Why We Are a Self-Pay Practice
I am not one for brevity, so I’ve offered the short version and key points first, and then offered the long version afterward if you’re interested.
Effective February 28, we will no longer accept insurance benefits.
Over the past year, we’ve been asked to perform duties related to accepting insurance that are not improving patient care and would force patients to come to the office more frequently for less care.
What this means for you
We’re still in network until February 27, so you can continue to use your benefits until that date without change. On and after February 28, we’ll provide you with the paperwork necessary for you to submit to your insurance company for out of network reimbursement.
Rather than agreeing to the inappropriate rules of engagement with insurance companies who are looking out for their bottom line and not your overall health, we’ll give you the best care and you can get reimbursed for any out of network coverage you have.
Our Rates, Effective February 28:
New Patient Exam: $185
Follow-up Appointment: $85
Dry Needling Appointment: $40 add-on
New Pediatric (under 12) Exam: $125
Follow-up Pediatric Appointment: $65
Re-Examination (for new injuries or patients who haven’t been seen in a year): $105
Acupuncture and Traditional Chinese Medicine Rates:
Acupuncture Initial Visit: $175
Acupuncture Follow-Up Treatments: $135
Additional acupuncture services incur add-on charges:
Re-exam: $40
Cupping or Gua Sha alone: $65-100
Cupping or Gua Sha as add-ons: $45
Herbal Consultation: $85
Herbs: range from $26-50
Facial rejuvenation: $200-$275 (total, not add-on)
If you’re using your in network insurance, you’ll be switched to our cash rates.
If you’re a cash patient: things will stay the same.
If you’re already using out of network benefits, you’ll receive a superbill to submit for those benefits.
If you truly can’t afford to continue care with us after we’re out of network, you can submit financial hardship documentation so that we can do our best to accommodate you, or we can refer you to another practice.
Why we made the change
We want to continue providing the best care, and aren’t willing to compromise that principle.
Long Version
North Carolina chiropractors are part of a clearinghouse (HNS), meaning that we are either “in” network or “out” of network. We can’t select which insurance companies we work with. We knew this when we opted to go in network, but all of the HNS insurance companies seemed to be doing approximately the same things, so it didn’t seem to matter.
In October of 2021, we saw updates to what an insurance company (Optum) was allowing for manual therapies (which is a large part of what we do in practice: whenever we have our hands on you but you aren’t doing exercises or adjustments, that’s considered the billable code for manual therapy). Over the past year, they’ve become more and more stringent, to the point where we’re mostly getting denials on these claims despite our best efforts to document the necessity of these therapies.
Best available evidence supports manual therapies in conjunction with adjustments, but no insurance company will reimburse providers if they do manual therapies in the same region as an adjustment: meaning at no point can I do manual therapy on your neck and adjust your neck and get paid for manual therapy. We used to be able to document that the soft tissue work was done in the thoracic spine or shoulder, but as of last October, most insurance companies followed suit of Optum and decided that neighboring areas also could not be billed for manual therapy.
Essentially, we’ve been put in a place to either do the best care for our patients or get paid for the work that we do. Patients recover faster when we do manual therapy in addition to adjustments, which is why we do it. We want the best for our patients. If we followed the insurance recommendations, we’d increase the number of times you have to come into the office to ultimately recover from an injury.
In September of this year, another notice was sent out: this time starting from Blue Cross Blue Shield. Despite legally (and ethically) being required to do an examination on a patient before adjusting them, BCBS will not pay for those two things to be done on the same day. Within a month of starting care, we are required by insurance companies to perform a re-examination. This means that if we were to follow the insurance company guidelines, on your fourth or sixth visit, we would re-examine you but not treat you.
In order to function under the new insurance model, we would have to separate an adjustment from the examination, again meaning that you would have to come in more frequently for less care. This makes absolutely no sense.
