Chiropractic Treatment of Children: Reimbursement Issues

Issues in insurance coverage of chiropractic care for children Imagine successfully treating a 10 year old child for low back pain, torticollis, asthma, or otitis media, only to be denied reimbursement by the insurance company citing “treatment unproven and investigational.” In 2007 one major national carrier released a policy which would have denied treatment to children and adolescents citing treatment as “unproven.” 1 That policy was suspended but other discriminatory benefit policies still exist in scattered payor systems around the United States. When faced with improper denials, what should you do? How would you respond? This article explores the issue of discriminatory insurance reimbursement related to chiropractic care of children and provides strategies to address these issues when they occur. Most large payors avoid obvious discriminatory policies by stating that reimbursement does not depend upon the age of the patient, but upon the ICD9 and CPT codes submitted. Therefore while many carriers do provide reimbursement for common childhood conditions managed by chiropractic physicians, others may take a more back-door approach for denials. Some carriers may implement internal edits which match certain diagnostic codes to employer identification numbers which identify the provider type, and when a chiropractic physician is identified, payment is denied. Chiropractors should report all improper denials to their national association. When a policy is identified that affects the treatment of children, our profession needs to act, as it did in 2007 to obtain the suspension of the policy mentioned above. For some outside of the chiropractic profession, treatment of children seems illogical, even dangerous. Why? Similar to the general population, most medical physicians and insurance administrators are unfamiliar with the literature related to the chiropractic management of childhood disorders. Additionally, most have never witnessed a spinal manipulation and/or do not consider the reality that chiropractic is a profession, not a procedure. All too often medically oriented providers and administrators reduce the chiropractic profession, for reimbursement purposes, to the single procedure of a chiropractic adjustment, coded as spinal manipulation(s) (ex., 98940-CMT 1-2 areas, or 98941, CMT 3-4 areas). based upon licensure alone many insurers inappropriately deny reimbursement to chiropractic physicians for other medically necessary services such as E/M codes, nutritional analysis, advice on fitness, wellness, and prevention, which are all services normally reimbursed if provided by medical physicians. The evidence base for chiropractic care for children with mon-musculoskeletal conditions