Chiropractic and Insurance: What You Need to Know
Updated: Oct 5
When searching for a chiropractor, one of the first questions many people ask is, “Does this chiropractor take my insurance?”
At Stiso Chiropractic, we understand how important that question is. Our office has been serving patients in Manasquan and the surrounding New Jersey communities since 1965, and we have decades of experience working with health insurance companies, Medicare, Medicaid, and automobile insurance.
Dr. Frank R. Stiso, DC participates with many major insurance plans, including:
Medicare • Horizon Blue Cross Blue Shield of New Jersey • Blue Cross Blue Shield • Aetna • Cigna • UnitedHealthcare • Oxford • AmeriHealth • Oscar • Medicaid/NJ FamilyCare • Horizon NJ Health • Aetna Better Health • UnitedHealthcare Community Plan • Wellpoint, and many other insurance plans and networks. And we also treat patients who have been injured in automobile accidents.
Insurance can be complicated. Understanding your deductible, copayment, coinsurance, out-of-pocket maximum, visit limitations, and the difference between primary and secondary insurance can help prevent unexpected bills. Our experienced staff will make every reasonable effort to verify your benefits, but we also encourage every patient to understand their own insurance coverage.
When a chiropractor participates with an insurance company, it generally means the doctor is part of that company's network.
It does not mean that every chiropractic service is automatically covered.
Insurance companies offer many different plans, and benefits can vary significantly from one plan to another. Two patients who have the same insurance company can have completely different coverage.
Coverage may depend on:
· Your deductible
· Your copayment or coinsurance
· The insurance company's allowed amount
· The diagnosis being treated
· The number of chiropractic visits allowed
· Whether prior authorization is required
· Whether a particular service is excluded
· How much the insurance company will pay for a particular visit or service
Chiropractic Coverage Can Depend on the Diagnosis
Some insurance plans determine whether a service is covered based on the diagnosis being treated. For example, certain plans may not cover treatment for TMJ/TMD when performed in a chiropractic office. Some plans also have restrictions on examinations and X-rays performed in a chiropractic office. Medicare and some Medicaid plans have specific rules regarding these services.
This is why being told that a chiropractor is “in-network” does not necessarily mean that every service performed by that chiropractor will be covered.
Does Insurance Cover Wellness or Maintenance Chiropractic Care?
Another common misconception is that having chiropractic insurance benefits means insurance will pay for regular adjustments indefinitely. Most health insurance plans require treatment to be related to a symptom, condition, or diagnosis that meets the insurance company's requirements for covered care.
Routine wellness or maintenance chiropractic care may not be covered, even when a patient believes continuing care is beneficial. Dr. Stiso can provide care that you choose to receive, but whether your insurance company is required to pay for that care is a separate question.
Understanding Common Insurance Terms
What Is a Deductible?
A deductible is the amount you may have to pay for covered healthcare services before your insurance begins paying according to the terms of your plan.
What Is a Copayment?
A copayment, or copay, is a set dollar amount you pay for a covered service.
What Is Coinsurance?
Coinsurance is generally a percentage of the insurance company's allowed amount that you are responsible for paying after applicable deductible requirements have been met.
What Is an Out-of-Pocket Maximum?
Your out-of-pocket maximum is the amount your plan requires you to pay toward covered services during the plan year, subject to the terms of your policy.
Once the applicable maximum has been reached, the plan generally pays 100% of covered services for the remainder of the plan year.
Does Insurance Limit Chiropractic Visits?
Some insurance plans limit the number of chiropractic visits they will cover during a calendar or benefit year. Other plans may require additional documentation or authorization after a certain number of visits. It is important to know whether your plan has a maximum number of chiropractic visits per year before beginning treatment.
What Is Secondary Insurance?
Some patients have two health insurance policies.
Generally, the primary insurance processes the claim first. If there is a remaining balance, the claim may then be submitted to the secondary insurance according to its coordination-of-benefits rules.
Having secondary insurance does not necessarily mean that you will have no out-of-pocket responsibility.
