INVESTING IN YOUR HEALTH

 

Medicare has a specific published definition of “medically necessary” and will only pay for services that they consider to be medically necessary:

 

Necessity for Treatment.

The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition and offer reasonable expectation of recovery or improvement of function. The patient must have a subluxation of the spine as demonstrated by x-ray or physical exam…

Medicare also has specific published guidelines stating what treatments are not considered medically necessary.

 

 

Maintenance Therapy

Under the Medicare program, chiropractic maintenance therapy is not considered medically reasonable or necessary and is therefore not payable. Maintenance therapy is a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life, or therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.

 

Medicare has other guidelines about what is not covered. Medicare also requires that the patient be billed for all services provided to the patient, whether they are a covered service or not. The code manual lists thousands of codes, many of which are within the scope of practice for chiropractors, but Medicare covers only three codes. These three codes are all for spinal manipulation, and the only difference between the three is how many of the five regions of the spine are treated. Medicare may require the chiropractor to take X-rays or perform an exam, but they are not covered services. Waiving fees for services required leaves the provider open to legal penalties. For example, say a patient is out walking their dog and the dog suddenly jerks the leash, resulting in an injury to the shoulder which subsequently causes dysfunction in the neck. This injury requires an exam, but since Medicare does not cover this service, the patient much be billed. The neck problem is caused by the shoulder problem. Until the shoulder issue is corrected, the neck problem will not resolve. Medicare will not pay for adjusting the shoulder, so the patient must be billed for correcting the shoulder issue. Not collecting these charges can be considered Medicare fraud. The government has determined that waiving these fees is an inducement for you to seek treatment from that provider, and the provider can be punished by fines and other legal proceedings.

 

The chiropractic technique that we employ, while it addresses the neuromusculoskeletal conditions recognized as medically necessary, excels in what is not covered in that it “seeks to prevent disease, promote health and prolong and enhance the quality of life or maintain or prevent deterioration of a chronic condition.” Our goal is to not only correct neuromusculosketetal conditions, but also to promote health and enhance the quality of life.

 

Since at least some of every treatment we provide to patients fits the Medicare description of “maintenance” which would have to be billed in addition to the covered services, we have determined that for Medicare patients all treatment plans seek to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition.

 

This decision allows patients to receive the care their condition requires without the concern of whether or not it is a covered service. This results in a more predictable fee and has the effect of saving the patient money, even without possible reimbursement for some portion of treatment.

 
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