"Insurance doesn't pay for maintenance care." How many times have you heard that line? It's been repeated so many times that many people in the Chiropractic profession actually believe it.Indeed many people in the insurance industry believe it. However, what if I told you that insurance plans, including Medicare, pay for maintenance care every day, and in fact have been doing so for decades? You'd probably think that I was crazy or at least mistaken. Well fortunately neither is true. Insurance companies do pay for maintenance care…just not Chiropractic maintenance care.
Before I go any farther explaining this issue, let's define what is considered active/corrective care and what is considered maintenance care. To do this let's turn to the Centers for Medicare and Medicaid Services (CMS) for the definitions.
Active/Corrective care: Active care may be defined as a treatment plan that contains any intervention that is expected to be an improvement in, or arrest the progression of the patient's condition. In other words Active Therapy is anything that seeks to improve and/or correct the issue that is causing symptoms.1
Maintenance Care: "Maintenance therapy is defined (per Chapter 15, Section 30.5.B. of the Medicare Benefit Policy Manual) as a treatment plan that seeks to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, the treatment is then considered maintenance therapy."1
The manual goes on to define chronic subluxation by saying that "Chronic subluxation-A patient's condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered."1
Medicare Rules Set the Standards
Now, armed with these two definitions, you may be asking if Medicare is the only entity that uses them, or if other insurance companies do as well? In order to answer that, we simply need to state that Medicare generally sets the standards for both reimbursement fee schedules, and billing and coding requirements.
In other words, Medicare must be the lowest payer, and most private insurance companies use Medicare billing guidelines for their own billing and documentation requirements. Therefore whatever Medicare determines is maintenance care, other private pay insurance companies do as well, which is how we have arrived at the generalization that insurance does not pay for maintenance care.
However, Medicare does pay for maintenance care, but not Chiropractic maintenance care! Here's an example. If we do a phrase search of the Medicare Benefit Policy Manual in PDF format, and search for the phrase "maintenance therapy", we get 12 hits. In other words the phrase "maintenance therapy" is mentioned in the manual 12 times. 10 out of the 12 are relating to Chiropractic, 1 relates to rehabilitative services, and the other is a reference to the maintenance therapy dose for vitamin B12, which incidentally is covered by Medicare.