Whiskey Tango Foxtrot Insurance?
A new patient came into my office today with a stack of information about a recent car accident he was in. Let’s cut right to the issue. The cost for a local hospital visit, just ONE VISIT; Totaled over $5,000! Of particular interest were the x-ray charges. This new patient’s cost for just one lumbar series of four x-rays of the low back (CPT code 72110) was $550.00. Excuse me?! Does insurance actually pay them that? How can the local hospital justify that kind of cost when most don’t even know what a NORMAL lumbar curve looks like? CLICK HERE for an explanation of the normal structure of the spine.
The combined arrogance and idiocracy are beyond bearable sometimes. For comparison, Corrective Chiropractic currently charges $150 for the same service. And, in my not so humble opinion, the service is superior to that of most hospitals. Specifically, as it relates to patients with spinal structural injuries from whiplash and car accident injuries. Also, every person is able to and in fact required to see their x-rays immediately after being taken, the perks of digital x-rays.
After all, it’s nice to see what is going on without having to wait hours or days later. Only for someone to tell you “it’s not broken so just take these pills for pain and muscle spasm and you’ll be ‘fine’… eventually.”
There are certainly radiologists that are better equipped to read these images and identify specific cancers and pathologies than myself. The key point here is that I don’t indicate they are normal when a clearly abnormal finding is present. This is the beauty of referring out.
Why Refer Out to a Chiropractor?
If I see something that looks questionable, I send the patient and image for a second opinion. Reverse scenario. Radiologist, MD, surgeon, etc. sees an image with not cancer or fractures but with the patient’s neck curving in the complete OPPOSITE direction. Radiograph report reads…. Normal. Fortunately, this is not a problem 100% of the time. However, on the rare occasion that a radiologist recognizes abnormal spinal structures on an x-ray, they will almost NEVER refer that patient to the appropriate healthcare professional, (a structural chiropractor) for the necessary treatment to correct the problem.
If I see something that looks like cancer, I refer to a primary care physician or oncologist. It’s time for medical doctors to be appropriately educated on who the spinal experts are. Hint: no it is not just spinal surgeons.
Don’t forget that surgeons can never FIX abnormal spinal structure. Surgery is sometimes necessary in emergency situations but there is NO case in which a patient’s spine changes from abnormal to normal after surgery. It is NEVER normal to have your spine fused. Your spine is NEVER fixed after surgery. NEVER NEVER NEVER. Stop saying you just want to be “fixed” and then get surgery. You are fooling yourself. Your symptoms may have changed but that does not mean that the structure of your spine is normal. It is not. It is the opposite of normal to have metal hammered into your femur or screwed into your spine. Your spine will NEVER be the same.
Structural Chiropractors have more education and experience reading x-rays than MDs unless they are radiologists. However, a radiologist’s education typically only focuses on the identifying pathologies, like cancer. As a result, there are missed diagnoses that fail to identify and inform other doctors and their patients of obvious spinal structural issues. The same missed diagnosis is seen with soft tissue damage and vertebrae instability seen on flexion and extension (looking down and up) studies of the neck and low back. These images are a Hallmark diagnostic tool to determine ligament damage in your neck. Which is important in determining the severity and treatment of the patient, particularly a patient involved in a car accident.
Maybe it would be important to the medical community if they had a clue how to fix it, but they don’t, and that’s fine. There’s nothing wrong with that unless you think you can charge high prices to repeatedly miss these abnormal findings. Then send the patient home telling them they are fine and the pain will just get better over time. Now obviously, the terrible price point is not the fault of the doctor. That falls on both the hospital and the insurance companies who feel the need to reimburse chiropractors poorly and their medical counterparts not so poorly for the same services (see example above).
I don’t’ have a clue how to perform surgery to remove a cancerous tumor, but I am still responsible for identifying abnormal growths on an x-ray. If I fail to perform this duty in a reasonable manner I could be sued for negligence. An MD has no such responsibility when it comes to identifying abnormal spinal structures, which are a LOT easier to identify on an x-ray than cancer.
Even if the radiologists or MDs were trained to look at spinal x-rays with a minimal degree of scrutiny for structural abnormalities and spinal ligament damage, which they are not, it really doesn’t justify the insane cost difference that you would find in our office. This service being given is the same legally. It’s the same CPT code and the same general area. Insurance companies set their reimbursement rates according to what is “normal and customary” for each CPT in regional areas. I can guarantee you that if I set my prices that high NO health insurance or car insurance (for a personal injury patient injured in a car accident) would pay me in full. NONE! Despite the fact that the quality of the service of far superior in regards to a patient’s spinal structure abnormalities.
Here’s the rub.
In order for insurance to pay me or my patients, I have to set my prices at a rate that is “customary and reasonable” for my area. If I do not. 1.) Insurance can simply refuse to pay. 2.) I will go out of business. How many of you are willing or able to pay $3,000 for the first office visit? Medical healthcare does not have this problem. Reimbursement for chiropractic care and diagnostic testing for the same diagnosis is vastly different.
