Chiropractic Insurance and Billing–Picture This:
You go to the doctor as you have been instructed to do for pain, the flu, or another nagging symptom. Of course, it is the right thing to do but then six months later you receive a letter in the mail from your insurance company stating that you owe the provider money. You thought you were covered for this service, what happened? In the world of privatized health insurance, federal regulations and reform, and confusing policy documents, it’s not a surprise that many patients are not aware of what is going on behind the scenes. Sport and Spine Rehab wants to help create transparency in the system and help patients to better understand how health insurance billing and processing works. This knowledge will allow patients to set expectations, make decisions, and prepare for the costs of those very important visits. We want everyone to be ready to invest in their own health and happiness.
Here are your top 3 Health insurance questions answered!!
1. When I go to my primary care doctor, I often don’t have to pay anything. Why do I owe different amounts when I see a specialist, a Chiropractor or Physical Therapist?
Your insurance policy is somewhat individualized to you. I always tell people that each insurance policy is like a snowflake, specific and different. Your insurance policy is a very long and detailed document that lays out what benefits will be applied to each type of service. For primary care visits, particularly your annual wellness visits, there is often no patient responsibility and the services are 100% covered. However, most policies have separate benefits for each type of Doctor or service you have. No two insurances decide to process services and claims the same way. Most likely you will have a copay, coinsurance, and/or deductible (or a combo of 2 or all 3) when you go to a chiropractor or a Physical Therapist. This means that you and your insurance may pay part of the bill.
2. I went to the doctor months ago, why am I just receiving a bill now?
There could be a few reasons for this.
- Possibility 1: Technically speaking, your Doctor has up to a year to file the claim for the services that you had at their office. Crazy, but true. So, you may be just receiving the bill much later simply because the provider may not have filed that claim right away. You can always ask a Doctor’s office when you can expect them to file the claim so that you can check the status of it on your insurance website or by calling your insurance’s member services number.
- Possibility 2: There can be a lot of back and forth that can go on between an insurance company and a provider’s office as the office works to demonstrate medical necessity or supply the insurance with additionally requested information or documentation. Remember, claims processing can take anywhere from a few days or weeks to months or longer.
- Possibility 3: Sometimes, claims are initially paid out according to a certain benefit but after an audit, the insurance company rescinds their payment and denies the visit. This can happen up to a year after a visit has occurred. If the proper documents have been signed by the patient, then the provider’s office can try to fight to get that claim re-paid. If they are not successful, then the patient could receive a bill more than a year after their service was rendered. (This can be caused by a patient not disclosing all of their insurance information to the provider up front–having more than one insurance–or their policy being terminated due to unpaid premiums).
Be sure to keep your healthcare providers in the loop from day one so that they can do everything possible to help get your claims paid for you.
3. I have a deductible, why do I owe different amounts for each of my visits?
Deductibles are one of the trickiest benefits to explain and for people to understand. When you have a deductible your insurance company states that they will not pay for anything until you have paid that amount for your own medical services that year. In addition, there is the complication of contracted rates (also known as allowed fees) that come into play. Here is the basic journey of a claim that is being applied to a deductible.
- The patient attends the appointment
- The claim is created with each of the charges (also known as CPT procedure codes). These will be dependent on what type of treatments are performed, some will be determined by the length of time or by the number of areas affected. Doctors must bill according to what they performed and are not permitted to underbill (neglect to charge for something that was done).
- The claim is submitted to the insurance company
- The claims are processed per the contracted rates for each unit and code. The difference between the dollar amount billed and the contracted rate is written-off and no one is responsible for paying that portion.*
- The Contracted rate is then applied to the patient’s deductible. The deductible decreases by that amount and it is the patient’s responsibility to pay that amount to the provider/doctor’s office.
- The EOBS are sent to the patient and the doctor’s office.
So, the patient may have slightly different services at each visit. They could be doing rehab for different lengths of time, perhaps the doctor does some re-examination tests at a visit, they adjust different areas of the spine, or do an added treatment of taping or myofascial release. All of these things may change the codes that are billed, therefore altering the amount that is applied to the deductible. Just like each insurance policy, each visit is individualized to the patient’s case and progress.
*This applies to in-network insurance only. Out of network insurances will still apply the contracted rate to the deductible but the patient is responsible for the full cost of the charge and nothing is written off.
The most important thing you can do is to ask questions and to also call your own insurance carrier before you attend appointments to find out and ensure you understand what your benefits and rights are. As a courtesy, Sport and Spine Rehab verifies your benefits with your insurance company, but these are never a guarantee of coverage and it is always best for you to get that information straight from the horse’s mouth too! With that in mind, SSR is always here to help so reach out to us anytime if you have questions about your insurance, billing procedures, pricing, your payment options, or how to get the best and most from your health insurance coverage.
Insurance and Billing: Your Top 3 Questions Answered!
Cat Lovejoy gives her expert advice on insurance and billing at Sport and Spine Rehab.
“I am the Director of Service Excellence for Sport and Spine Rehab. I have over 10 years of experience working in the administrative side of healthcare. I have worked for large hospitals, elite specialty clinics, and small healthcare companies. As a specialist in insurance policies, billing, and customer service it is one of my goals to help increase transparency and understanding for patients in the healthcare world so that they can make informed decisions to improve their health and happiness.”