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Clarification of Patient Benefits

, January 22, 2014

Vivi-Ann FischerI have heard from some chiropractors who have expressed concerns regarding insurance companies selling health plans with unlimited chiropractic benefits. They shared concerns about a perceived lack of clarity regarding the management and limitations of those services. 

I understand that benefit coverage rules can be confusing for members as well as providers and office administrators who receive little to no training regarding insurance coverage through their education process. I am taking this opportunity to share some key information, and provide clarification on benefit coverage criteria, with the entire ChiroCare network.  My intent is to inform you, so that you are able to provide clarification to your patients and minimize patient complaints and your financial risk associated with the delivery of non-covered services. 

Key points to understand include:

  1. An unlimited benefit does not always mean that all services are covered.  The reference to unlimited within the context of a chiropractic benefit often refers to the number of allowed (medically necessary) visits, not the coverage of specific services provided during a chiropractic visit. Providers can check with each payor they work with to determine what specific services are eligible for reimbursement. In nearly all cases, all health care services are subject to medical necessity in order to be eligible for payment through the member’s plan. Most member Certificates of Coverage documents exclude coverage of maintenance care. This general rule is applied to all services, not only chiropractic. For members who hold a policy with an unlimited chiropractic benefit, maintenance care services are typically still listed as an exclusion and as such, clinical reviews may result in denials of authorization request or claims. 
  2. There may be specific requirements in order for a specific service to be covered. For example, rehabilitative care rendered to diagnose and treat acute neuromuscular-skeletal conditions is only covered when provided in conjunction with another service.  Additionally, under some plans, massage therapy cannot be billed separately from chiropractic treatment, and is covered only when provided in conjunction with another covered service and as part of the patient’s treatment plan.
  3. Details regarding coverage limitations for each member’s specific plan can be found by checking the patient’s certificate of coverage under the following: specific benefit or services area, exclusions, and services not covered sections. General benefit information can typically be found online however, the specific method in which that information is made available to providers will vary by each payor. 

In my clinic, my staff and I occasionally saw patients who were confused after speaking with their insurance company because they believed that they had unlimited chiropractic services.  I contacted a couple of different insurance companies and confirmed that they have call center scripting and in most cases, the scripting is approved by the State and the Centers for Medicare and Medicaid Services.  This scripting includes statements like “Chiropractic services are subject to clinical review to ensure that the care meets XYZ medical coverage criteria.”  The scripting also includes this information “We cover chiropractic services for rehabilitative care, provided to diagnose and treat acute neuromusculo-skeletal conditions.”

So, why are the patients confused?  I took the opportunity to do a little research and learned that a majority of members of health plans are generally confused on how health insurance works – this is what the industry calls a low “health literacy”.  The National Health Action Plan to Improve Health Literacy released in May 2010 highlights the importance of engaging all stakeholders in an effort to improve health literacy.  Some organizations in Minnesota, HealthPartners, BCBS of MN, and UCare, have developed implemented health literacy strategies designed to provide accurate, accessible, and actionable health information and communications to improve the health and quality of life of their members.

ChiroCare also continues to develop materials to assist you in better understanding how health care works and provide you with tools to assist your patients and improve their health literacy.  These tools can be found on our website, ChiroCare.com.  For example, we have a free document that you can download to educate your patients about maintenance care.  To obtain this document or any other patient focused educational tools, please visit us at: ChiroCare.com > Chiropractic Practice Management > Chiropractic Tools Forms

Annually, ChiroCare sends out a network satisfaction survey in which we gage your level of satisfaction regarding these types of tools.  We also provide you with an opportunity to share your feedback and request other materials and tools.  You don’t have to wait until our annual satisfaction survey to let us know how we are doing and what else we can do to help support you in providing high quality, patient centered care to our health plan members/patients.  Please feel free to contact me any time you have a suggestion or request.  You can reach me at 763-204-8570 or via e-mail at VFischer@chirocaremn.org.