"Insurance doesn't pay for maintenance care." How many times have you heard that line? It's been repeated so many times that many people in the Chiropractic profession actually believe it. Indeed many people in the insurance industry believe it. However, what if I told you that insurance plans, including Medicare, pay for maintenance care every day, and in fact have been doing so for decades? You'd probably think that I was crazy or at least mistaken. Well fortunately neither is true. Insurance companies do pay for maintenance care…just not Chiropractic maintenance care.
Before I go any farther explaining this issue, let's define what is considered active/corrective care and what is considered maintenance care. To do this let's turn to the Centers for Medicare and Medicaid Services (CMS) for the definitions.
Active/Corrective care: Active care may be defined as a treatment plan that contains any intervention that is expected to be an improvement in, or arrest the progression of the patient's condition. In other words Active Therapy is anything that seeks to improve and/or correct the issue that is causing symptoms.1
Maintenance Care: "Maintenance therapy is defined (per Chapter 15, Section 30.5.B. of the Medicare Benefit Policy Manual) as a treatment plan that seeks to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, the treatment is then considered maintenance therapy."1
The manual goes on to define chronic subluxation by saying that "Chronic subluxation-A patient's condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered."1
Medicare Rules Set the Standards
Now, armed with these two definitions, you may be asking if Medicare is the only entity that uses them, or if other insurance companies do as well? In order to answer that, we simply need to state that Medicare generally sets the standards for both reimbursement fee schedules, and billing and coding requirements.
In other words, Medicare must be the lowest payer, and most private insurance companies use Medicare billing guidelines for their own billing and documentation requirements. Therefore whatever Medicare determines is maintenance care, other private pay insurance companies do as well, which is how we have arrived at the generalization that insurance does not pay for maintenance care.
However, Medicare does pay for maintenance care, but not Chiropractic maintenance care! Here's an example. If we do a phrase search of the Medicare Benefit Policy Manual in PDF format, and search for the phrase "maintenance therapy", we get 12 hits. In other words the phrase "maintenance therapy" is mentioned in the manual 12 times. 10 out of the 12 are relating to Chiropractic, 1 relates to rehabilitative services, and the other is a reference to the maintenance therapy dose for vitamin B12, which incidentally is covered by Medicare.
[pb]The point here is that the only two places that the phrase "maintenance therapy" is used in the Medicare Policy Manual, are in the sections relating to Chiropractic and rehabilitative services, both of which are services that a Chiropractor may provide. No other type of provider mentioned in the Medicare Policy Manual has this restriction placed upon them.
So how does Medicare, and more broadly, the insurance industry as a whole handle reimbursement for treatment plans that use pharmaceutical methods of care?
Drug Therapy: Is it Maintenance Care?
Well, let's first look at some common pharmaceutical methods of treatment (drug therapy) and see which category they would fall into.
According to the Merck Manual 17th edition, there are generally four classes of drugs that actually correct the problem for which they are prescribed. These are: antibiotics2 (antibacterials), antifungals3, and antivirals4. Certain chemotherapeutic agents may also fit into this classification as well5. So how does this work? If someone takes an antibiotic, the drug kills the infection and "corrects" the problem. Same can be said about the case of antifungals. Antivirals are used to drive the virus into dormancy and therefore correct the problem according to the definition above. Lastly, certain chemotherapeutic agents kill cancerous cells, which is the reason why they are prescribed. All of the drugs classes that have been mentioned thus far either kill or eliminate the source of the problem for which they were prescribed, and therefore fit the definition of active or corrective care.
But what about some of the most popular drugs that are prescribed today? Drugs such as: those that lower cholesterol, blood pressure, blood sugar, and drugs designed to ease asthma symptoms. Each of these drugs maintain, or prevent deterioration of a chronic condition. In other words if the patient stops taking them, the signs and symptoms come back. The condition has not been corrected, and therefore these drugs, by definition, have to be classified as MAINTENANCE DRUGS! Remember that contained within the definition of maintenance therapy is the term "Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further treatment is considered maintenance therapy."
In other words if we look at a condition such as type II diabetes, pharmaceuticals are prescribed to lower the patient blood glucose levels. Once the optimum level is reached, the drugs are prescribed continually to maintain blood glucose levels within a normal range. The treatment that was prescribed was never intended to correct the problem, but merely lower blood serum glucose levels and keep them at that level. Once the patient stops taking the drug, the serum glucose levels go back up. Nothing was corrected, and the underlying problem still remains.
