Insurance and Chiropractic

I frequently get emails asking if I take such and such insurance. I wish my response could be as easy as yes or no but it never is. The insurance/provider arrangement is as complicated as a Kardashian relationship. I will try to explain but if you do not understand it is probably not because I am not saying it clearly enough but because it is so stupid you will be left wondering why in the world it is like this.

There are several Health Insurance companies in the US. They are typically large companies that have regional or statewide sub-companies. For example. Blue Cross Blue Shield has corporate headquarters in Missouri (I think), but there is also Anthem Blue Cross Blue Shield which is headquartered in Indiana. Then there is Blue Cross of California, Blue Shield of California, Blue Cross Blue Shield of Texas, Minnesota, Illinois, North Carolina, Arizona, Federal Employees, Exchange (for Obama Care) and the list goes on. The same can be said of all of the rest, too. They are massive entities with more subsidiaries with either identical names plus the region or completely different names altogether depending on merger agreements and who has subcontracted with whom.

Sound complicated? I have just begun. Most, but not all, of these companies do not handle chiropractic claims. Instead, they subcontract out with insurance companies that specialize in chiropractic claims or to similar sized companies who have a local division who does. Most of the time these specialty insurance companies are an HMO. Stay with me, I know what you are thinking. You have a PPO so this does not apply. Yes, it does. They manage PPO benefits, too, but under a different set of rules and typically only if you go to someone out of network. Speaking of networks, doctors never really know with whom they are contracted because companies constantly change who is managing their benefits which changes the network. By the way, different regional companies subcontract with different regional specialty managers.

Now that your brain is hurting a little, let me give you some examples in an effort to help you understand that which is incomprehensible.  Currently, I am a Blue Shield of California provider. I have been for almost 10 years now. On the occasion someone comes in and they have Blue Shield of California, I am in-network. However, I am not a Blue Cross provider because they let an HMO known as ASH (American Specialties Health) manage their benefits. Only doctors willing to contract with ASH can be Blue Cross Providers. So, if someone comes in with a card that says Blue Cross/Blue Shield, we cannot tell if I am in-network or out of network. We can call and hope they give us correct information but until we get the first check with an explanation of benefits, it is iffy.

The BC/BS arrangement is probably the most convoluted. Cigna and Aetna are East Coast companies and so they subcontract their chiropractic benefits to local HMO’s, the most common being ASH and ACN. Kaiser is the largest insurer in California and even they do not handle chiropractic claims. When I first started my practice they contracted with ASH. A few years ago they stopped offering chiropractic benefits across the board. Recently, I think there are some plans that have chiropractic benefits again through ASH. There are smaller local companies like Western Health Advantage who let their subsidiary, Landmark, handle chiropractic claims. Again, they are a managed care company or HMO. Sutter Select, for Sutter employees, is managed by UMR but their chiropractic benefits are now contracted with ASH, even though Sutter employees have a very liberal PPO benefits package. ASH is new for Sutter. Before them, UMR was relatively easy to work with. Now, it is a bunch of red tape and rhetoric.

Then there is the question of in network vs. out of network. If you have an HMO, you have no choice but to go in-network. If you have a PPO, you are supposed to have a choice. Some companies are getting ridiculous with PPO benefits trying to force you into only going to an in-network doctor. They do this by dramatically raising your out of pocket cost if you go out of network like raising your deductible and/or increasing your co-pay amount or percentage to astronomical levels. They want you to go in-network because they have contracts with in-network doctors allowing them to control the amount of care and therefore the amount of money they will be responsible to pay. If you have a plan that punishes you for going to an out of network doctor, chances are the deductible will be so high that the insurance company will never pay anything. For other companies, there is no difference between in-network benefits and out-of-network benefits.

When you ask the question, “Do you take my insurance?” it opens a Pandora’s box of scenarios. Thankfully, my assistants are great at finding the answers and asking the right questions. Besides determining if you have chiropractic benefits, at all, then figuring out if we are out-of or in-network, we also need to discover if you have a deductible to determine how much you will pay out of pocket before the insurance company covers anything. Then, we need to determine how much your co-payment will be after your deductible has been met.

Rest assured that we know what we are doing even if nothing I wrote above makes any sense to you. Our commitment is and always will be helping you live a healthier life. To that end, let me be clear. We will make chiropractic care available and affordable for you regardless if you have no insurance, if you have crummy insurance, or if you have great insurance.


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