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How Insurance Works: What is and isn’t covered

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 even 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 your wish for 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:


1.  What is Active Care? (Acute care)

Active care is care that is rendered with a specific treatment plan in place. A treatment plan has a pre-defined time-frame, type of care, definable goals, and number of visits expected.  Care is typically more frequent in the beginning of care and less frequent as the patient becomes more stable and has less complaints and dysfunction. Periodic examinations are required and treatment goals need to be monitored, updated, and documented.  Active care would typically never exceed a 2-week gap between visits.

2.  What is Maintenance/Stabilization/Wellness Care/Supportive Care?

Maintenance care is care that follows active care once the patient’s health status has become stable. The goal of maintenance care is to maintain the improvement that was accomplished with active treatment. Even though the patient may still have some degree of pain or discomfort, once their improvement has leveled off they must be released from active care and placed onto a maintenance program of care. Maintenance care typically exceeds a 2-week gap between visits.  This is never covered by insurance of any sort. (Except very few self-insured health plans)

3.  What is “Medical Necessity”?

Medical Necessity is a term the insurance industry uses to define what services are covered by insurance and what services are not covered by insurance. Health insurance companies provide coverage only for health-related services that they define or determine to be medically necessary. Insurance will not pay for healthcare services that they deem to be not medically necessary.  The best way to prove medical necessity which includes the initial intake, history, exams, daily treatment notes, a treatment plan with measurable functional goals, and imaging when appropriate. When medical necessity is established, this is called active treatment. When this criterion is not met, patient care is defined as maintenance, supportive or wellness care; thus, clinically appropriate, but not medically necessary. 

4.  “I just want to come in whenever I feel I need to and I don’t want to be on a treatment schedule.”

That is completely acceptable. However, you need to understand that chiropractic treatment provided on an “as-needed” basis is determined by the insurance industry to be “not-medically necessary” and is therefore NOT covered by insurance. Even if your insurance benefits say you have a certain number of chiropractic visits per year, those visits must follow strict guidelines under an active treatment program prescribed by the chiropractor to be covered. Patients that are seen on an “as-needed” basis and are not on a specific treatment plan are required to pay for the services out-of-pocket since insurance will determine the care to be maintenance in nature.

5.  “But I’m still in pain. Why won’t insurance cover my care anymore?”

Whether insurance will pay or not actually has nothing to do with symptoms or how a patient feels. Insurance will only pay for services that it determines to be medically necessary. Once a treatment plan has been completed (or not followed by the patient) and long-term improvements are not expected, called “Maximum Therapeutic Benefit” or “MTB”, then the patient must be released from active care without regard of any remaining symptoms. Once MTB is achieved then active are is to be stopped and maintenance care started.

6.  “But my insurance says that I have 30 visits per year covered.”

Insurance will only pay for services that it determines to be “Medically Necessary”.  30 visits is the maximum allowed per year.  If 12 visits are used during an active treatment protocol then they should be covered; however, if 12 visits are used on an “as-needed” or “once-a-month” basis then insurance will not cover those visits. Maintenance visits are determined by the insurance industry to be not-medically necessary and are therefore not covered services. Non-covered services also do not apply towards any deductible so there is no need to even bill insurance for this type of service.  Maintenance visits do not count toward your 30 visits that are covered in a year.

7.  “My insurance says that the doctor just needs to change the code and then they will pay.”

For a doctor to bill insurance using a code that is different than the service that was provided would be insurance fraud and our office would never participate in that practice.

8.  “Can I go back on active care once I’ve been on maintenance care?”

Absolutely. There just needs to be documented legitimate new condition or injury, exacerbation or relapse of a past condition. A new examination must be performed in order to determine if an active treatment plan is necessary. If a treatment plan is recommended then active care can be started again and continued as long as change and progress can be measured and documented. Active care likely would require therapies and rehab procedures in addition to the chiropractic adjustments and typically would not exceed 2 weeks between visits. If the treatment plan is not followed for any reason then the patient would need to be discharged again to a maintenance status.

9.  “If my insurance won’t pay, then I can’t afford it.”

About 50% of the patients in our office have no insurance benefits at all. About 70% of my patients are under Wellness/Maintenance care at this time.  Unlike most medical care, chiropractic care is very affordable for most people. Especially considering that the average cost of back surgery is $65,000, most of which could be prevented with chiropractic care that costs a very small fraction of that amount. We make care affordable so that anyone can get the care they need. An entire year of chiropractic care usually costs less than what most people spend on a new computer – and our maintenance visits are only $50-$60. How we spend our money is all about priorities. We often don’t think twice about spending a large amount of money on entertainment (if our TV went our we would be at Best Buy the next buying the latest and greatest) but when it comes to our health we tend to put in on the back-burner – until its too late. It is much cheaper (and healthier) to invest a small amount in prevention instead of waiting for a health problem to get more serious which will be far more expensive. Chiropractic care is by far the best deal in healthcare. Chiropractic is like insurance – premiums small, dividends large!

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