Does Your Colorado Insurance Carrier Meet the Minimum Definition of a Chiropractic Benefit.

2011 Colorado Chiropractic Listserv  Survey:

Position Statement on Colorado Insurance Carriers Meeting Minimum Standard Definition of an In-NetworkChiropractic Benefit.

A chiropractic benefit shall include:

1. Coverage of diagnostic examination and periodic reexamination necessary to render safe, appropriate chiropractic care separate from treatment procedures. This includes diagnostic imaging and clinical lab testing.
2. Coverage of 1-3 individual treatment procedures within the scope and expertise of a chiropractor including:

1.      Chiropractic adjustment of the spine or extremities

2.      Adjunctive supportive procedures (1-3 units of 15 minutes per date of service) including

• Heat and cold therapy
• Trigger point therapy
• Therapeutic exercise such as core stability and other injury preventative strategies.
• Dry needling and acupuncture
• Spinal decompression therapy
• No coverage for treatment procedures that are considered investigational or experimental.
• Copay or coinsurance that are no more than 30% the usual cost of an average office visit. Many carriers are calling chiropractors specialists simply to charge a higher copay than your primary care copay. A specialist copay is intended to offset the fact that specialists have higher treatment costs to the insurer. This, in fact, is NOT the case with your chiropractic care.  
• No per diem coverage where a copay is $30 and usual office visit costs between $40-95 for the above services yet the insurer attempts to attract providers that will simply do potentially less than a case needs for a $45 per diem reimbursement even though your policy covers 1 manipulation and 2-3 adjunctive procedures above.

Method of Survey:

• 700 Colorado chiropractors were polled whether each major Colorado insurance carrier met the minimum standard necessary to provide adequate and basic chiropractic care to Colorado consumers. An insurance carrier meets the minimum standard if more than 60% of respondents replied “meets” (meaning that carrier meets the minimum standard in their policies to provide safe, comprehensive chiropractic care).

Carrier (In network contracts only)	Status	Issue	Affect on Consumer
Aetna	Meets
Cofinity	Meets
Humana	Meets
United Healthcare	Meets with conditions	Fee for service contract that covers each service a patient needs however providers are “tiered” by a network administrator Optum Health based upon how closely they can match network “averages” for how many times doctor bills for a high vs. low complexity exam, xrays, and even supportive therapies.	Assuming all clinics see the same type of cases and pressuring providers to conform to those artificial “network averages” is unethical. Sports clinics or those with a high population of seniors will xray more cases than wellness clinics for example.
Cigna/Great West	Does not meet	Per diem contract that reimburses chiropractor $45 for visit regardless of what case needs while its network administrator Columbine Health Plan charges Cigna $61 for your care.	Consumer only receives a portion of what a case may need even though your policy clearly states covers manipulation and up to 3 supportive therapies if medically necessary. Examination and diagnostic imaging is not covered so those costs are rolled into potentially longer treatment plan/your time than necessary.
Kaiser	Does not meet	Per diem contract that reimburses chiropractor your copay for visit regardless of what case needs while it’s network administrator Columbine Health Plan charges Kaiser up to $220 for your initial visit for capitated care.	Chiropractor is pressured to discharge a moderate to high complexity case prematurely as it’s not cost effective to see an individual patient more than 2-3 times even though your policy clearly states your chiropractic benefit provides comprehensive care.
Blue Cross Blue Shield	Does not meet	Per diem contract that reimburses chiropractor $45 for visit regardless of what case. .	Consumer only receives a portion of what a case may need even though your policy clearly states covers manipulation and up to 3 supportive therapies if medically necessary. Examination and diagnostic imaging is not covered so those costs are rolled into potentially longer treatment plan/your time than necessary.
Medicare	Does not meet	Per diem contract that reimburses chiropractor $40-45 for visit regardless of what case.	Consumer only receives a portion of what a case may need even though your policy states it covers chiropractic care if medically necessary. Examination and diagnostic imaging is not covered so those costs are rolled into potentially longer treatment plan/your time than necessary.
Medicare supplements	Does not meet	If a service code, trigger point therapy or xrays for example,  is not covered under your primary Medicare policy it won’t be covered by your supplement. A supplement only covers the unpaid amount your primary policy did not pay on a covered service.	Consumer only receives a portion of what a case may need even though your policy states it covers chiropractic care if medically necessary. Examination and diagnostic imaging is not covered so those costs are rolled into potentially longer treatment plan/your time than necessary.

How do I get my employer to improve my access to chiropractic care?

The answer is complicated for all parties involved. Employers are trying to get the best overall benefit value for their employees via their human resource department or benefits agent who advises your employer on such matters of value. Prioritize what services (medical, chiropractic, and prescription drug benefits) are most utilized by yourself or your family. Communicate those priorities and this position statement to your employer and benefits agent so that they can make informed decisions every year at your annual enrollment period.

Additionally, find peace that if your insurance carrier doesn’t have your personal health strategies and ideals reflected in your chiropractic benefits, ask your employer to drop your chiropractic benefit and fund your HSA account equally instead. Many times seeing a out of network provider on a self pay basis costs only slightly more than your historically high specialist copay to see a chiropractor. With this employer-employee HSA arrangement, you see the best possible chiropractic provider and each case gets exactly what it needs. Please understand that your insurance carrier’s ONLY criteria in contracting providers is simply who is the lowest bidder. Clinical experience, post-graduate specialty training, efficiency in managing challenging cases, or patient satisfaction are given no consideration. Doctors are like all other professionals ie the lowest bidder for a job may not have the same level of communication with other providers, specialized training, years in practice, etc. Sometimes in network providers  simply can’t provide comprehensive care if your insurance carrier has forced them into a contract that they can only do 1 procedure ie adjustment even though your case needs core stability education that takes 30 minutes the first few times you see your chiropractor. Measure overall value not just whether the provider is in your network or not. The services an out of network chiropractor can provide in some cases (United, Cigna, Blue Cross specifically) are drastically different than what an in network provider will provide because they simply don’t get reimbursed to provide anything above the bare minimum the case needs.

For the purpose of analogy, if your insurance carrier above does not meet the minimum standard of a chiropractic benefit above, your employer is effectively paying for gym membership for it’s employees however when you arrive at the gym you’ll be directed only to use the weight room because that’s what the insurer has negotiated with the gym who have accepted this contract.

The greatest travesty occurs when employers are charged for adequate chiropractic benefits with in or out of network chiropractors yet fail to deliver even the minimum standard to provide individualized chiropractic care as defined above.