Understanding your health insurance benefits is a critical park of seeking out any kind of medical treatment. We often hear from people interested in CLEAR treatment that have questions about whether or not it will be covered by their insurance company.
To help you find answers, we’ve put together the following information to guide you through this oftentimes complicated and frustrating process.
How CLEAR Can (and Can’t) Help
When a chiropractor completes our Certification Process, they are allowed to refer to themselves as CLEAR Certified and their clinic as a CLEAR Scoliosis Center. However, CLEAR does not own these clinics, nor does CLEAR have any control over their fees or insurance billing policies. For this reason, you will need to contact each clinic directly to inquire about their fees and insurance information.
While state and federal laws tend to make it impossible for us to make this process easier for you, there are some ways that we can help you to navigate the confusing landscape of insurance reimbursement for CLEAR scoliosis treatment. Please keep in mind that these are general guidelines, and ultimately the responsibility for payment and finances rests between you, your treating doctor and your insurance company.
In-Network and Out-of-Network Doctors
Every healthcare facility has the option of being either a Provider (In-Network) or Non-Provider (Out-of-Network) for each insurance company. Insurance companies prefer for patients to visit their In-Network doctors. This is because, in signing the contract with the insurance company, the doctor agrees to provide certain discounts and to allow the insurance company to decide in part what services the patient should receive.
Doctors who choose not to sign this contract are considered Out-of-Network, Non-Providers for that insurance company. Your insurance company doesn’t want you to visit these doctors because these doctors have not signed a contract to agree to provide discounts to the insurance company, among other things. So, the insurance company will ask you to pay more to visit doctors that are outside of their network.
If there are no other specialists in the network who can provide these services, some insurance companies are obligated to provide coverage for Out-of-Network services at the same level as they cover In-Network services.You may want to inquire about this with your insurance company if your chosen CLEAR Scoliosis Center is Out-of-Network for your plan.
Understanding Your Insurance Benefits
It’s important to understand that your insurance policy is a contract between your insurance company and you (or your employer). Different insurance plans have different chiropractic benefits; it’s important to purchase a plan with good chiropractic benefits if you want these services to be covered. Similarly, it’s important to purchase a plan with dental benefits if you want good dental coverage.
Every doctor wishes that all of the services that they feel are necessary and beneficial for their parents would be 100% covered by the patient’s insurance, but insurance companies are for-profit businesses whose primary goal is to make money, not to be responsible for the health of their customers. And while your chiropractor wants to help you navigate your health care challenges, they are best positioned to treat your spine and not complicated insurance matters like denials and appeals or figuring out your specific plan.
Determining What Insurance Will Cover
If you want to determine what your insurance company will cover, the first step is to call the number on the back of your health insurance card and inquire about your coverage for chiropractic and physical therapy services. Your CLEAR doctor may be able to provide you with a list of CPT codes, which stands for Clinical Procedural Terminology. These codes are numerical descriptors used to identify various healthcare services. By providing a list of these CPT codes to your insurance company, they should be able to tell you which services are covered under your policy.
Also, be sure to ask if Preauthorization is required for any services, and, if so, for which ones. When you became a customer of your insurance company, you signed a contract which gives them the right not to pay for certain services if you don’t follow the correct process for seeking prior approval. This can be inconvenient to say the least, but keep in mind that it is in the insurance company’s favor not to pay for healthcare services. If some services require Preauthorization, be sure to follow the steps to obtain it. If you don’t, you may then be responsible for the charges.
Letters of Medical Necessity (LMN)
The CLEAR Scoliosis Institute has provided all of its doctors with a detailed and comprehensive Letter of Medical Necessity (LMN) template that satisfies all local and federal guidelines for documenting medical necessity to all major insurance companies. A Letter of Medical Necessity can only be written by the doctor after they have had an opportunity to evaluate you in person and review your x-rays and medical history. This can be a helpful document in obtaining Preauthorization, however, it can sometimes be a little bit of a “Catch-22.” The insurance company will refuse to let the doctor see you until you submit evidence of medical necessity, and the doctor cannot provide evidence of medical necessity until they see you.
