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"Understanding" Your Insurance


Understanding your Chiropractic and Acupuncture insurance benefits can be frustrating and confusing. So this is my attempt to explain and make sense of this very inconsistent world. We will start with defining a few of the keywords that you’ll often hear regarding your insurance plan: Deductible, co-pay, co-insurance, out of pocket maximum, In-network & out of network.


Deductible: Depending on your insurance, your visit may be subject to a deductible. Deductibles can range from several thousand to a few hundred dollars. Sometimes, even when your insurance plan has a large deductible, your chiropractic and acupuncture visit may not be subject to it. This means that you will only have to pay your co-pay or co-insurance. In other instances, your chiropractic and acupuncture visits are subject to a deductible, in which case this set amount of money will have to be met before you start only paying a co-pay or co-insurance. Most plans have a personal deductible but may also have a family deductible. If you find that your deductible is too high and that you likely won't come close before the end of the year, there are also cash pay options available to make your care a little more affordable.


Co-pay or Co-insurance: After your deductible is met, or if your care is not subject to one, this is the fixed amount you will pay at each visit. A co-pay is usually a fixed dollar amount. A co-insurance is where your insurance company agrees to pay a fixed percentage of the services rendered that day, most commonly I see a 20% co-insurance, which means that insurance will pay 80% of the charges from that visit and you are left to pay 20%. Charges can change visit to visit depending on what your provider does treatment wise that day. Some plans even have a combination of the two in use. So you may owe just a co-pay, a co-insurance, or both a co-pay and co-insurance.


Out of Pocket Max: An out of pocket maximum (OOP) is the amount of money that your insurance plan allows you to pay out of your pocket before all services are covered by insurance at 100%. After reaching this monetary amount, you can come in and be seen for any of the approved services on your plan at no cost to you. This OOP is generally a high number but can be met via any eligible medical services. For instance, if you have a baby or require a costly procedure at any point in the year, it’s likely your OOP will be met, after which you are covered at 100% for the rest of the year for any medical care that accepts your insurance!


IN vs OUT of Network: Being in- network with your insurance company means a provider has agreed to accept your insurance and the contracted reimbursement rates that come along with it. In most cases, being in network is beneficial because it gives you as a patient access to care while in most cases only being responsible for a copay. If your provider is out of network with an insurance company this generally comes along with a different deductible before services are covered. However, some insurances have comparable in and out of network deductibles and co-pays. One in particular I am out of Network with is United Health Care. For many Nike employees with United, your out of network benefit for chiro care is only a 20$ co-pay with no deductible and no limits on care! This is always worth inquiring before completely discounting care from a provider who is not in your network.


Chiropractic Vs Physical Therapy Benefits: Just when you thought things couldn't get more confusing…In the world of “alternative medicine” sometimes benefits can get lumped together. If you have been a patient of mine before, you know that I often teach exercises or do soft tissue work to help you get better faster. Sometimes when manual therapy or rehab codes are billed by a chiropractor it is covered under chiropractic care, which is great! You only have to worry about your usual chiro co-pay. Other times your chiro benefits will ONLY cover the adjustment, and the other things I do in the visit may come out of the physical therapy benefit. I always check your PT benefit ahead of time as well to see if there is a separate deductible or limited amount of visit. However, sometimes how the insurance company tells me something is being billed is not how it actually gets billed. So while I do my best to be transparent about which benefit is being used, this is also something to keep an eye out for or ask your insurance company when calling to double check your benefits.


I am happy to verify your benefits for you as a courtesy. I also stress to patients how important it is to be familiar with and keep track of your own benefits as well. While we do our absolute best to be accurate, there are always instances where the person or online portal we verified with has given incorrect quotes. Even when verifying we are given a notice that what we are quoted may not be a correct amount and that the insurance company can not be held responsible for any mistakes in communication, leaving the payer responsible. If you run into any surprise charges we are always happy to dig into the billing to see what is going on and if there are any errors, but ultimately being aware of your benefits before care is the most empowering place to be!


In conclusion:

- The more I learn about insurance companies, the less sense the world makes.

-Every plan, even within the same company, can be so different.

- I do my absolute best to get all the information I need to make sure you have no surprises with billing, but ultimately I end up just as surprised as you sometimes.

-Never be afraid to ask questions about your benefits with your insurance company!

-Never be afraid to have an open dialogue with me if you don't understand a bill or need something explained!




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