Why Insurance Verification Is More Complicated Today
Insurance verification used to be relatively straightforward. A doctor's office could call the insurance company, speak with a representative, and ask specific questions about a patient's benefits.
Today, many insurance companies direct healthcare providers to online portals or systems such as Availity to verify benefits. The problem is that electronic benefit information is not always complete. Some insurance companies also limit the information they will provide to healthcare providers over the telephone.
Patients themselves can often obtain more detailed information because they are the member of the insurance plan. For this reason, our staff will make every reasonable effort to verify your benefits, but we strongly encourage patients to contact their insurance company directly.
Always Document Your Insurance Verification Call
This is an important step that many patients overlook. When you call your insurance company to ask about chiropractic coverage, write down the date of the call, the name or identification number of the representative you spoke with, and the reference or call number provided by the insurance company. Also write down exactly what you were told.
For example, you might ask:
“Is chiropractic treatment covered under my plan?”
“How many chiropractic visits are covered each year?”
“Do I have a deductible or copayment?”
“Are chiropractic examinations and X-rays covered?”
“Is there any restriction based on the diagnosis?”
Always ask for the representative's name and a reference number for the call to keep it with your insurance records. Why is this important?
Occasionally, a patient is told by an insurance representative that a particular service is covered, only to have a claim later processed differently or denied. Having the representative's name or identification number, the date of the call, and the reference number gives the insurance company information it may be able to use to locate the original call or documentation.
If the insurance company maintains a recording of the call, that information may help support an appeal when the information provided to the patient conflicts with the subsequent processing of the claim. It does not guarantee that an insurance company will overturn a denial, but documenting the conversation gives you much more information to work with if a dispute occurs.
Chiropractic Care After an Automobile Accident in New Jersey
Automobile accident insurance works differently from traditional health insurance. New Jersey is a no-fault automobile insurance state. In general, medical expenses resulting from an automobile accident are handled through Personal Injury Protection (PIP) regardless of who caused the accident, subject to the applicable policy and New Jersey law.
One of the first questions is therefore not simply “Who caused the car accident?” but rather “Which automobile insurance policy provides the applicable PIP coverage?”
What If You Were the Driver?
For the driver of a vehicle, the automobile insurance covering that vehicle is generally the starting point for determining applicable PIP coverage.
What If You Were a Passenger?
Passenger claims can be more complicated.
Depending on the circumstances, applicable coverage may involve:
· The automobile insurance covering the vehicle in which you were riding
· Your own automobile insurance
· An automobile insurance policy covering another vehicle in your household
· Other applicable coverage depending on the circumstances
New Jersey has specific rules governing the priority of PIP coverage. Our office therefore gathers detailed information about the accident and the available automobile insurance policies rather than simply assuming which insurance company should be billed.
Our Experience With Auto Injury Patients
Our office has treated patients injured in automobile accidents for decades. We also work with personal-injury attorneys and understand that an automobile injury case involves more than simply providing chiropractic treatment. When requested, our office prepares narrative reports and detailed medical documentation regarding a patient's injuries, examination findings, diagnosis, treatment, response to treatment, and prognosis.
Dr. Stiso has also worked with attorneys in matters involving expert testimony. Proper documentation can be important when an injured patient is dealing with insurance companies, attorneys, automobile adjusters, medical treatment, and other issues following an accident.
An Experienced Chiropractic Office for Insurance Patients
Our practice has been serving New Jersey since 1965. Over the decades, the insurance industry has changed dramatically—from simple telephone verification and paper claims to today's electronic portals, automated systems, complex networks, and increasingly detailed benefit requirements.
Our experience allows us to help patients navigate that process. Whether you are looking for a chiropractor who accepts insurance, a chiropractor who accepts Medicare, a chiropractor who accepts Blue Cross Blue Shield, Aetna, Cigna, UnitedHealthcare, Oxford, AmeriHealth, or Oscar, or a chiropractor experienced with Medicaid and automobile accident injuries, our office can help you understand the insurance information available to us and get your treatment started.