We run into a lot of questions and confusion when it comes to what insurance covers in a Chiropractic office, or for any medical office for that matter. 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”, as it does not help you stay healthy technically. Medical insurance only covers “Medically Necessary”, “Active care” that is prescribed under a treatment plan, for dysfunction you are experiencing. We must have this “dysfunction” identified and create objective treatment goals, so we know when to end the treatment plan, and know when to stop treating. These treatment plans typically run 4 weeks at a time, and you must continue to improve toward and meet the goals of each plan before you can continue to the next phase of care. It is typical for our patients to go through 1 to 2 phases of 1 month 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 under corporate medical policies.
Once these phases of “Active care” are done, it may make sense to you maintain and stabilize your changes that we have worked hard on and spent good time and money achieving. Maintenance, Wellness, Preventative, Supportive or Stabilization care (all synonyms) are common in our office, but again are NOT covered by insurance polices. It’s like a Health Club Membership, it is good for you, but is not covered by “health insurance”. 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 of these rules:
What is Active Care?
What is Maintenance/Stabilization/Wellness Care?
What is “Medical Necessity”?
“I just want to come in whenever I feel I need to and I don’t want to be on a treatment schedule.”
“But I’m still in pain. Why won’t insurance cover my care anymore?”
“But my insurance says that I have 30 visits per year covered.”
“My insurance says that the doctor just needs to change the code and then they will pay.”
“Can I go back on active care once I’ve been on maintenance care?”
“If my insurance won’t pay, then I can’t afford it.”