Serving Chiropractors and Their Patients

How to Obtain and Prioritize the Use of a Patient’s Medical Pay Coverage

Chiropractors are often faced with the situation where they are treating a patient who has medical payments coverage under an automobile policy, or similar “personal injury coverage protection” (Often referred to as “PIP”)  During the course of care, either the patient or their attorney will occasionally request that the Doctor bill an insurer other than the medical pay provider.  As a consequence of such a request, the reimbursement rate is frequently unavailable or lower under another form of insurance coverage.   A contributor at this website, David Michel of Petty, Michel, and  Associates, a leading chiropractic consulting group, recently provided insightful information on how to address this situation involving “medical pay”coverage.  Those comments are stated below:

In Wisconsin, it is the patient’s choice on whether they use their Med Pay or Group Health/Major Med, with the exception of Medicaid. That being said, most clinics have a policy that if the patient chooses to use their health insurance, the policy for health insurance is that all non covered services, visits over the max allowed, co-payments and deductibles, are the patient’s responsibility. Once we present the financial options (ie: let us bill your med pay, which will pay in full, or we can bill your health insurance and your portion will be $1234, how would you like to handle your portion … ), the patient usually decides to bill their med pay.

Most clinics already realize that it is unproductive to bill the third party or party liable for the accident, as they will not pay until the case is completely settled and they do not have any obligation to adhere to the assignment of benefits.

The question really comes up when the patient’s attorney, for financial reasons, tells the DOCTOR to send the bills to Medicaid or group health.

In those situation the doctor can promptly send a letter to the attorney and cc to patient letting them know any policy limits that will result in the patient paying out of pocket for their care or not getting the care they need for the auto accident, and ask the attorney to let us know which way they prefer we go. I have included some of the verbiage below:

We wanted to make you aware of the limitations on this patient’s policy.

(The patient has Title 19 Medicaid). Under Wisconsin laws, Medicaid will only cover a minimal exam, two x-rays, and 20 spinal adjustments. The treating physician feels that Mr. Patient Name needs a more comprehensive exam to document and substantiate injuries received, additional radiographic films, and modalities consisting of therapeutic exercise, intersegmental traction, and electric muscle stimulation. The total per visit, not covered by Medicaid, will be an average of $89 per visit. As Medicaid does not cover these services, and as you are unwilling to provide a letter ofprotection1 and as allowed by Medicaid with advanced notification1 Mr. Patient Name will be responsible for the additional charges each visit.)

(The patient has a managed care plan through ACN under United Health Care). Our experience is that ACN will only cover a minimal exam, two x-rays, and between 8-12 spinal adjustments. The treating physician feels that Mr. Patient Name needs a more comprehensive exam to document and substantiate injuries received, additional radiographic films, and modalities consisting of therapeutic exercise, intersegmental traction, and electric muscle stimulation. The total per visit, not covered by ACN, will be an average of$89 per visit. This would be in addition to the deductible of $500 and a per visit co-pay of $45. As ACN does not cover these services, and as you are unwilling to provide a letter of protection, and as allowed by our provider agreement with ACN with advanced notification, Mr. Patient Name will be responsible for the additional charges each visit.)

All other attorneys we have worked with in our <ten> years of practicing here have not bad a problem with signing a letter of protection in exchange for our agreeing to await settlement. We are not clear on your refusal.

Please indicate as soon as possible, preferable by return call to our office manager, Manager’s Name, or to the treating physician, Doctor’s Name whether you would prefer:

a) We bill the patient’s health policy and change the patient each visit for services not covered, (estimated patient out of pocket approximately $2,400) or
b) You are directing the physician to only provide those services as covered under Mr. Patient Name” s existing health insurance plan, or
c) If you are willing to provide a letter or protection or honor our physician’s lien as executed by our patient/your client. We need your answer on the above as soon as possible so we know how to proceed on this case. You seem to have a specific idea on how you want our office to handle this and would like you guidance on how you would like us to proceed before our patient incurs a large balance.

Mr. Michel also prepared some sample letters which can be sent to the patient’s attorney.  Those letters can be found under the “Forms” section of the Resources page of the website.  The sample letters are found here (under Practices and Procedures).

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