There are two types of chiropractic care:
ACTIVE CARE which includes Relief, Correction and Stabilization of a condition. This care requires frequent visits that reduce in frequency as the patient improves. In addition to the chiropractic adjustments, treatment during this phase of care usually requires additional services such as therapeutic modalities (EMS, IST and ultrasound) as well as physical therapy rehabilitative exercises. A doctor-prescribed treatment plan is necessary during this care phase and treatment intervals typically do not exceed 2 weeks. This is the only type of care that is considered by the insurance industry to be "medically necessary" and potentially covered by any insurance benefits.
MAINTENANCE CARE is meant to prevent future relapses and maintain the condition after active care has been completed. This is also known as Wellness or Preventative Care. This care requires periodic check-up visits in order to prevent future relapses and/or maintain the health status that was achieved during active care. Maintenance care visits are usually anywhere from 2 weeks intervals to 3 month intervals, although most patients would ideally benefit from monthly chiropractic check-ups to stay in optimal health and wellness. The insurance industry considers maintenance/wellness/preventative chiropractic care to be "not-medically necessary" and therefore does not cover these types of visits - similar to your car insurance not covering oil changes and tune-ups which are required for proper vehicle maintenance.
Frequently Asked Questions:
What is Active Care?
Active care is care that is rendered with a specific treatment plan in place. Care is typically more frequent in the beginning of care and less frequent as the patient becomes more stable. Periodic examinations are required and treatment goals need to be monitored and documented Active care would typically never exceed a 2-week gap between visits.
What is Maintenance 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.
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.
"I just want to come in whenever I feel I need to and I don't want to be on a treatment schedule."
That's okay! 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 need to fall 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.
"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) and long-term improvements are not expected, then the patient must be released from active care without regard of any remaining symptoms. Once maximum therapeutic benefit is achieved then active are is to be stopped and maintenance care started.
"But my insurance says that I have 12 or 20 visits per year covered."
Insurance will only pay for services that it determines to be "Medically Necessary". If the 12 visits are used during an active treatment protocol then they should be covered; however, if the 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.
"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.
"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. An 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.
"If my insurance won't pay, then I can't afford it."
About 35% of the patients in our office have no insurance benefits at all. 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 $55. 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!