The problem with medical insurance

My wife and I pay about $1200 a month for our personal medical insurance.

That’s a hefty chunk of change and yet by no means an expensive plan comparatively speaking, but since we pay for insurance, that means everything we need is covered, right?

No.

Oh, well we can at least choose the best provider in Portland for specialty care, though… Right?

Yeah… also a no. That insurance plan only allows you to see providers “in-network”.

Hmm.. Well, I need this procedure done and found a provider “in-network” who thinks it should fix my problem and wants to do it. So my insurance will let me do it and cover all of it, right?

Oh boy. No. No. Noooo.

I mean, it’s possible, but not guaranteed. They might approve it and pay for some of it and you may be paying the cost of the rest. It depends on a lot of things completely outside of you and your doctor’s control:

1) If the AI insurance software that sorts your claim finds the right combination of words and phrases that it likes, it MAYBE will approve your claim.

2) If it gets denied by the AI filter, then the random 3rd party insurance adjuster (NOT A MEDICAL PROVIDER) assigned to your case MAYBE will decide that there is sufficient enough documentation that you need this procedure and push it through OR deny it because they think (despite their lack of medical education) that it doesn’t meet the standard to be approved.

3) If that random 3rd party insurance adjuster (NOT A MEDICAL PROVIDER) decides you need the procedure, then they decide how much they are willing to pay for your procedure.

4) If insurance agrees to pay a portion for that procedure, your “in-network” doctor is then forced to accept whatever price the insurance company offers. This leaves them to decide to either pass the remaining cost of the procedure off to you (the patient) or eat that cost.

FUN FACT: The amount insurance actually pays your doctor will be a lot less than what your doctor needs to charges for that procedure because seeing you (the patient) for that procedure, costs that doctor X amount of dollars in materials, employee wages/insurance benefits, utilities (electricity, water, internet, sewage, trash), rent/mortgage, loan repayment, liability insurance, and so much more.

Your doctor cannot eat that cost and they have to pass the cost on to you, the patient. In many cases, insurance reimbursement is low enough that the only way the doctor can make it work is to cut down the time they spend with you so they can see more patients to pay the bills.

So, chances are that you are going to be paying for at least a chunk of that procedure either in your co-insurance, co-pay, or your deductible. IE paying additional on top of whatever your monthly insurance payments are.

5) Lastly, there may be procedures that your insurance just flat-out won’t pay for even if it’s beneficial for you. So in those cases you are stuck with the full cost of the procedure usually at full price.

Why?!

Because in many cases, your doctor cannot offer you a lower price for those uncovered services as they have legally binding contracts they have to sign with insurance companies saying so.

…Yikes. Well my insurance now may not be great, but at least when I turn 65, Medicare will kick in and pay for all my healthcare needs. I’ll just wait until then to see my chiropractor and have my knee and shoulder finally addressed.

Oh boy. Buckle up.

Did you know that Medicare only pays for spinal manipulation and NOTHING else? Did you know that what Medicare pays for spinal manipulation is often less than what it actually costs a chiropractor to see a patient?

FUN FACT: Medicare will not cover the following services performed by chiropractors:

-Physical exams

-X-rays ordered or read

-Rehabilitation exercises

-Lifestyle counseling

-Nutritional counseling

-Massage

-Passive stretching/mobilization

-Myofascial work

Current medical research shows that the best care pathway for musculoskeletal injury is a combination of hands-on therapy (massage, passive stretching, myofascial work, mobilization), rehabilitation (home exercises/stretches), and lifestyle counseling (nutrition, stress management).

Why doesn’t Medicare cover these things? Call your state representatives and ask.

Wow. I had no idea the medical insurance system was that flawed. So… what should I know about providers who don’t take insurance?

If you find a provider who doesn’t work with medical insurance, this means they have wised up to the flawed system and refuse to let the quality of their care suffer as a result!

Longevity Chiropractic is a great example of this.

By not dealing with medical insurance, we are able to offer you the care you need, not the care you have to accept. There is no guesswork about whether or not a procedure is covered, how long your provider can spend with you, what services they can provide, and you will never receive unexpected bills due to medical insurance not paying out!

Our longer visits cost less cost than any other clinic in the area because we aren’t stuck playing the insurance games. We’re able to focus our time working with YOU to help you get out of pain, return to normal function, and prevent your injury from causing you problems down the line.

So let’s get to work and get you back on your path to Longevity!

Sources:

https://www.medicare.gov/coverage/chiropractic-services