The leaves are changing, the air is crisping and pumpkin spice has invaded your life with a vengeance. Fall is here, and with it comes open enrollment. This is my favorite time of year.
It’s a rare window of opportunity where our patients can free themselves from plans that have been driving them crazy all year. Unfortunately, for some this may also cause a lot of stress. No one wants to get stuck another year with a plan that costs an arm and a leg but won’t cover any repairs you may need your remaining extremities.
Insurance is an ancient language of hieroglyphics and deductibles to most people which always seem to lead to you paying more than what you think is right for your care.
I have learned over the years, from listening to our patients talk about their premiums and how their coverage was explained to them, that there is no golden insurance company or plan that won’t cost you an extremely high premium. Most plans that are worth their weight are administered by large corporations or federal employers whom the insurance companies cannot risk losing so they don’t mess with their plans. Unfortunately, for us unlucky majority, large insurance companies are developing new tactics that make it difficult to get your care covered.
Examples of this, which we have seen from several heavy hitters in the last couple years, are preauthorizations and “fine print” on basic benefits.
Preauthorizations are marketed to the public as your insurance company making sure that you are only being billed for medically necessary care. They boast that they are keeping you from being taken advantage of by your doctors. While this sounds like they are doing you a favor, in most cases I beg to differ.
There are doctors out there that will go crazy with their treatment plans. Making you sign contracts stating you will have appointments 3 times a week for the next 4 months for a stiff neck or something to that affect. Those chiropractors are out there and I’m happy to say that we are as far away from them as you can get. Our practice focuses on how your body responds to treatment which is why we re-evaluate your progress every 4 weeks so as to alter your treatment plans and treat you only as necessary.
So you would think that with our extensive notes and obviously necessary treatment plans we would have no problems authorizing your care.
Que the paperwork.
Preauthorizations are overseen by a third party who is employed by your insurance company. It is through this company that we submit your findings. We are now required for a large number of patients to fill out extensive paperwork based on tests they have deemed appropriate for us to administer. This third party has taken away your doctors ability to freely diagnose and treat their patients. They must now follow the guidelines of the third party who has developed a generic template for your care.
Another kicker with these submissions are that they are only allowing a certain number of visits over a 30 day period. The first submission we usually receive a reasonable number of visits and then the second we receive less and they generally require a new injury. This means that this third party has decided you need to get better within 4 weeks and only 6 visits or your chiropractor, physical therapist or massage therapist is not going to get paid to treat that area any longer without extensive testing to justify that treatment which will usually account for 4 more visits over another 4 week period. This does not take in to consideration any trips or illness that may interfere with that time frame, it also doesn’t hold the patient accountable for following their prescribed home exercises and healthy posture.
What makes us incredibly frustrated with these preauthorizations isn’t the paperwork or insult to our credibility as diagnosing providers, it is the fact that they are denying your use of the benefits you have already paid for. Each month, a (most likely high) premium is pulled from your bank account with the assurance that it will go to covering the benefits you were told that you had. Now companies have decided that you are unfit to be responsible for deciding when your care is warranted. This third party rates your injury based on a point system and even if you say you have debilitating pain, if they don’t see it in their tests and required diagnosis then your care is not “medically necessary” to them.
There is also the fact that they have not made this clear to their customers. As far as I am aware, there were no notices sent out to their customers that this was taking affect. For some plans it will be automatically implemented in November, most likely without warning. When I go over plans with patients, they usually are surprised that this is part of their plans now since they were assured it was the same plan they had before. A lot of people also don’t realize that when an insurance company denies a claim as unnecessary or if it is too old or improperly coded, providers cannot ask you for what’s owed. So now providers are not getting reimbursed and they are tired of the hoops they have to jump through to get you the benefits you’ve already paid for.
Along those same lines falls the deceptive wording in certain benefits. This will be especially important for you to pay close attention to this November. The issue we have seen the most of this last year was with massage therapy benefits. Massage therapy is typically billed as a code 97124 by a licensed massage therapist. Some massage therapists bill a 97140 but we have been warned not to bill that code by a highly renowned coder since a few states are already requiring massage therapists to only bill 97124 for their services. I can’t tell you how many times we have had patients come in confident in their massage coverage only to be told they do not actually have it. This miscommunication happens in the fine print of your massage therapy benefit.
An increasing number of insurance plans have altered their massage coverage to only allow a chiropractor or physical therapist to administer your massage. This means that any treatments administered by a licensed massage therapist will NOT be covered. They do this because this way they can advertise that the plan has a benefit for massage therapy without actually having to offer those benefits in a traditional sense. This can be very frustrating to our patients.
These are two things you should watch out for when choosing your plan this month. Some more obvious factors in choosing a good plan for you would be the total deductible and the benefits in which it applies.
A high deductible plan, where it applies to all benefits is typically referred to as “catastrophe plans”. This menacing nickname is due to the fact that these plans make sense for the people who utilize their insurance only for large surgeries or bad accidents. They make sense because most of them have a deductible of 3,000 to 5,000 but then cover all benefits 100%, so essentially your heart surgery will cost you $5,000.00 but then all of your check ups, rehab and any additional surgeries would be covered completely for the rest of that calendar year. Castrophe plans are not great for people who see the doctor frequently but do not have anything major which will satisfy that deductible before it resets again the following year, although they do usually come with a much lower monthly premium.
We’ve seen premiums rise exponentially recently and they aren’t predicted to stop rising. This is why it is more important than ever that you thoroughly examine what benefits are most important to your individual needs and what makes the most sense for you financially. It is also important that for employer funded plans, you take your concerns to your human resources department. Providers have been rallying with congress to try and force major insurance companies to withdraw their preauthorization programs and bring down patient responsibility for medically necessary benefits, but the people with the most voice are you, their customer.
Happy plan shopping!