Insurance: How does it work?

Here is a non-exhaustive oversimplification of how insurance works in relation to your visits to our office. Take 5 minutes to read this and you will better understand insurance. Hopefully.

First off: the insurance statement you receive in the mail from your visit is called an Explanation of Benefits (EOB). It is not a bill.

We take all insurances, including Medicare*. We are currently only in-network with Blue Cross Blue Shield. In rare cases, your policy may not have out-of-network benefits (most of the time out-of-network benefits are just a reduced rate).

All of the different services we provide in our clinic have corresponding Current Procedural Terminology (CPT) codes. For example, 98940 is the code for a standard spinal manipulation, or "adjustment." Based on your area code, each CPT code has a monetary value according to standard insurance fee schedules. The total billed amount on the EOB reflects the combination of CPT codes that were performed on your visit. Certain CPT codes can have multiple units performed per visit, like when soft-tissue mobilization is performed on multiple areas.

The deductible is an out-of-pocket amount that must be first met before the insurance company reimburses the medical provider for its services. Your visit to the chiropractor applies to your major medical deductible. The deductible can either be an individual or a family amount.

Once the deductible has been met, your policy pays at a certain co-insurance rate, ranging from 50-100%, leaving the patient with what is either called your "patient share" or "patient responsibility." Your patient share is the copay that you pay our office while your insurance is paying. Every insurance company and policy is different, so patient shares vary.

After the deductible there is an out-of-pocket amount, which may or may not include the deductible amount. Like the deductible, the out-of-pocket amount may be either an individual or family amount. After the out-of-pocket amount is met, coverage jumps to 100% of the allowable, leaving the patient with no payment responsibility.

Once insurance starts paying, you most likely have an annual maximum specific to chiropractic or physical therapy. This may be a dollar amount, number of visits per year or number of days per year. Once the annual max has been met, insurance no longer reimburses us and the patient is left with full patient responsibility the remainder of the year.

Other things to note:

  • The average policy refreshes per calendar year regardless of effective date, meaning the deductible and out-of-pocket amounts refresh and must be re-met; some people have carry-over that allows amounts from the last 3 months of the year to apply to the next year's deductible
  • Your policy may have restrictions on number of modalities/codes per visit (i.e. your policy may allow one manipulation CPT code and 4 modality/physical therapy CPT codes per visit)
  • Sometimes your policy may give you a copay on the "office visit" CPT code. There is a difference between an office visit and treatment, so a visit to our office may reimburse us for that particular code, but the patient is still left with the patient share for the treatment CPT codes.
  • *MEDICARE: Medicare only covers the "spinal manipulation" CPT code (i.e. if you come into our clinic for tennis elbow, Medicare will not cover it)
  • You may have a pre-existing waiting period after your effective date saying your insurance will not cover treatment on injuries previously recorded


If you have any questions regarding insurance, call our office and ask for the office manager, Charis. She will be happy to take some time to go over your benefits and billing.