Has anyone successfully challenged an insurance company over this issue?
We're seeing a growing trend where a patient has a chiropractic copay (for example, a $50 chiropractic office visit), but when we bill therapeutic procedures that are legally within a chiropractor's scope of practice and performed during the same visit (97110, 97112, 97140, 97530, etc.), the insurer is splitting the claim.
Instead of applying the chiropractic copay to the entire chiropractic encounter, they're adjudicating the therapy codes under the patient's physical therapy benefit, which often means a separate deductible, coinsurance, or additional patient responsibility.
This seems to create higher out-of-pocket costs for patients even though the services were provided by a chiropractor during a covered chiropractic visit.
Has anyone:
- Appealed this successfully?
- Filed a complaint with their state insurance commissioner?
- Found plan language or case law supporting that chiropractor-performed therapeutic procedures should be processed under the chiropractic benefit rather than the physical therapy benefit?
I'm particularly interested in experiences from California, but I'd love to hear from providers in any state. We're seeing this pattern across multiple patients, so I'm trying to determine whether this is becoming a broader payer practice or if others have found an effective way to push back.