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Chiropractic cash practice vs. insurance: the debate

Should chiropractic cash practice or insurance reimbursement drive treatment recommendations? Is there a difference when care is patient-centered?

Should chiropractic cash practice or insurance reimbursement drive treatment recommendations?

After 35 years in practice, it is still a surprise that the debate of “cash versus insurance” remains a hot topic around the country. Truthfully, does it really matter who pays the bills? The bigger concern is that over time, we have come to rely on insurance reimbursement as a critical decision-making tool when it comes to treatment recommendations.

When did we stop making decisions and care recommendations for our patients based on their diagnoses, physiology and underlying complications, and start recommending plans based on what insurance would cover?

What is this debate really about?

There are many in the profession who believe that “going all-cash” will provide them a sense of freedom and relieve them of the frustrations of dealing with insurance companies. The reality is that by becoming a chiropractic cash practice, other than eliminating the aggravation of dealing directly with the insurance companies, nothing else changes.

You must document correctly, code correctly, bill correctly and collect correctly. Most every state has rules and regulations set forth by boards of examiners that dictate the minimum standards for documentation, billing, coding, and/or the requirements to establish medical necessity. That doesn’t change just because you decided to get out of the insurance game.

Additionally, cash practices still see insured patients as out-of-network providers. If you choose to see these patients, you surely understand that they will take your super-bill or receipt and attempt to submit it to their insurance carriers for reimbursement. Just because you choose not to participate in the health plan does not mean you are relieved of the duty to establish medical necessity or have treatment plans and goals like any other in-network provider.

Market share and patient behavior

In 2017, 91.2% of U.S. adults had health insurance coverage for at least part of the year (Berchick, Hood, & Barnett, 2018). Insured patients are penalized financially if they go to an out-of-network provider. How much does this play into a patient’s decision when selecting a provider?

We conducted a poll of the general public online, in which more than 200 people from a wide range of socioeconomic backgrounds completed the survey. While this was not a scientific survey, it is clearly an indication of how patients think and make decisions. According to the survey, 77% of respondents said they absolutely would pick an in-network provider over an out-of-network provider.

Their comments made it clear that while their health care is important and they want the best doctors, they do have a propensity to go in-network rather than out-of-network.

What about Medicare?

Ten thousand people enroll in Medicare every day. Sixty-four million will be enrolled by 2020, and 80 million by 2030. By 2050, it is estimated that people over 65 will represent more than 20% of the U.S. population (MedPAC, 2015).

Today’s aging population is healthier and living longer, and their goal is to continue living in their own homes. According to AARP, nearly 90% of people over age 65 want to stay at home for as long as possible (AARP, NCSL, 2011). They are a population that wants and needs chiropractic. But, to treat a Medicare patient, DCs have to be a part of Medicare (a form of insurance coverage).

DCs have the option of being participating or non-participating providers, and if they are non-par, the patient can pay them directly. DCs do not have the option of opting out of Medicare and having patients pay directly.

The box-on-the-wall days

I was raised by two amazing parents, also chiropractors, who put a box on the wall that allowed patients to insert payments based on whatever they could afford. Today, we would call it a cash practice, but back then it was just a chiropractic practice. Coverage for chiropractic care was non-existent when my parents started their chiropractic careers.

Medicare began to cover chiropractic adjustments in 1972, which was followed by an era known as the “Mercedes ‘80s.” No one was debating “cash versus insurance” when insurance companies would pay for any service you provided to the patient. Attitudes didn’t change until coverage for chiropractic became more limited, utilization reviews began, reimbursements declined, and denials were on the rise.

Make no mistake. I don’t want to go back to the box on the wall that my parents had many years ago. And, I don’t want to stay in a world where we allow the insurance companies to dictate what can and can’t be done on behalf of patients. Years ago, I decided to focus on patient-centered care and just be a chiropractic practice: not a cash practice and not an insurance practice. What I mean is that I don’t care who is paying the bill, and to be honest, have no way of knowing when I am treating my patients. Recommendations are based on what my patients need clinically, no more and no less. It allows me the freedom to unabashedly tell my patients exactly what they need based on my clinical findings and experience.

There are services that are not considered medically necessary, but that doesn’t mean they are not clinically appropriate. The only thing worse than patients believing that they must not need what insurance doesn’t cover is when DCs begin to believe it, too. Patients bought the lie that if insurance doesn’t cover something, they don’t need it, and what is even worse is that DCs have bought the same lie if they limit recommendations only to what insurance covers.

Don’t limit yourself

Warren Buffett said, “Never depend on a single source of income.” By not defining a practice as cash or insurance, we created a much more stable business model that allows for diverse revenue streams with a healthy case mix of group health, Medicare, Workers’ Comp, personal injury, and a growing number of chiropractic cash patients.

Practices have collapsed following legislative changes due to dependency on a single stream of income, such as personal injury or Workers’ Comp. Today’s patients have become health care consumers and the dollars and cents of chiropractic care matter to them. By simply implementing a rock-solid financial policy and clearly discussing fees and payment policies upfront with patients, DCs can eliminate this problem.

At the end of the day, it shouldn’t matter that covered services are limited by insurance because patients know that the care you recommend is the care they need. And they are happy to pay out-of-pocket. Don’t limit yourself, or your patients, by defining a practice as cash or insurance — simply open the doors and welcome patients regardless of who is paying the bill.

RAY FOXWORTH, DC, FICC, MCS-P, is president of ChiroHealthUSA and a certified medical compliance specialist. He maintains his practice on NewSouth Professional Campus in Flowood, Miss., home to a large multidisciplinary spine center, with services ranging from chiropractic to neurosurgery. He can be contacted through

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