Services & Techniques

Medicare allows only services that are medically necessary, except as mandated by statute. For chiropractic services, this means the patient must have a “significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct, therapeutic relationship to the patient’s condition and provide a reasonable expectation of recovery or improvement of function. The patient must have a subluxation of the spine, as demonstrated by x-ray or physical exam.”1 I’m sure some of you are wondering – “what does that even mean?” stick with me and I’ll explain!

Every single chiropractor and every single speaker we have heard speak on Medicare (seldom from Medicare) will have slight variations of this. What does this mean?

It appears to me that in the world of musculoskeletal pain, insurance companies prefer to see the following:

1. Injury date

2. Exam

3. Treatment Plan

4. Condition/issue resolved at the end of the treatment plan

Frankly, I like that plan too and wish that is how it always went. However, any health care provider who has been working with patients more than 6 months soon figures out that some conditions are chronic. Most patients with chronic pain find they can keep that pain tolerable if they keep consistent with certain activities. That may be diet, weightlifting, running, yoga, meditation, stretches, walking, and believe it or not, regular chiropractic care.

Regarding most insurance companies, and specifically Medicare, it is not medically necessary to treat a patient knowing that improved pain and function is unlikely. What many chiropractors and patients find frustrating is that they have to wait until the pain becomes significant enough to limit their function.

To sum this up, I want to share a story a speaker once told us. Mary is a Medicare patient with chronic low back pain. From time to time she uses a variety of health care options, but finds the most success with chiropractic. She lives on the 3rd floor of her apartment building. If she isn’t careful, her low back pain can get significant enough that she is unable to climb the stairs to her apartment. She and her chiropractor have been able to maintain her lifestyle through regular chiropractic care. Some might call this maintenance care – in this example, 1x/month. If Mary is seen 1x/month, she has very little trouble. Unfortunately, Medicare does not deem this medically necessary. To bill Medicare, we must have reasonable certainty that we can improve function - in this example, able to climb 3 flights of stairs. So until Mary is in so much pain she can no longer climb her stairs, she is not able to bill Medicare.

No doubt, this is a confusing topic that I could go on about. The key takeaway is it is possible to be treated by a chiropractor and not bill Medicare. Medicare is a wonderful insurance, but it is not a free for all. If you have questions about this, I’d be happy to visit with you.


Sources:

1. cms.gov/medicare

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