This blog is designed to educate us on improving our health and avoiding the pitfalls of modern medicine. This past week I flew over the edge about something else.
I received an explanation of benefits (EOB) from one of the largest insurance companies (who shall remain nameless) this week. An EOB goes over what our office had billed for services, how much the insurance companies allows, how much they paid and how much the patient owes us.
Now, receiving an EOB is nothing new. Our office gets them all the time. But last year things changed drastically.
Before I describe the changes, you need a little more info as way of background.
I sit on a provider advisory panel for another very large insurance company. They have very clear data that, if a chiropractor is the first person seen for any type of musculoskeletal complaint, we save around 30% (don’t quote me on the 30%–but I’m in the ballpark..). That could potentially mean billions of dollars in savings to this insurance company annually if everyone saw a chiropractor first.
There are now multiple studies that confirm these findings: chiropractic care is safe, saves money and patients are very happy with their care in our offices. But, much like every other profession, we have those in our ranks that have some integrity issues. Here in AZ, much of this centered around billing issues, and, from the information I had been able to gather, it was about 5% of chiropractors that were billing way out of line with their peers.
Billing for massage inappropriately was a biggie. I mean seriously–who would NOT overuse massage therapy if your insurance was paying for it??? But insurance will only pay for massage under some very detailed scenarios, and this is not what was being billed out.
In a perfect world, we would’ve round up a modern day posse and drilled these 5% on their billing behaviors. Maybe they really did have a unique practice that meant they were billing out of line with the other 95% and their treatment notes would’ve held up to scrutiny. Most likely not, though…
Certainly, these outliers were costing this particular insurance company more money. But in the scheme of things, chiropractic reimbursement is a drop in the bucket. As an example of waste billed in other professions:
- More complex spinal surgeries billed to Medicare for $50K more than simple surgeries went up 1500% in 5 years with worse outcomes
- Half of the $50,ooo procedures for putting a stent in the heart (in a non-emergency situation) were unecessary
- Statins like Lipitor and Crestor are just short of worthless, and yet cost society tens of billions per year
Either one of these alone exceeds the entire amount reimbursed to the chiropractic profession annually. In other words, we are such a drop in the bucket cost wise that just the cost of any number of these abuse situations in other aspects of medicine would pay for every chiropractic claim in a year.
Despite this drop in the bucket, we add tremendous value to the system far out of proportion to our direct costs. Our office alone is frequently instrumental in getting patients to change unhealthy habits that will save tens of thousands of dollars for that patient alone.
So back to the story..
Instead of the posse, two of the biggest insurance companies decided to hire a middleman company to manage their chiropractic claims beginning in 2011. Additional paperwork and massive blunders by the middleman company aside, the bottom line is that the contract with this middleman company paid chiropractors in Arizona, on average, 50% less.
Much like every other chiropractic office in Arizona last year, our office took a massive hit. Also, like every other chiropractic office in Arizona, we absorbed almost every dime of this loss so that patients wouldn’t be provided with less care or worse outcomes even if we were no longer getting paid for it (a perfect example–orthotics for the shoes to help people with foot, ankle, knee or low back pain are reimbursed at LESS than the actual cost of the orthotics!! This means that it costs our office money to provide this needed device to patients).
So how does this relate to my recent EOB that I received?
You see, this is clearly discriminatory towards chiropractic care for some strange reason. We are the only provider group that has to use a middleman to manage our claims and take a huge chunk of our money.
Ironically, in AZ this is actually against statute (Unfair Claims Practice Act, ARS 20-461), but the Director of the Dept of Ins wasn’t really interested in getting the problem fixed when asked under oath in court.
Worse, the allowed amount that this particular insurance company now pays dropped massively only for those codes typically billed for by a chiropractor. Evaluation and management codes (referred to as E/M codes–they are the codes that are attached to the initial exam of a new patient or an existing patient that comes in with a new problem) which are billed by all groups of physicians (not just chiropractors) were NOT TOUCHED.
So when I saw this EOB and saw the E/M code reimbursed at it’s normal level, but the other codes that our office typically bill were hacked to pieces, the discrimination was smacking me upside the head more so than at any point in the past.
Where do you come in? Remember that I said that the EOB also describes how much YOU owe? Since your insurance company (if you are insured with one of these two that moved to using a middleman in 2011) now pays less, YOU OWE MORE.
Let me put this in clearer language. Nothing changed. You still get the same great service you always have gotten. But now, the insurance company is saving mass amounts of money on chiropractic services by hiring a middleman, AND you have to pay more!!
I think one of the reasons why this EOB hit me so hard now (rather than over the past 1.5 years) is that I also happen to be insured by this particular insurance company. I have never filed a claim. Never missed a payment.
I just got notice that my premium is jumping 13%.
It must be because of all those damn chiropractors getting paid 50% less…
So, now that you know that insurance companies are slasihing costs everwhere, have you noticed your premiums and out of pocket costs going down?