As you know, our initial patient visits are an hour long so that we can thoroughly examine you as well as collect relevant health history and establish a plan for your care that is individualized to you. Rather than performing a separate re-exam appointment, we actually do quite a bit of re-examining throughout your care by auditing your progress through palpation and observation of your movements and the quality of your tissues.
That ongoing level of auditing that we do, which we consider to be the best form of care and has served our patients incredibly well for almost 11 years, is not sufficient for third party payors. We need a longer examination with specific documentation (both taking more time out of our schedule to see and help more patients), which doesn’t actually improve patient care but does show the insurance companies that the care is “warranted.” And we can’t perform that on the same day as an adjustment.
We are again being asked to choose between what’s best for our patients or get paid for what we do. We can continue to do our best work and not get paid for it, but that’s not only unethical, it’s not sustainable and would eventually put us out of practice.
Most people think of paying for their care as a certain dollar amount for a service that they’re receiving. That’s not wrong, but it’s not the full picture. You are paying for an individualized approach to care, the time you spend with your doctor, the education that your doctor received in order to be able to practice in the first place, and the ongoing education that each of us continues to do (exceeding our yearly continuing education requirements by at least three-fold each year) so that you’re receiving the best care possible. You’re also paying for our ability to have a physical office with incredible staff that support our ability to see patients, and the livelihood of the ten incredible people who work at TriangleCRC.
When you use your insurance to pay for care, you’re paying that company in exchange for helping you cover your healthcare expenses. They may or may not do that, but you still pay them. By being in network, we are also paying the insurance company a portion of what you pay for your care and we’ve agreed to be paid a lesser rate for providing care in exchange for your ability to use your insurance and (theoretically) expose our office to more patients. (In reality: insurance is rarely the reason people find us. Our number one driver of new patient calls has always been from referrals.)
Translation: it’s a racket.
We looked back through some reimbursements after the most recent BCBS edit came through in September and Dr. Smith got paid just over $3 after spending an hour with a new patient. Not only did she not actually make any money from the incredible work that she did, we actually lost money as a practice in order to see that patient because we still had to pay HNS, the billing company, staff support, and other overhead expenses.
The insurance company got paid and the patient was cared for, but our office actually suffered financially and Dr. Smith’s work was egregiously disrespected. That’s just one example of many similar ones.
We want to continue to offer the best possible care to our patients, but insurance is trying to force us into adjustment mills by only paying for adjustments. If that’s the type of care you were looking for, you’d already be at another practice. We don’t function that way. We are intentionally a low volume practice who spends more time with patients implementing other forms of active care and manual therapies to best support you in your recovery and health.
When Mary was killed, my immediate reaction was that I couldn’t do this without her. Yes, I can continue to run my office, but I couldn’t do insurance without her. I sat with that thought for quite a while, knowing it ultimately wasn’t true. Of course I can do this, and we are doing this. But then I turned the statement in my head into a question:
Do I want to do this without her?
And the answer is a resounding “no.”
Mary was the person who kept the ball rolling regarding insurance (among many other things). I knew it was a risk for a practice like ours to go in network, but I wanted to try it and said I would remain in network if and until insurance started to dictate the care we offered our patients. I hired Mary to run the front office on our very first day of accepting insurance. She was in charge of all scheduling, billing, insurance, and non-health patient encounters. She did that and more, eventually promoting herself to Back Office Manager (BOM).
At a staff meeting in September, we discussed that if insurance didn’t get their act together, we’d probably end up going out of network because it wasn’t fair to our patients, doctors, or staff. She joked that we wouldn’t need her if we went out of network. That now seems eerily foreshadowing. We can continue to practice how we always have, just without the limitations that insurance had been placing on us.
We can and will continue to do everything we’ve always done: provide the best manual care for our patients within a welcoming environment where people feel seen and heard from the moment they walk in the door. And I will remain true to my word from three years ago: I will not allow insurance to dictate the care that you receive.
I am truly grateful that you entrust us with your care. It is not a responsibility we take lightly.
Yours in Health,
Lindsay Mumma, DC
TriangleCRC President