Understanding Your Insurance Coverage

If you have questions about your insurance coverage, billing statements or your balance, please contact our billing specialist, Jene McMahon, at 360-513-5741 or send her an email.

You know the deal. You twisted your back while settling the kids in the car, or you’ve had a vague, nagging neck ache for a few months and just yesterday it flared up badly, so you called the chiropractor your neighbor recommended to make an appointment, and even though money is the last thing you want to worry about when you’re in pain, the whole question of insurance has to be addressed.

Not all chiropractors will bill insurance. We work regularly with most insurance companies.

When you choose coverage with an insurance company, that coverage is a kind of contract where you, as the patient, agree to pay your premiums each month, and you agree to pay whatever cost-sharing is indicated in the structure of your plan. Cost-sharing includes co-payments, co-insurance, and deductibles. Cost-sharing is the portion that you pay for your healthcare so that your insurance company is not paying 100% of your medical costs, and each insurance plan will vary in how the cost-sharing is structured. Your premium contributes to the big pot of money available for the insurance plan to dip into in order to pay the medical costs of other patients, and it provides the confidence of mind to do dangerous and fun things like skiing, or traveling, where injury or accident may strike.

  • Co-payments are fixed dollar amounts which are due at any office visit,
  • Co-insurance is a percentage of the cost of a visit to the doctor. Both co-pay and co-insurance amounts will vary depending on the type of doctor you are seeing.
  • A deductible is the amount indicated in your specific benefit plan that you are required to pay out-of-pocket for healthcare related costs before co-pays, co-insurances, or insurance payments will be effective. When you pay costs towards your deductible with an in-network doctor, you are still benefiting from your insurance company’s network discount.

When a doctor is in-network, it means that that they have signed a contract with that insurance company. This contract requires doctors to write-off some portion of their in-house fee schedule. This cost-saving for the patient is part of the reason why we pay premiums on our insurance: you pay in advance for future cost-savings (and hope it balances out!) When you see a doctor who is ‘out-of-network,’ they are not bound to the lower fee schedule set by the insurance company, and are also covered at a lower rate, which means that if you have a $20 co-payment for an in-network specialist, you may have a $40 co-payment for a specialist who is out-of-network. This also means that even if you paid your co-pay, and the insurance paid their portion, but there were still costs not covered by the insurance, the doctor is legally allowed to bill you for the remaining balance because they are not bound by contract to write-off that portion.

Here, at City Fit, Dr. Herrst and Dr. Jewell are in-network with most local insurance plans.  Our office is out-of-network with OHP, CareOregon, Cigna and FamilyCare.  
So, you’re on the phone to schedule your appointment and we take your insurance ID number, group number and date of birth to verify your coverage for care. Sometimes we’ll  have this information for you directly over the phone, sometimes we’ll send it to you in an email with other information, and sometimes we get it ready for you when you come into the office. We always do our best to make sure that we have the most accurate information on file for your billing so that you get as few surprise bills in the mail as possible, but it is important to know that it is always the responsibility of our patients themselves to know the details of your insurance plan and coverage limitations.

Now, let’s take a step back because things can get a little complicated  here.

All over the world, doctors treat people with back pain, and they do it in several different ways; with medication, with exercise, with surgery, with acupuncture or manual techniques like massage or chiropractic. All of those different treatment types have a code so that if you get acupuncture in India, and your doctor in Australia wants to know about it, she will see the code, and know at least with some specificity, what they did. These codes can be very specific, for example: 98940 is the code most of you will see on a receipt or a billing statement at some point and it means “chiropractic adjustment of 1-2 areas of the spine,” while 98943 indicates a “chiropractic adjustment of an extremity.” Each code has a different price associated with it, and some codes are covered under different benefits. This is why we always check both your chiropractic benefit as well as your physical therapy benefit. Some techniques that our chiropractors use fall under the category of a physical therapy code, and massage therapy is sometimes covered under that benefit rather than a specific massage benefit or under chiropractic benefits. So, this could mean that you have a $20 co-pay for chiropractic care, but any physical therapy codes are covered at a co-insurance rate, or is subject to your deductible.

Co-insurance is another form of cost-sharing, just like a co-payment is a form of cost-sharing. The difference between the two is that a co-payment is fixed dollar amount, like $20 per visit, while co-insurance is a percentage of the cost. When your benefit indicates a co-insurance, we will bill your insurance for the total cost of the services we provide, and they will pay, say, 80% of those costs after the contracted write-off, and then the remaining 20% will be the patient’s responsibility. Your insurance company may determine that the cost is subject to your deductible, which is the amount you agree to pay out-of-pocket before your insurance coverage will kick in (sometimes the deductible is waived on specific services, which we always try to know about beforehand). This is what happens when we don’t collect any payment from you at your appointment time, but instead send you a bill in 5 weeks for your balance due. Remember, it usually takes between 2-4 weeks for the insurance company to process the claim (bill) we send them, so there is always a lag time from your appointment to when we have a balance for you.

So let’s say that under your insurance plan, you have a $500 deductible, a $20 co-payment for chiropractic care with the deductible waived, and a 20% co-insurance for physical therapy subject to deductible, up to 30 visits per calendar year:
We would only collect your $20 co-pay at your appointment time, but once we receive verification from your insurance company, we see that the two physical therapy techniques Dr. Herrst or Dr. Jewell performed on you are accumulating towards your deductible. You would receive a bill in the mail from us either around the 1st or the 15th of the month (depending on your last name), for example, of $60. You would end up paying your $20 co-payment (which does not apply to deductible) at each visit, and paying up to your $500 deductible as per the use of physical therapy techniques in your treatment plan, until your insurance begins paying their 80% portion of those costs, or until you reach your 30 visit maximum, whichever comes first. It may also be that your visit to the dermatologist, or other healthcare provider accumulates towards your deductible and speeds up the process of reaching that bar.

Other things to take into consideration:

  • Keeping track of your out-of-pocket health-care expenses is a good habit, because these costs count towards your out-of-pocket maximum. This is the maximum amount set by your insurance plan that you are required to pay per calendar year for healthcare services. This usually includes co-payments and deductible amounts in addition to any other costs incurred for your healthcare per year. Once you have spent that maximum amount, your insurance company is required to cover 100% of all healthcare related costs.
  • Some insurance plans require pre-authorization before we can begin treatment. What this means, is that if indicated by your plan, a referral is required by a Primary Care Provider or MD that must be approved by the insurance plan for medical necessity before we can begin care.
  • Often we see visit limits on insurance plans as well. This is when your insurance carrier sets a specific number of times treatment of a certain type will be covered. For example, we see many plans with a limit of 12 visits per calendar year for massage therapy. This does not mean that you can only receive massage therapy once a month; you may utilize your benefits as you and your healthcare team see fit.

Please remember that all insurance plans in the US are intended for the purpose of acute injury or illness treatment. Routine maintenance care, or preventative care is unfortunately not built into any health insurance benefit plan. Many insurance plans have also begun to request clinical documents, or authorizations for treatment in order for representatives of the insurance company to determine medical necessity. Should your insurance plan determine that treatment in our office is not medically necessary, the cost for said treatment is the patient’s responsibility.

For patients with no chiropractic care benefit coverage, high deductibles, or for patients who have reached their insurance plan’s limit for care in our office, we do offer ways to help balance the cost of your care.  Please call the office for help.

If you have questions about your insurance coverage, billing statements or your balance, please contact our billing specialist, Jene McMahon, at 360-513-5741 or send her an email (alternativebillingsolutionsnw@gmail.com).