July 2005

Can insurance and cash coexist in a subluxation‑based wellness practice?

by Dr. Dennis Nikitow

I often get asked if you can combine the use of both insurance billing and cash in a practice without shifting the patient's focus on subluxation‑based wellness to just back pain treatment. The answer is found in your positioning.

Let me go back about 20 years when I was teaching the "Cash Practice Seminar" to start the cash practice trend. It was my humble beginnings in chiropractic that got me to realize you could build a large healthy practice by conveying the principles of chiropractic in a specific way ‑‑ so patients would value it and put chiropractic on their health care team for their entire family.

It had nothing to do with cash vs. insurance but with the focus patients had. Patients who understood chiropractic principles had higher value for chiropractic for overall health and wellness. They understood that subluxations don't cause symptoms, but interfere with the nervous systems control of busy functions and therefore health potential. They understood their kids could be subluxated without knowing it, and therefore got their kids under chiropractic care to maintain their spines.

In contrast, insurance practice patients focused on back pain related conditions. They would do chiropractic care if insurance would pay. Otherwise, in order to achieve their desired outcome of pain relief, they'd use whatever medical means insurance would cover.

The patient's focus and resultant practice identity was a result of the doctor's focus and identity.

Although most doctors embrace the chiropractic principles and philosophy, some run a paradoxical practice of pain relief because they need to satisfy the insurance protocols, parameters, and guidelines in order for insurance to pay their patient's bill. Therefore, they communicate in insurance language, identify patient problems with insurance protocols, and structure what the patient needs based on what insurance will pay.

Since our actions follow our focus, insurance‑based doctors speak the same language to their patients. In essence, their patient education becomes symptoms, condition‑oriented because this is the language they use to speak to insurance companies, i.e., that same message is carried over to the patient.

On the other hand, the cash‑based doctor is communicating subluxation‑based principles to maximize patient value, resulting in patients finding a way to do chiropractic for their entire family regardless of insurance payment.

Since insurance code‑based charges are higher ‑‑ but in line with what insurance will pay ‑‑ the insurance‑based doctor's focus becomes more concentrated on understanding the maximum reimbursement for each specific code. As long as everything is in line, the insurance pays and both sides are happy.

The problem is these doctors are frustrated with the insurance game of code numbers, changes in restrictions, increased paperwork and the time and focus needed to substantiate payment and receive insurance reimbursement they are solely dependent on for their income. The appeal of a cash practice, on the other hand, includes less hassle with paperwork, prepayment of services by patients who understand the principle of chiropractic and why we should be on their health care team, families' adherence to maintenance and prevention concepts, and the satisfaction of spinal correction to a consistent model.

Although fees for service are lower, they are in line with what people could realistically pay for themselves and their families. The trade off is higher volume, and bringing wellness service to more people.

The question is, can the two be blended to maximize profitability, yet maintain subluxation based wellness philosophy? The key is in a few important strategies.

First, the focus and communication doctors lead with must be "value driven" by conveying the principles and philosophy of chiropractic so patients understand that they put a DC on their health care team to maximize nerve integrity for optimum health potential. Once patients place a high value on chiropractic and commit to care, the administrative side of the practice can move easily. They must understand that the spine has a normal model, and that they'll be on a corrective care program to restore their spine to that normal model.

Next, patients need to be clear on the fact that all adjustments, exercises and rehabilitation are to change nerve muscle memory so the spinal model can be restored and evidenced on, before, and after x‑rays. Adjustments are not to merely correct symptoms.

You can incorporate a rehabilitation center in your practice to help accomplish this. This could include exercise equipment for strength, stretching and proprioceptive training. If these fall within the boundaries of restoring the spine to its normal model, it aligns with the chiropractic philosophy of correcting the VSC for maximum nerve integrity and optimum health potential.

Put together cash packages for rehab under "bill insurance under PT or rehab," since it will be more reimbursable than under chiropractic.

By having retail fees and prepay cash fees, you can have options for the patient to maximize affordable correction. If you bill insurance, then charge retail fee but have discounts for rehab packages if prepaid cash. Use in‑clinic rehab for a short period of time as an intensive phase to get the patient moving in the right direction, and continue home rehab throughout the entire corrective program and maintenance program.

Recommend only what's needed to help restore the spinal model and do not base rehab recommendations on insurance coverage.

Don't include therapies at rehab. Therapies are symptom treatments and are within the boundaries of pain practices not subluxation‑based wellness practices.

If the doctor remains focused on correcting subluxations and restoring the spinal model then I feel both insurance and cash can be integrated nicely. The key is the patient's understanding of chiropractic, commitment to spinal correction for optimum wellness, and putting a DC on his or her health care team.

If patients commit to using chiropractic care it will be because they value it, not because of insurance payments. Insurance then becomes a feature to use or not use as partial reimbursement for adjustment services or rehab. Most important, patients will continue their care for maximum spinal correction and be excited about the outcomes.

The result will be a healthy practice with families, higher volume, larger profitability, with less administrative hassles.

(To learn about the Certainty System, Certainty Practice Products and Dr. Dennis Nikitow's upcoming seminar schedule, call 800‑544‑3884. Outside the U.S., 303‑721‑6202.)