OK, now that I have your attention, what about vaccines? Which category do they fall into? Well, by definition, vaccines "seek to prevent disease", and therefore fall into the maintenance drug category. At this point if you're not hopping mad you should be.
We as a profession have bought this stupid policy that insurance companies do not paying for maintenance care for too long. Almost all health plans pay for the maintenance drug classes mentioned above, some on a 90 day refill basis and most on a 30 day. But none pay for Chiropractic adjustments on similar maintenance schedule, even though a properly delivered Chiropractic adjustment removes the subluxation for which it was given. Paying for one type of therapy on a monthly basis and not another reflects outright discrimination against the Chiropractic profession.
What Can Be Done?
So what can be done? Well in the past, not a whole lot. Remember that at the heart of this issue is Medicare, and because Medicare is a federal law and not an insurance company, it literally takes an act of Congress to change it. Additionally, with this discriminatory language being written into the federal code, there was little hope of ever getting private insurance companies to change their policies regarding non-reimbursement for Chiropractic maintenance therapy.
However, with the Supreme Court of the United States (SCOTUS) upholding of the Patient Protection and Affordable Care Act (PPACA), we have hope. The PPACA contains a nondiscrimination section, (section 2706) also known as the Harkin amendment that changes the rules of the game and gives us the firepower to correct this issue like we have never been able to do before.
[pb]It reads:
''SEC. 2706 o42 U.S.C. 300gg–5.. NON-DISCRIMINATION IN HEALTH CARE.
''(a) PROVIDERS.—A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider's license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.6
The passage of the PPACA, with section 2706 in place, creates a federal law that leaves insurance companies, including CMS, only two choices moving forward.
After January 1st, 2014 health insurance companies can force the appending of the AT modifier on all of the four corrective drug classes mentioned earlier, and eliminate payment for all maintenance drugs, which would eliminate the discriminatory practices against us, or they can remove the requirement of the AT modifier for Chiropractic adjustments, and pay us for Chiropractic maintenance care. There is no middle ground under this new law. I bet you can guess which option they won't take. The removal of payment for maintenance class drugs would result in an outcry from the public at large, as well as financially damage the pharmaceutical industry, which are two very powerful lobbying groups.
So how do we get the insurance industry to comply with this new law? Well in order to begin, ALL OF US have to understand that we are being discriminated against on a daily basis, and begin to reframe the conversation. We as a profession have to give a voice to this issue and let congress, Medicare, and the insurance industry know that we've had enough.
Start talking to and writing insurance companies' provider relations departments about this issue. If they know we're on to them on a national scale it will affect the game I assure you. Also, we need to begin talking to our patients about maintenance drugs and how they fit the same definition as maintenance adjustments, but that maintenance adjustments are not covered and drugs are, even though drugs are more expensive and have some bad side effects.
Next, our national organizations must begin to take this fight to CMS and private insurance companies and not be afraid to stand up to them. It's high time that we as a Chiropractic profession quit rolling over and playing dead for the insurance industry. We are not the bargain basement of health care, and should not be discriminated against. Lastly, it may take legal action against the insurance industry to win this fight, but it is a fight that we must have, and a fight that we can win.
Dr. Jarod Adlington, DC CCIHS is the president and CEO of HRV Enterprises, and a clinician in full time Chiropractic practice for over 11 years. He is also an educator, and author in the field of Heart Rate Variability. He has delivered post graduate seminars on HRV to doctors and staff throughout the United States. He is the author of several books, including A Physician's Guide to HRV and ANS Assessment. He can be reached at drjwadlington@yahoo.com.
References:
When sports chiropractors first appeared at the Olympic Games in the 1980s, it was alongside individual athletes who had experienced the benefits of chiropractic care in their training and recovery processes at home. Fast forward to Paris 2024, where chiropractic care was available in the polyclinic for all athletes, and the attitude has now evolved to recognize that “every athlete deserves access to sports chiropractic."
It is estimated that 61% of patients with CTS avoid taking surgical options due to postoperative complications and costly surgical procedures. Chiropractic care offers a comprehensive and effective treatment for carpal tunnel syndrome, addressing the condition from multiple angles. Recent studies also have unveiled a game-changing adjunct to chiropractic treatments for CTS: nerve flossing.
Some doctors thrive in a personality-based clinic and have a loyal following no matter what services or equipment they offer, but for most chiropractic offices who are trying to grow and expand, new equipment purchases help us stay relevant and continue to service our client base in the best, most up-to-date manner possible. So, regarding equipment purchasing: should you lease, get a bank loan, or pay cash?
