As you have probably found as you call around to various chiropractic offices, many of them are out-of-network and do not take insurance. This is not unique to the chiropractic profession as we see more and more medical doctors opening concierge practices and going “fee for service.” Now understand, these offices are not doing this because they don’t like you. In fact, it is because they care more about you. Here are three reasons Chiropractors do not take insurance.
This first reason is that it often costs the patient MORE money to utilize their insurance. When I first opened my practice and I was in-network with a few insurance carriers, the majority of the patients who came in either had a deductible so high that they were considered a “cash” patient or their copay was actually HIGHER than my office visit! If I would have remained in-network and accepted insurance I would have needed to hire at minimum 1-2 additional people and possibly even an outside billing company to manage the paperwork and follow up necessary to get paid on the services that would have been provided. One of my colleagues did the math and found he would have needed to raise his fees 35% to cover the additional burden to take insurance. That ends up costing you a lot more money for the same service!
The second reason chiropractors do not take insurance is because it is much simpler. Simple is beautiful because it cuts out confusion. There is a fee for services rendered and it is agreed upon from the start. There is no question what will be covered or not covered, what “should” be covered verses what “is” covered. It can be very confusing because of the rules and laws that govern our practices and the language that is used. I have been in the rooms when that patient calls the insurance company and the office calls, the patient is told one thing and the office is told another. The sad part is that usually the patient is the one getting yanked around. For instance, when you as the patient calls and your insurance company tells you that you have 35 chiropractic visits, what they don’t tell you is that they are all based on “Medical Necessity.” Now, you and I may say that most everything is medically necessary because there is pain or some other symptom presenting. But, that is not the definition of medical necessity. As an example, if you came in with a headache that you said was an 8/10 on the pain scale and you were seen for several visits and it reduced to a 4/10 and continued to remain there for some time, by definition you are considered “medically stable” and further care would not be covered because it would be deemed “NOT medically necessary.” As the doctor, it is my job to know when that has been reached to the best of my knowledge and if I don’t, I risk my license and ability to practice on the grounds of fraud. If the chiropractic office you go to does not bill your insurance for you, you can still submit those services to your own insurance company seeking reimbursement for out-of-network services if you have out-of-network benefits. But understand, even you may only submit those dates of service with which would be deemed medically necessary and not considered “maintenance or wellness,” otherwise it is still considered insurance fraud. I take this very seriously because my family depends on me being able to practice chiropractic to provide for our family.
The third reason chiropractors do not take insurance, and frankly the most important reason, is to protect the doctor-patient relationship. This is one of the main reasons I choose to go out-of-network with insurance and practice in a fee-for-service model. If you have dealt with insurance when trying to get a procedure or even imaging, then you likely have experienced how insurance companies dictate the course of care and or treatment. I was attending a continuing education seminar this past weekend and the speaker was talking about his friend who was an orthopedic surgeon. The surgeon explained to him how after the initial consultation he knows what is going on and just needs the MRI imaging to identify the levels and severity before performing the necessary surgery. However, the insurance company makes the patient go through injections first and wait sometimes 4-8 weeks before getting the necessary imaging. The patient ends up suffering longer and the insurance company ends up delaying care as they make the patient jump through hoops and hurdles to get their claims paid. We had something similar like this in chiropractic. When a patient comes in and I see what they are presenting with and I identify on X-ray what the problem is, I have a very good idea on what the treatment plan is going to look like based on my years of experience. Now, when the patient calls their insurance company they would tell the patient they had over 20 to 30 chiropractic visits per year on their policy. What the patient doesn’t know is that that same insurance company would only pay the chiropractors for 5-8 visits! Doctors are tiered in their system and if most of their patients came in for the max 5-8 visits, next year they would drop it down to 3 or less. This puts the doctor and the patient in a horrible situation. The patient is told one thing while the doctor knows how the system works because they had to sign a contract that looked like the size of an old encyclopedia. Can you see how this becomes problematic? Then, when the chiropractor stops getting paid for services rendered he/she has to transition the patient to a cash patient and the patient does not understand why, the patient often gets angry (especially when they call their insurance and are told they have x number of visits without being explained medical necessity or their tiered system for doctors), it builds distrust between the doctor and the patient, and in the end the patient likely doesn’t get the necessary care that they actually needed to help them with their chief complaint. In over a decade of working in 3-4 different offices, some fee-for-service and some in-network, I wanted nothing to do with insurance and the barrier they placed between the doctor-patient relationship. That relationship is between the doctor and the patient, the insurance company is not in it nor should they be “playing” doctor and dictating the patient’s care- they are not the treating doctor!
As you can see above, there are three very good reasons for chiropractors not to take insurance. The doctor-patient relationship is built and trust and the three reasons above cause a breakdown in that trust. Caring for my patients goes beyond what I do to treat them, it means looking for ways to save them money, keeping things simple and providing clear expectations, and providing recommendations that I believe will help my patients, not providing services only because insurance will pay for it. Like my parents used to say to me as a kid, “We do this because we love you!”