Insurance Guidelines vs Healthcare Guidelines

All healthcare professionals from chiropractors to medical doctors and surgeons have guidelines that they are expected to follow. Primarily for the interest of the patient’s health and well-being. These guidelines are put in place as a result of decades of research and treatment. They sometimes change as new and updated information becomes available. These guidelines are very important in helping to determine the standard of care that your chiropractor is expected to follow so you to get the care needed. Chiropractors or medical doctors who stray outside of these guidelines run the risk of being held accountable for malpractice. If a patient is hurt as a result of negligence while practicing outside of practice guidelines.

For example

A well-known guideline for chiropractors and medical doctors is the need to take an x-ray of the spine if a patient is having neck or back pain. This standard of care is in place in order to protect the patient. There is a great deal of research to show that neck or back pain can be the result of many different maladies that may require more than just an adjustment. For example, additional structurally focused exercises and spinal remodeling traction is often needed. By correcting the shape of the spine and preventing the cause of these symptoms. Another potential cause of low back pain or neck pain could be due to bone cancer.

If the chiropractor chooses to ignore the standard of care they may put the patient at risk for a lifetime of chronic pain due to spinal degeneration or even death if the pain is caused by a bone tumor. These guidelines require the chiropractor to keep the patients best interest as the priority. If the chiropractor chooses to ignore this standard and continues to treat the symptoms. Where the patient ends up dying because the chiropractor failed to follow the professions proper standard of care he/she could be and should be held liable for negligence.

It is important to understand that professional healthcare guidelines and insurance guidelines are VERY DIFFERENT. For chiropractors in-network, they are contractually obligated to follow insurance guidelines. This so they are able to get reimbursed (paid) for the services they provide. Anything outside of those insurance guidelines the patient will have to pay for out of their own pocket. It doesn’t matter whether or not the insurance guidelines completely contradict your doctors or the guidelines of the profession for what would be considered negligence. In fact, most insurance companies’ guidelines are in stark contrast to what is best for the patient.

Let me give you some examples.

In North Carolina, in order to be in-network with the major health insurance companies for a chiropractor, you have to be a part of a “fourth-party” managed care company. This company claims to exist to help your chiropractor file health insurance claims more efficiently.  So as to avoid the major health insurance companies from denying their claims to pay for services. In exchange, this fourth party company is paid about 10% or more of the claims made. This service sounds good but in practice, it doesn’t work this way.

The major medical health insurance companies encourage this. This is because the managed care company really benefits them, not the doctor and not the patient. The managed care company has their own set of “guidelines” that must be followed in order for the health insurance to pay for the patient’s chiropractic care that is supposed to be covered. Basically, they are making up the rules to benefit insurance companies. While you think you have a health insurance plan that provides 30 visits of chiropractic care, in reality, you do not. In order for your health insurance to pay for those 30 visits, your chiropractor must play by their rules.

And guess what. Their rules benefit them only.

For example, the International Chiropractic Association has adopted specific guidelines from the Practicing Chiropractors’ Committee on Radiology Protocols For Biomechanical Assessment of Spinal Subluxation in Chiropractic Clinical Practice that is supported by hundreds of peer-reviewed research articles. These guidelines specifically state “Since the spine is a contiguous structure that is inseparable in function it should be inseparable in an evaluation using Spinography.” Meaning if you’re going to evaluate the spine to treat the spine, you should x-ray the entire spine. Compare this to managed care guidelines. That at best allow the x-ray evaluation of only one are of the spine if symptoms are present. In some states, health insurance or managed care companies will even offer financial incentives to the chiropractor to NOT take ANY x-rays!!!

How is this legal?

It is legal because this is an insurance guideline. This is NOT a health care guideline. This is no different than an insurance company “allowing” only 12 chiro visits a year. Despite the FACT that more chiropractic care may be necessary. It’s the same if your insurance will only cover 1 MRI a year. This is what is allowed per policy. Health insurance and managed care companies are committed to “cost containment” NOT public health.

This is one of the reasons trying to understand health insurance practically requires an associates degree. There are a massive amount of different types of government and private plans that offer different coverages and different reimbursements.

• Will pay for x-rays some will not.

• Some will pay for multiple therapies some will not.

• There are some that pay an average of 80% of the usual and customary rate of chiropractic care while some will pay a dismal 50% reimbursement rate.

• Some plans allow for more than therapy in addition to your chiropractic adjustment, some plans will pay for ONLY an adjustment.

At the end of the day, you are comparing apples to oranges to pineapples to mangos to lemons to cucumbers to rosemary….. and the list goes on and on. It is incredibly challenging to find an insurance plan that covers the services that you want. This becomes even more of an issue when the government and not the free market are the ones determining what you should have covered in order to be “healthy”.

The most important thing to understand is that the person treating you SHOULD be the one helping you make decisions on what you need to be healthy. I know that’s something that you can’t always count on. It is best to make sure that your doctor is someone you TRUST. If not, then you’re likely going to be subject to the whims and wishes of the insurance companies guidelines. Again they are set in place for the benefit of their shareholders and not your health.