Payment for Treatment
In most cases, your CLEAR Scoliosis Center will ask that payment is due at the time that services are rendered. Just like with every other business, you become obligated to pay for a service once it’s been provided.
We do understand that it can be frustrating to cover the cost of services in full and then wait for reimbursement from your insurance company without knowing exactly what portion they will cover. Please remember that your doctor is not responsible for the decisions and rules set by your health insurance company. Their primary obligation is to do the best job they can to take care of your spine.
Your CLEAR doctor might also provide you with a “Superbill” that you can send to your insurance company (or they may provide assistance to you and submit this bill to your insurance company on your behalf). Your insurance company will then respond with an EOB (Explanation of Benefits) that goes over what services they reimbursed, as well as which ones they did not, and why.
If You are Denied Coverage
If there are any services which are not covered, your next step will then be to appeal the decision of the insurance company. Your doctor can provide you with a Letter of Medical Necessity as described above, as well as copies of your clinical records explaining why the treatment is necessary.
It is important to directly address the reasons why the insurance company denied coverage for those services. If the reason is because they are not covered under your plan in accordance with the terms of the contract you signed with the insurance company, it can be very difficult to formulate a successful appeal.
Appeal Timeline and Process
After filing the first appeal, your insurance company will have some time to review your appeal and eventually respond (they have a maximum of 60 days in which to do so). If the first appeal is denied, most insurance companies will then grant you the right to a second appeal, which usually comes in the form of an internal “peer-to-peer review.” This means that your chiropractor will get on the phone with another physician who is being paid by the insurance company and have a discussion about your case. Technically it is supposed to be a peer, meaning a member of the same specialty, but most times it is a medical doctor.
After reviewing the doctor’s notes and the specific clinical details, the peer doctor will then make a recommendation to the insurance company regarding reimbursement. In some cases, they may even recommend that the insurance company make an exception to its policies. This can happen when the CLEAR doctor does a very good job of demonstrating how the treatment is reducing and stabilizing the scoliosis and helping the patient to avoid surgery.
When the insurance company is confronted with the choice between covering $5,000 in chiropractic care or covering the cost of a $120,000 spinal fusion surgery (with a risk of complications and additional surgeries that they must then cover on top of the initial cost), strong documentation and objective evidence of the success of treatment can make a very big difference in the amount of reimbursement you may receive!
Filing a Complaint
If, however, the results of the peer-to-peer review are still disappointing (or, as has happened before to me, the insurance company refuses to even grant a peer-to-peer review), there are still a few options remaining.
The best option is for the patient to file a complaint with their state’s Health Insurance Commissioner. You can also file a complaint with your state’s Office of the Attorney General. If your health insurance policy is provided by your employer, you may wish to contact their HR department to explain your situation and ask for their help in switching plans or negotiating with the insurance company. Since employers typically sign larger contracts with health insurance companies than do individuals, they may have more weight at the bargaining table. You can contact the U.S. Department of Labor’s Employee Benefits Advisors for help with this at (866) 444-3272.
Lastly, you can also contact lawyers who may be interested in filing a lawsuit against the insurance company. While this may seem like a drastic step, patients of CLEAR doctors have successfully worked with lawyers to file lawsuits against large insurance companies, demanding payment in full for their treatment and therapy items (like the Scoliosis Traction Chair). These patients had successful verdicts covering 100% of the costs of their care as well as their legal fees!
Health insurance in America can be a tricky landscape to navigate. By researching your benefits in advance and being proactive in working with insurance companies, we hope the process of finding insurance coverage for CLEAR treatment is as pain-free as possible.
What has been your experience having CLEAR treatment covered by insurance? We’d love to hear from you in the comments below.