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HOW DOES IT WORK? I find patients who understand their financial responsibility in our office get the best results and have the best experience. For that reason I will go over some details as to how insurance works and what you can look forward to regarding your care. Remember every policy is different and my description is accurate from a general point of view. The specific coverages of your policy will have to be determined by conversation with your insurance company. Also, in today's day and age, most insurances are not designed to cover all of your treatment. In most cases it is a mistake to expect your insurance to pay the majority of your care, an even greater mistake is to base your treatment on your insurance coverage. That being said, let s get on to the description of the types of policies available. Medicare and medicare supplemental insurances: Medicare works
differently in a chiropractic office than in a general medical office.
Medicare has limitations that you need to understand so that you
can determine to what degree you choose care. Medicare REQUIRES
that spinal x-rays are on file before it will even consider paying
for any treatment. While it requires these x-rays it DOES NOT pay
for them in a chiropractic office. And, when Medicare doesn't pay
for a procedure, your supplement, in most cases, also doesn't. Medicare
also does not pay for physical examinations or physical therapy
that may be needed in your case. Medicare DOES pay for the chiropractic
adjustments and it has limitations of 12 visits in a 12 month time
period. This time period IS NOT a calendar year time period. For
example, if you start on March 17th, HMO: An HMO is an organization that has one major goal, that is, to reduce costs for an insurance company. In many cases an HMO is not even an insurance company. It helps manage the costs for the actual insurance company. Here is an overview of how an HMO works: Initially, an HMO looks like a bargain. There is a monthly premium that looks reasonable. These premiums allow you to have no deductible and usually very low co-pays. Looks good so far. However, here is where it gets interesting. You are assigned or pick a primary care physician. This physician s job is to handle your minor health issues and be a gatekeeper for referrals for more serious conditions . He or she decides the severity of your condition and IF a referral is required. If the gatekeeper decides no referral is necessary, in most cases you have no simple way of getting further care THAT IS PAID FOR BY THE INSURANCE! Notice, I did not say you couldn't get further treatment. I said if the referral is not approved, you can still get the care provided that you pay for it yourself! Unfortunately, in my experience HMO s tend to make financial decisions regarding your health rather than purely health decisions. From my experience, I can tell you that each month or quarter an HMO doctor gets a report notifying him of the amount of referrals he has made and the amount of procedures performed. There is incentive to have less referrals because the amount of referrals and procedures affects your pay from the HMO each month. After understanding how the HMO s worked, I decided I could not in good Conscience treat patients under HMO's and still offer them the quality and quantity of care that their specific condition required. For that reason I am not an HMO doctor. How can I expect HMO patients to visit me given these facts? Let me give you a real time example which may shock you. Let s say your HMO advertises that it allows up to 20 chiropractic visits per year. You go to your gatekeeper and he agrees that a referral is warranted. He pre approves 3 visits. You go to the chiropractors office and after examination and x-ray it is determined that you need more than 3 visits. Unless the gatekeeper, after another visit with him, agrees with the assessment, you will only get 3 visits paid, EVEN THOUGH YOUR POLICY SAYS IT ALLOWS 20 VISITS PER YEAR! There are other scenarios that I could mention & suffice to say they lead to the same conclusion & The HMO determines how much care they are willing to pay for, period. How have
I made the system better for you? PPO insurance: Preferred Provider
Organizations can go by a variety of names & PPO, PPC, POS,
to name a few. The basic rules are these. If you go to a network
provider (ie. Doctor on your plan) you pay either no deductible
or a smaller one, have a smaller co-pay, or pay less percentage
of fees. I am currently on a variety of plans, however, it is literally
impossible to be on all plans. For those patients who have insurances
that I am not affiliated with I can help you determine what your
fees will be in my office. Since most patients are referred to me
by family, friends, or co-workers, I realize you have incentive
to come to my office. For that reason, I will make every attempt
to make your fees manageable so that you can get the care and results
you desire while seeing the doctor you were referred to. Auto insurance: The health part of auto insurance is called PIP, personal injury protection. The standard policy in Florida on the PIP part of the insurance is $10,000 at 80% coverage. While this may seem like a lot of coverage it may not be. For example while that would be plenty for treatment in a chiropractic office, one day at the emergency room and testing could cost $5,000 or more. What if you need surgery? What if I have to send you for an MRI? I think you get the idea. Call your insurance agent and ask how much it would cost to increase your policy to $10,000 at 100% and compare it to $20,000 at 100%. What you will find, as I did, is that this increase is not as expensive as you would expect. Given the high number of accidents during these times, it would be prudent to at least find out and compare. One word of caution& be very careful getting deductibles on your PIP coverage. The deductibles severely decrease the amount of money your insurance company pays on a claim. For example, in order to reduce your premium significantly you would have to take a $2000 deductible. This means that if you have a 100% policy, the first $2000 of medical bills are YOUR responsibility. Now you might say, well, I have health insurance that will cover it. That may be true. However, in Florida, if you have a legal case and get a settlement, any medical insurance payments have to be REPAID to your auto carrier from settlement before you get one dime. So, in essence, you have to pay the deductible amount. By the way, usually this high deductible only knocks off about 12-15% of your premium. If you have a $1200 yearly auto premium, if you are lucky, taking the high deductible option may reduce your premium to approximately $1000. A savings of $200 for sure, but with auto accidents on the rise, only you can determine if the savings is worth the risk. Workers Compensation: If you are hurt on the job a few points to remember. You must fill out a timely injury report and give it to your employer. Second, you must go to the company doctor. For example, let s say you hurt your back lifting at work. After filling out a report, your employer helps you make an appt at the company s worker comp insurance doctor. He examines you, gives you a few days off from work and prescribes medication to help your pain. If you decide you want to go further, you have to notify your employer, but you now have the right to go to my office, for example, and receive the care you may need. I, of course, must notify your insurance company to let them know what treatment I am recommending. If you take these steps, usually things run smoothly.
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Cooper Chiropractic, Acupuncture and Rehab Center
1501 Robert J. Conlan Blvd Suite 3 Palm Bay, Fl 32905
321-726-8116 • www.CooperChiro.com • Stanton@cooperchiro.fdn.com
Cooper Chiropractic, Neurological Diagnostic & Acupuncture Center