Recently Corrective Chiropractic briefly got in-network with an insurance company, let’s call them Less Than Optum and Unified HealthCare. They informed us shortly after that they were moving to a “per visit” reimbursement rate to reduce “unnecessary charges”. That rate? $55 a visit. I could do $400 of NECESSARY treatment, exams, x-rays, adjustments, etc. and I would get a max of $55 for that visit total. Being In-network would also mean that the patient would not be responsible for anything beyond that $55. Mmmmm.. $55 for a chiropractor vs. $5000 for the hospital.
Chiropractors are not dishing out heavy duty addictive and dangerous narcotics.
Structural chiropractors are actually, fixing the cause of the problem instead of covering it up. Meaning, you will actually be healthier and with a spine that is closer to normal instead of held together with screws and plates. This means the patient is more likely get better and heal properly with MUCH less risk of future chronic and potentially debilitating symptoms. Resulting in more expensive drugs and surgeries that insurance will likely pay. Although, as many of my patients have reported to me they were told that they should “just get used to being in pain” or “there is nothing wrong with them” despite their pain. The reason they say that is because they don’t know what happens when your spine is in an abnormal position which is easily diagnosed via x-ray.
If that doesn’t sound like Less Than Optum and Unified HealthCare are being unfair, it’s because they are not. I guarantee you no hospital or MD is doing $5000 worth or services for a $55 reimbursement. Granted this example is assuming we are using health insurance and not MedPay or liability auto insurance to cover the costs. But when you get right down to it the same principles apply. We’re just going to stick with the health insurance example for now because it’s easier and more relatable for everyone to understand.
What does this all mean? Here’s the deal.
Currently, insurance is now a “requirement” under penalty of tax fees and ultimately prison if you don’t pay your tax. E.g. more people have insurance and hospitals can set their prices high without fear of losing business because the insurance reimbursement rates are paying them pretty well. While most patients have no clue what they are actually being charged. Hospitals do NOT have to rely on the free market or people paying cash to keep them in business. If they did their prices would be FAR more reasonable. Chiropractors do not receive the same abundant reimbursement rates and covered by health insurance. The above example is just the tip of the iceberg as to how bad it is.
Even my staff didn’t realize how terrible chiropractic reimbursement rates were until our little in-network experiment. Insurance companies fight chiropractors tooth and nail for every dollar. Compared to a hospital who can afford to staff coding and billing employees, small town local business chiropractic doesn’t stand a chance. We don’t’ have the resources dedicated to fighting for the scraps that insurance drops from the table where the hospitals doling out drugs and surgery are eating. Nor should we have to. A chiropractor, or any doctor, should be able to focus on the needs of the patient. Not the insurance company’s red tape requirements.
Let’s take LASIK eye surgery for example.
When this procedure was first developed in was covered by insurance and as a result, MDs and hospitals set their prices high, very high. Fast forward several years later after insurance labeled LASIK as “elective” and thus not covered. As a result, patients had to pay for LASIK out of their own pocket. Guess what happened? The price plummeted. Currently, doctors and hospitals don’t make their prices easily available and they don’t have to compete on price because most patients are unaware of the prices because they don’t have to know them. Insurance segregates them from the need to make price comparisons and acting like consumers. If you don’t have to pay out of your pocket you won’t care what the overall price is, only what YOUR cost is. That’s what happens when someone else is picking up the tab.
Feel free to argue this point but I guarantee you that less than 10% of patients who used insurance to pay their last doctor’s visit have no idea what the actual cost was. And even if they do they didn’t BEFORE they went. They likely just when to whoever was In-network instead of shopping for the best doctor with reasonable fees.
The problem with chiropractors is that the knee jerk reaction is to let insurance dictate our worth.
While medical costs that are excessive are getting reimbursed by insurance companies, reimbursement rates for chiropractic care are minimal bordering on pathetic, often because of managed care. Managed care organizations are a fourth party organization that insurance companies appoint to reduce the costs of the care from the In-network providers they reimburse. In no way does manage care improve the quality of care provided. It often does just the opposite, which is understandable. Your health insurance is responsible to their shareholders and cutting costs makes them happy. Regardless of whether their customers (patients) are getting better.
If you’re a chiropractor you’re likely being backed into a financial corner.
It may be difficult or even impossible to get health insurance to pay more than $55 a visit, regardless of what treatment or tests a patient needs. To make it even harder, managed care in NC, and many other states make it difficult for chiropractors to get paid for more than SIX visits! This arbitrary number is often the “average” that a particular managed care company expects chiropractors to treat. Treating more than this can get you penalized. Most of the time by removing the chiropractor from the network or charging a higher percentage fee for every reimbursement.
Oh yeah, I forgot to tell you that those managed care companies that insurance requires chiropractors to participate in, takes 9-12% of all the chiropractor’s reimbursement. The more treatment a chiropractor gives the more they pay the managed care company. Don’t forget that none of this is based on valid research and is in direct conflict with the organizations. Organizations like the ICA (International Chiropractic Association) Best Practices and Practice Guidelines. But what do you expect? Insurance makes their own rules. They decide what’s “best” not your chiropractor.
The next time you blindly pick an In-network chiropractor for your spinal care, do some research first. Make sure you are getting the kind of care that you want. Not the kind of care that your insurance company wants you to get.