Some time back in the 1980s, ICA and ACA, in one of their rare moments of accord, agreed that it was normal and ethical to itemize and charge for everything you did. There was an attempt to get the profession to escape the "everything I do falls under the office call" thinking and get in step with the health care industry.
At last, it wasn't questionable to itemize your services; it was legitimate thinking. If you did it, you could/should charge for it. Whether you got paid for it was another matter entirely, but they (ICA/ACA) recognized that we did more than just adjust on a routine visit. This type of billing was/is a lot more "honest" because we itemize what we actually do and itemize what we charge for each service.
While I may use one type of insurance as an example, with rare exception, it applies to all insurances. For example, Medicare came out with its "989" codes a couple of years ago. Did chiropractors as a group take the fee they were then charging, only for an adjustment (because Medicare then only paid for an adjustment), and increase their fee to reflect additional service and documentation that Medicare now required? In my experience, no! They took the fee they'd been charging and sliced it up in pieces.
The more savvy DCs added on to their current fee to reflect the additional time and cost of record keeping and additional exams and testing. I understand that many of you may have been doing these services, or a form of them, prior to the code change. Good patient care and prudent record keeping may have required them, but Medicare was not requiring documentation or paying for them. It certainly made sense to increase your fee for an adjustment at that time, because Medicare raised the bar by now including an exam/office visit and supporting documentation in the adjustment code.
A sizable number of chiropractors continued to charge exactly the same amount, which means that they were actually being paid less for adjusting the patient. They now had additional bookkeeping required because Medicare requires that you do a preadjustment evaluation/exam and record the findings. Although Medicare is a federally funded program, the documentation/implementation varies from state to state to one degree or another. One state requires that you have a written treatment plan for the patient that complies with what makes the patient's condition a "payable" one. Another may not.
As the 989 codes use increases and spreads into other areas of insurance/third-party pay, the thinking that it's ok to do more work and get paid less often seems to follow unchallenged. Insurance carriers that once paid full or partial payment for preadjustment exams/evaluations now want you to switch to the 989 codes. They want to roll exams and record keeping into the visit and stay at the same level of payment that was previously used for only an adjustment. Why? Because that's what Medicare does.
Now, when did Medicare ever pay fees that were connected to reality? Medicare freely admits that the fees they pay are only at a percentile of the usual, reasonable and customary fees in a given area, yet we just roll over and take it when other carriers try to fly under the Medicare flag! Worse, in some sort of misguided effort to "make things easier," too many offices convert all possible billings to the 989 codes before carriers have asked. Many do so with adjusting their fees to reflect the increased service and work required.
It's not just insurance that's out of kilter. Take a look at how you are charging your uninsured and underinsured patients. Your are in for a shock. Many patients are paying fees that are less than what it costs you to take care of them. Doctors always insist this isn't so, but without exception, any office I've worked with on money issues has far too many people getting reduced fees simply because they want them. I think there is a logic in being able to charge people less if we aren't required to do every service on every visit.
A restaurant comparison is having the main course without soup and dessert. It's perfectly adequate if you don't need the rest. The restaurant can charge less, and so can you. If the uninsured patient gets the "whole thing" and pays less than the insured patient, there may be a problem. Many of the services we do for the insured patient are just not needed for a cash patient. I'm not talking about compromising the patient's care or health, but cutting down on unnecessary things. Take a look at the thickness of a cash patient's file versus an insured patient's file. We actually do more for the insured patient.
If you aren't doing something for people with real need,* you should be ashamed. If you let people beat you up for a lower fee, you should really be ashamed. Your fee should be realistic and reflect the cost of doing business. Have your accountant help you figure out your overhead and what it actually costs you to take care of someone. That's a fee that you can only reduce for someone who is in real trouble, not someone who wants to buy a boat with your fee reduction helping to make the payments.
There are laws against price fixing. I'm suggesting you fix your prices. If it was possible for a DC to make a good (or better than good) living in 1962, why can't it happen today? No gimmicks, no huge patient loads, no gouging third parties -- just fees that reflect the actual cost of taking care of a patient. Attract patients because you have a great service and you really know how to deliver it.
Now pull up your socks. I don't want to hear about anyone else going out of business because they can't make a living. Your ability to take care of yourself, your family, your patients and your profession are literally in your hands.
* Real need is just that. It is different from want.
* "I need a fee reduction because I'm out of work and am the sole support of two kids. I'm willing to prove this. I'm looking for work and only need a reduction until I'm working again. Of course, in appreciation, I'll never waste your time, miss an appointment, be a problem or fail to say good things about you. I'll try to send you patients who can make up for the financial loss you're taking on me. I'll be a perfect patient."
* "I want a fee reduction because I want the money to maintain my lifestyle. I'm only going to stay around until I get what I want or until I can find someone cheaper. I'll take a lot of your time to be sure you like me and won't cancel our deal. You won't be a priority after I start to feel better, because I didn't give up anything to get it. I'll send you people who I've told how to get lower fees."
