Q: I have a patient whose insurance plan limits annual chiropractic services to 20 visits per year, but has 45 visits for physical therapy. As a chiropractor, is it possible to access and get paid for doing physical therapy services when the chiropractic benefit is exhausted?
A: It has become increasingly common for insurance carriers to place a limit on services, whether it is a number of visits or a monetary cap. These allowances vary from one type of provider to another and may be based on specialty or license. (This practice should change once the Harkin amendment on equality is enacted in 2014 under the new health care reform regulations. Under the terms of that amendment, a practitioner working within their scope cannot be discriminated against, regardless of their profession.)
A common example of limits of care is as you stated - the policy limits chiropractic visits to 20 per year, but allows 45 visits for physical therapy. In the past, it was common that a plan of this type would continue to pay the chiropractic provider for physical medicine and rehabilitation services when the chiropractic benefit was exhausted. Though manipulation was no longer payable, the physical medicine and rehabilitation services would be paid separately to the doctor of chiropractic. Manipulation, although provided would be the responsibility of the patient, as there was no further insurance benefit.
However, I have noted some recent changes whereby carriers are not allowing a continuance of payment in this fashion. In these instances, the carrier is limiting not the type of service, but the specific provider of services. They will deem any service performed by the chiropractor as chiropractic and any services performed by a physical therapist as physical therapy, and in fact, that is a correct determination. The allowances of services are distinct and separate based on the provider of services.
A prime example is the California workers' compensation system, which allows 24 visits to a chiropractor, 24 visits to a physical therapist and 24 visits to an occupational therapist. Each provider has their own distinctive allowance and may not use the DC, PT or OT limits after their visit limit is exhausted, regardless of the services provided. This clearly is a limit based not on the service, but who delivers the service.
Therefore, we cannot assume that a policy with greater benefits for physical therapy would cross over and allow continued chiropractic care for physical medicine services. In deference, I am sure chiropractors would be in agreement that they would not want a physical therapist who has exhausted their benefits to continue using the benefits under the policy for chiropractic.
Consequently, it may be possible that you can continue to be paid for physical medicine and rehabilitation services after chiropractic limits are exhausted. However, do not assume such; verify with the insurance company. Specifically, inquire whether the visit cap on chiropractic is based on manipulation services only and if continued physical medicine and rehabilitation services will be paid under the higher limits for physical therapy.
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