cover the claim thereby making it the patient;s responsibility.

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