We are in network with many major insurance companies. We will verify coverage and benefits to the best of our ability and provide you with a good faith estimate.
Health insurance coverage for chiropractic care only reimburses if you have an Acute Injury and you are on an active care or treatment plan that shows objective improvement. By definition, insurance carries do not pay for maintenance or wellness care, even if you don’t have a visit limit or restriction the plan calls for medical necessity.
We pride ourselves in offering the most comprehensive chiropractic care, however most insurances do not cover all of the services that we provide at the office.
Our doctors and staff use a combination of modalities and therapies along with the adjustment to get you better, faster. This means less down time, and less office visits!
What is Active Care?
Active care refers to care that is administered on a specific treatment plan for a specific length of time set out by your doctor. During this phase, you will be seen in office more frequently, usually 1-2x/ week depending on your condition. During the active care phase, you will need to be monitored and documented. Visits during this stage are weekly, usually not exceeding a 2 week gap between treatments.
What is Maintenance/wellness Care?
Once a patients original complaint has improved and has become more stable, insurance will no longer cover visits. 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 maintenance or wellness care. Maintenance care typically exceeds a 2-week gap between visits. The doctor will present you with options for wellness or maintenance care. The goal of maintenance care is to maintain the improvement that was accomplished with active treatment. Like going to the gym, your chiropractic visits build on each other helping to further improve your overall health and wellness.
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. This is determined by the insurance company not your doctor. 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.
“What is a non-covered service charge? With my insurance I only have a co-pay”
Our doctors and staff use a combination of modalities and therapies along with the adjustment to get you better, faster. This means less down time, and less office visits. However, most major insurance companies will only reimburse for the adjustment, while some may reimburse for 1 or 2 modalities. This means we are often not reimbursed for the extra time we spend with our patients. Our office charges an extra $20 charge each visit to most of our patients who use insurance in addition to whatever copay or deductible may be required, so we may spend the necessary time to get our patients well.
"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, 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 plan prescribed by the chiropractor to be covered considered for coverage. Patients that choose to be 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 and not medically necessary.
"But I'm still in pain. Why won't insurance cover my care anymore?"
Insurance reimbursement has nothing to do with symptoms or how a patient feels. Insurance will only pay for services that it determines to be medically necessary. A treatment plan must have a beginning and an end date. Once a treatment plan has been completed, not followed, or no significant improvements are able to be objectified, then the patient must be released from active care regardless of any remaining symptoms. This is referred to by the insurance industry as maximum therapeutic benefit.
Once maximum therapeutic benefit is achieved then active is stopped and maintenance care started.
"My insurance says that I have 12/20/unlimited visits per calendar 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 since this would be classified as chronic, wellness, or maintenance care. Maintenance visits are determined by the insurance industry to be “not-medically necessary” and are therefore non-covered services. Non-covered services also do not apply towards any deductible or insurance reimbursements.
"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?"
Yes! As long as there is a documented new injury or exacerbation of a previous injury. A re-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 resume until the issue is resolved. Active care likely would require therapies and rehab procedures in addition to the chiropractic adjustments and typically should not exceed 2 weeks between visits. If the treatment plan is not followed for any reason, then the patient would need to be discharged from active care and return to maintenance.
How much does maintenance/wellness care cost if I can’t use my insurance?
More than half of our patients are self- pay, as many find our options more affordable and convenient. We do offer a package discount for 6 and 12 visits.
“Can I use my HSA to pay out of pocket for maintenance/wellness care?”
Yes! Since we are a medical practice your HSA does qualify. We can supply you with the necessary receipts to submit to your HSA for reimbursement.
*please note we cannot guarantee reimbursement by your insurer.