This is a topic that can be confusing to a lot of people. Insurance companies and the Office of the Inspector General (OIG) are cracking down on treatments that are not “medically necessary.”
There are two types of care: 1) Active or Acute Care, and 2) Maintenance or Wellness Care.
1)Active Care
Active care is the treatment of a specific medical condition, new or chronic. For example, if you have a sports injury or fall and there is a new problem or exacerbation of an old problem. A treatment plan is required that includes specific and measurable objective goals (such as range of motion or improvement in activities of daily living). For a chronic condition, treatment is covered if it is expected to improve the condition; with the caveat that eventually the condition will reach a level of what is called “Maximum Medical Improvement” and no further progress has been observed or is expected. The patient is then switched to maintenance care. Since commercial or private insurance companies most often follow the guidelines proposed by Medicare, maintenance treatments are not covered and are to be paid out of pocket.
2) Maintenance/Wellness Care
By Medicare’s definition from their provider manual:
Maintenance therapy: includes “services that seek to prevent disease, promote health and
prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic
condition. When further clinical improvement cannot reasonably be expected from continuous
ongoing care, and chiropractic treatment becomes supportive rather than corrective in nature,
treatment is then considered maintenance therapy.”
It is part of the provider contract that we be compliant with Medicare guidelines and violation of this statute can result in an audit followed by the insurance company demanding the inappropriated funds be returned to them–which then can become the responsibility of the patient. If your doctor is billing maintenance visits and getting them paid, there is an unnecessary risk of a potentially large bill, depending on how many visits are considered maintenance in the audit.
With that said:
Now that we understand the difference of Active vs Maintenance care, an important point must be emphasized. If you are on maintenance and something happens, such as an injury, fall, or even a flare up, the doctor can do an exam and make a new treatment plan for the new problem; which WILL be covered by your insurance (provided deductible is met). The plan may be simple and last a couple weeks to get you over the flare up, or longer depending on severity of injury. Once the treatment plan is finished and a return to preincident status is achieved, the patient is switched to maintenance care once again.
Why isn’t maintenance care covered?
In my opinion, the medicare demographic (people over 65) all have some condition that may be chronic or something they have been dealing with for a long time that has no expectation of total resolution; therefore chiropractic care is always medically necessary. The same can be said about high level athletes that demand 100% from their bodies during sport. Unfortunately, insurance companies do not see it that way and they make the rules, with which we must be compliant. Budgets, profits, and administrative costs all have to do with this and these guidelines are not always made by doctors.
However, with regular treatments, quality of life can be maintained and the condition can be managed at a much greater level than without maintenance treatments. It is a lot like getting in shape: getting in shape takes a lot of work and dedication, but maintaining that strength is much easier. Since injury often occurs when we exceed our ranges of motion, I can’t emphasize enough how important it is to maintain good joint ranges of motion with maintenance care.
If you have further questions, please contact us at the office and we would be happy to answer them.