Insurance is confusing. Especially when it comes to coverage.
If a doctor is “in network” that means that they have a relationship between the patient, the doctor and the insurance company in the a somewhat strange relationship. The patient pays the insurance company. However, it is the doctor and the insurance company that have the contract that dictates the patient care. Insurance tries to tell the doctor when it is appropriate for re-exams, treatment and closing out care. This harms the doctor patient relationship because the doctor may not be able to give the patient what they need because care is dictated by the insurance company. The purpose of the “in network” relationship is to SAVE money for the INSURANCE company. It is not to save money for the patient.
The term “In network” as used by insurance companies, is basically a way for costs to be managed by the insurance company. Being an “in network preferred provider” for Blue Shield for example, we have to sign a contract each year in which we agreed to limit procedures and visits in order to cut costs for the insurance company. This can cut care plans short because the patient does not want to pay any further costs out of pocket. Does that sound like it is in the best interest of the patients? We did not think so. What this means is even though your actual Blue Shield insurance policy benefits may say you get “20 chiropractic visits per year.” Your insurance can stop paying because they don’t think it is medically necessary and we won’t find out that visits aren’t covered until the visits are already used. So, what this means is that you don’t have the insurance that you thought you had and are paying out of pocket for such visits.
The old fashioned way of insurance policies really utilized the patient/doctor relationship. The contract was between the patient and the insurance company as it should be. The doctor is not involved with the insurance company. Doctor prescribes best care and focuses only on that. Patient decides if they want the care. Patient pays insurance company. Insurance pays patient and patient either pays the doctor in full with cash or brings in the insurance check.
In the new, in network design, the doctor is obligated by their contract with your insurance company to limit visits. For example, Kaiser Permanente they limit all coverage to 5 visits per year as an average. This is without even knowing about injuries. If patients go past 5 visits, enormous paperwork is involved with information begging for more visits. If not approved, those visits will not be covered under their policy and the patient will have to pay for each visit not covered. This occurs normally AFTER the visits have already been used.
If you are a chiropractic patient and your policy says you get 20 visits per year and your chiropractor tells you they can only bill 6 for you and you are in pain, how would you feel? Most patients do not like this one bit and it was very hard for them to understand, especially if they clearly needed more visits. In most scenarios the patient gets angry at the doctor and their facility instead of the actual insurance company. Note: the doctor has no power or negotiation ability with the insurance company and if they are submitting billing to them, it is as a courtesy to you.
The visit limit is just one example of how preferred doctors are limited and controlled. Basically someone in a big office who has never met the patient is telling the DOCTOR what they can and cannot do for you. Telling them how many visits you can be seen. This is independent of what you may need or what you have paid for on your policy.
The bottom line? What does this mean for you?
Your insurance coverage may actually be much better for chiropractic care if you see an “out of network” doctor. This allows your doctor to provide the care that you and the doctor feel you need, not some adjuster that reads a piece of paper stating how much they are willing to allow you to use.
Any visits billed to Blue Cross or any other insurance company must still be “medically necessary” as most insurance does not pay for chiropractic “maintenance care even though there are many times when it is necessary. Just know that getting low cost insurance isn’t really saving you money, it is limiting your care and in most cases you end up paying out of pocket for visits that they do not cover.