Why doesn’t Health insurance cover Maintenance and Supportive Chiropractic care?

A more accurate name for health insurance would be “crisis insurance” or “sickness insurance”. They cover care to get a person out of crisis, but are not set up to enable a person to reach and maintain good health.  Insurances cover the initial portion of care to improve your condition.

The fine print of insurance policies and/or contracts between insurance companies and chiropractors clarifies that care needs to be “medically necessary” to be covered by the insurance. Around fifteen visits for a new condition can be considered “medically necessary” depending on severity of the condition. Beyond this number of visits, care falls into a “stabilizing”, “maintenance”, or occasionally a “supportive” classification.

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Insurances do not pay for maintenance or wellness care.

This is periodic tune-up treatments to maintain the health of the spine and nervous system. This allows your body to maintain and heal itself as well as possible and reduces the likelihood of pain returning.

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Insurances do not pay for supportive care.

This is care where there is no significant expected improvement even if continued care is keeping the patient from becoming worse. This would be people with severe pain and flare-ups who have to come in for care frequently but are not expected to significantly improve.

Frequently Asked Questions

Why don’t insurances pay for stabilizing, maintenance, or supportive care?

Just like with your MD, insurance will cover any treatment to get you out of “crisis mode”. If your MD prescribes you medication and lifestyle changes, insurance will cover that medication (sometimes), but will NOT cover the cost to you for those lifestyle changes. Insurance is not here to make sure you live an optimally healthy life or to make sure it takes care of your day to day needs. It is here help if you are in severe pain or in a health crisis.

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Why can’t we just keep sending care in to the insurance and see if they cover it?

It is the doctor’s responsibility to submit claims to insurances according to contracts between providers and insurances. A post-payment audit months or years after care is provided could be performed where a representative of the insurance would review the documentation and decide if the care provided was “medically necessary”. If the insurance representative decides care doesn’t meet the required standard, payments made to the doctor could be required to be paid back to the insurance by the provider. In some situations this could even result in accusations of fraud against the care provider.

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How do I know when my care switches back to being covered by my health insurance?

Your care could be submitted to your health insurance again if you have a significant new condition such as a fall, car accident, or flareup requiring an exam and plan of care involving 2-3 visits per week for at least three weeks.