Discussing Your Spine Related Treatments with Health Insurance Providers

Discussing your spinal care with health care providers can be tricky. Given recent developments in health care reform, there are realities to contend with:

Fact # 1: In spite of reforms, health care costs have risen significantly.

Fact # 2: This increase in costs does not necessarily translate into improved health care.

Fact # 3: To create a positive impact, three goals must be achieved by various approaches to health care: (a) it must improve patient health; (b) it must enhance patient experience; and (c) it must contribute to decreased per capita costs (Donald Murphy, Brian Justice, et al, July 20122).

Problems related to the back and spine are common. They are frequently referred to by the medical community as spine-related disorders or SRDs (involving the back, neck, headaches and other spine-related conditions).

Decreased productivity is one of the principal consequences of SRDs in the United States alone. We’re talking about lost wages (US$14 billion in 2002-2004) and lost man-hours.

Fact # 4: Given the pervasive nature of spine related problems, the consensus is that a primary spine care provider (PSCP) must be established. Family doctors or general practitioners are not trained to accurately diagnose and treat spinal disorders.

Approaching Health Insurance Providers 

Not many people are aware that patients with spinal disorders would benefit most if care and treatment would involve multiple specialists. Problems related to the spine are complex. Your family doctor is not familiar with what a chiropractor can do for spinal disorders, nor are chiropractors without specialized training able to successfully treat scoliosis. The operation of magnetic resonance imaging equipment requires a specific set of skills. Following this trend of thought, imaging specialists wouldn’t have a clue about pain management, non-surgical spinal treatment, medication and exercise.

Care and treatment of spinal disorders therefore is premised on a multiple specialist approach, which will ensure that with the right diagnosis, chances are better for targeting the best treatment.

Just as the general public is not aware that a multiple specialist approach is indispensable, we can hardly expect health insurance companies to understand the advantages of having multiple specialists in the care and treatment offered by specialists. Their primary goal is to reduce health care costs and increase the bottom line for their stockholders.

Chiropractors would benefit most if they can be designated as the primary spinal care provider. They may be in a better position to explain the multi-faceted approach to spinal care, and their arguments can be taken to health insurance providers.

What kind of discussion should you have with your health insurance provider? Some issues can be tackled from the perspective of:

1. controlling costs – one way to control costs is to have the opinions of back pain specialists (chiropractic physicians, Physiatrists) medication specialists (generally internists and family doctors). In other words, doing it right the first time would avoid those costly hit-and-miss methods of diagnosis.

1. disruptive innovation – Murphy, Justice et al describe disruptive innovation as occurring when “a company, a group of individuals, or a profession comes along with new ideas and a new approach that leads to the transformation of the industry so that products and services become dramatically more affordable and accessible.”

1. standardization of care – if the health care team for spinal disorders is knowledgeable and possesses the expertise required by a specific spine disorder, no money is thrown away by expensive surgery, unnecessary imaging procedures, and costly drugs and medication. Only a knowledgeable team will know which tests are necessary, and can determine if surgery is the only possible solution. This also avoids duplication of services which is all too common.

Before going through procedures and diagnostic tests, find out from your health insurance provider what costs they will cover. Everything depends on the health insurance package purchased by your employer. Read the fine print of their coverage booklet. In some cases they will not be able (or willing) to give you specifics, which is unfortunately a method that is used to protect the insurer from having to pay for a service (it is common that even when a ‘pre-approval’ is given there is always small print stating that “this is not a guarantee of payment”). Why then should a procedure be ‘pre-approved’ if it is not a valid confirmation of payment? Make certain you question this specifically and get names and contact information from your insurer.

Make sure that you have all the relevant information about your spine care so that you can inform your insurance provider just exactly what is involved. Prepare all the supporting documents. Your chiropractor will be able to help you present your arguments, and can in most cases provide you with the ICDA treatment codes that insurers utilize to reimburse from. It’s a question of convincing the insurance company that yours is a disorder that definitely needs care and treatment lasting several weeks or months. Don’t be afraid to go up the food chain if you are not satisfied with a response.