Providers: Frequently Asked Questions

The Discount Medical Plan (DMPO) model is not new. In fact, most DMPOs are owned and operated by insurance companies. ChiroHealthUSA and its policies were developed in conjunction with the healthcare group Copeland, Cook Taylor & Bush. After formation, the company requested independent legal opinions from Alice E. Knapp,Esq. and Larry J. Laurent,Esq., both of whom are directly involved in the chiropractic legal arena and active in the National Association of Chiropractic Attorneys (NACA). (NACA has not endorsed ChiroHealthUSA.) For more information, email questions to info@chirohealthusa.com.

No. The membership card is issued to the primary card holder. The doctor’s office may make a copy if they prefer for the dependent members. Most clinics set up patients under a “payer profile” such as ChiroHealthUSA that alerts the staff that they are members and entitled to discounts. If the member should change doctors, the NEW doctor’s office may call to verify eligibility.

A dependent is a spouse, registered domestic partner (if permitted in your state), dependent children under the age of 26, parents over age 60 in the household and any other IRS-defined dependent.

We do not place limits on the discounts our doctors offer. However, we caution strongly against giving services away for free,  or for $1 or other ridiculously low fees when the Actual Fee might be $35. Obviously, a fee that is free or $1 does not represent a “reasonable” discount even under a Discount Medical Plan Organization. This is an example of a “dumb doctor” deal.

Industry standard discounts for DMPOs are in the 30% to 50% range, at times up to 60% depending on the service. While we cannot advise you on what to charge, we do not want you to subject yourself to unnecessary scrutiny by going far below the normal ranges. Doctors who discount below the norm and are participating providers in health plans do not want to risk having their fees reduced by these plans as a result of a post-payment audit that reflects that a large percentage of their practice members are not being charged or only being charged $1 for a given service.

Also, please remember that if the fee charged for a CMT code is less than your region’s Medicare allowable fee for the same level of CMT, you MAY have to offer the lower fee to ALL Medicare beneficiaries.  Medicare rules do not permit you to charge Medicare “substantially in excess” of what you charge other payers.  “Substantially in excess” has NOT been defined by CMS or the Office of the Inspector General and will be determined on a case-by-case basis.

Every effort must be made to keep your discounts reasonable and ChiroHealthUSA will return your agreement if you are listing services as free or $1. Our recommendation when determining discounts for your practice is to start with whatever discounts you may be using now, (as long as you are not giving away free services) and simply use these fees to set your ChiroHealthUSA fee schedule. This is the least stressful for you, your practice and your staff. A simple and easy way to navigate your fees is to set an appointment with an account manager to review the fee schedule worksheet.

Employee doctors do not have to sign the contract, but they must provide proof of malpractice coverage and sign the authorization form in the provider packet to allow their carrier to notify us of changes in their policy.

Yes. You may change your fee schedule at your own discretion. However, you MUST honor the fees you agreed to for any patient currently under agreement until the end of the patient’s contract, which is one year from the date of the patients’ purchase.

The simplest way to manage patients who may be on different schedules is to assign them to a payer profile in your software program. Such as ChiroHealthUSA16. If you update your fee schedule for 2017, then simply set up the patients joining after the change to ChiroHealthUSA17. Your system will track it just as it does for any other payer profile.

We do not dictate how low a cash fee may go. We make the discounting legal by use of a network contract. We DO caution doctors to be reasonable in their discounts, i.e. an 80-90% discount or charging $1 for a service is not reasonable. The OIG has indicated that 10-15% is reasonable for hospitals, and contracts with networks may be lower, but should still be reasonable.

ChiroHealthUSA is NOT insurance and should not replace insurance. We do not cover or pick up any services and do not pay any claims. Our plan is considered a DMPO (discount medical plan organization) that can be used when there is NO insurance available or limited coverage available.

ChiroHealthUSA is only concerned with the offering and accepting of network discounts. We are not involved in any other office policy or promotions. However, any time you offer “free” services or “discounted” services that are not part of a network that you and the patient participate in, you could be in violation of OIG regulations; if offered to anyone covered under Medicare, Medicaid or other federally insured patients. We strongly urge you to get guidance from your state board of examiners and or personal attorney before offering anything of value that could be considered an inducement.

State laws will dictate whether pre-payment plans are permissible. Check first with your state board of examiners. If they do not have rules or regulations that prohibit them, check with the Department of Insurance. If there are no laws, rules, or regulations that speak to this, then most likely you can, simply because they are not regulated. Always check with your own legal counsel before implementing. There is nothing in the ChiroHealthUSA contract that prohibits you from using pre-payment plans as long as they are legal in your state. We are only concerned about you extending the discounts offered in your contract. How and when you collect are strictly up to you.

This could be considered a dual fee schedule and we do not recommend this. Document correctly, code correctly and offer discounts correctly.

ChiroHealthUSA may be used with patients when they have high deductibles IF they choose to self-pay and sign the “Election to Self-Pay” form provided by ChiroHealthUSA. See our website for a copy of this form and review the webinar on how to use this form. PLEASE BE ADVISED, YOU MUST VERIFY THAT YOUR CONTRACTS WITH CURRENT THIRD PARTY ADMINISTRATORS DO NOT PROHIBIT THIS ACTION.

No. ChiroHealthUSA may not be used to reduce or lower a patient’s deductible or copay. It is illegal to routinely excuse patients from insurance copayments and deductibles. Studies have shown that if patients are required to pay even a small portion of their care, they will be better consumers and select items or services because they are medically needed rather than because they are free. Routine waivers thus raise overall health costs. They are considered fraudulent because averaging them with the doctor’s full fees would make the “usual” fees lower than the amounts actually billed for. In Kennedy v. Connecticut General Life Insurance Co., 924F2nd (1991) a U.S. Court of Appeals held that by waiving the deductible and copayment, a chiropractor relieved both the insurance company and the patient of any obligation to pay for the chiropractor’s services.

The court reasoned that because the insurance plan required co-payments to help hold down the cost of care, the chiropractor could not waive them without violating his contract with the company. And because the chiropractor had contracted with the patient to accept whatever the insurance company paid on the patient’s behalf, the patient had no obligation either.

Source: Mario Fucinari, D.C., CCSP, DAAPM, MCS-P, www.askmario.com

No. A copay is part of the contractual obligations patients have to their insurance companies to pay what they are required to pay. Waiver of deductibles and/or parts of a copay is typically prohibited, and only allowed if the patient has met “hardship” guidelines.

No. We do not recommend you do this under any circumstances and would STRONGLY caution against this, particularly if the patient is Medicare or federally funded. Doing so could be considered an inducement and a violation of the OIG regulations. The patient must “elect” to join, agree to the contract, and sign the disclosure forms in order for ChiroHealthUSA to be in compliance with regulations. We are regulated by the Dept of Insurance, and they have been known to SEVERELY punish companies that “auto-enroll” customers, car buyers etc. in “credit life” or other “services” without the express written consent of the buyer…in our case patients.

CMT’s that are considered maintenance by Medicare MUST BE charged at your usual Medicare CMT amounts and the patient should sign an ABN form. Providers are typically required to offer Medicare their lowest fee for covered services and may not charge Medicare “substantially in excess” of what they charge other payers. Doing so could result in having to lower your fees to ALL Medicare patients. Therefore, we recommend you follow your Medicare fee schedule for your region. Medicare patients may join ChiroHealthUSA for services not typically covered by Medicare such as extremity adjustments, exams, therapies, etc. and receive the ChiroHealthUSA discounted rate offered by your office.