Medicare for Chiropractic in Petaluma

Todd Lloyd
August 1, 2022

Medicare covers chiropractic adjustments!

On this page, I will go over some of the basics of how Medicare works with all chiropractors, and how it works in our office specifically, as we are "participating" providers for Medicare type B.

Who has Medicare?

United States citizens must meet one of these criteria to be eligible for Medicare:

  • 65 years old or older
  • Disabled people who have received Social Security benefits for at least 2 years
  • People with End Stage Renal Disease or Amyotropic Lateral Sclerosis

Chiropractic care is covered under Medicare Part B or C Medicare Part B is the one that covered chiropractic care most of the time, but Medicare Part C is also known as a Medicare Advantage plan. Part A covers hospital visits, and Part D covers prescription drugs.

If you're a new patient in this office, we will scan your card to bill Medicare. But before you make an appointment, look over your card to make sure you have either Part B or Part C. is a "Participating Provider" for Medicare

In this Petaluma chiropractic office, Dr. Lloyd is a participating provider (PAR) for Medicare. Doctors have to go through a screening process to become validated and revalidated (every 5 years.) Participating providers, such as Dr. Lloyd has signed an agreement with Medicare. We accept assignment on all claims, and payments from medicare are made directly to us. Medigap insurance is automatically billed. Secondary insurance is automatically billed if it is contracted with Medicare.

Because this chiropractic office is a Participating Provider, we are able to bill 5% higher than non-participating chiropractic offices for a chiropractic adjustment.

Since we are PAR, Medicare will send 80% of the allowed amount directly to us, and the remaining 20% is your co-pay. If we bill the billing code 98941, then your copay becomes $8.76, payable at the time of service. As you can see by doing the math, Medicare does not keep up with inflation.

Medicare only covers the adjustment, but not other services

Here's the rub about Medicare. You, the patient will still be responsible for the cost of a new patient examination or other modalities that we find necessary to cure or relieve your pain or complaint.

In other words, if you have Medicare Part B, and you make an appointment to become a new patient, your fee for the first visit will be $162.22. Interferential treatment in this office, which might be necessary for an acute situation, would be an additional $23.89 (with prompt-pay discount.)

So on any given visit, your medicare co-pay might be $8.76, but then there might be an additional $23.89, brining the total for that visit to $32.65.

BEWARE OF ANY OFFICE WHO WAIVES THE EXAM FEE OR COPAY. This is fraud, unless it is done for a very specific and rare exception.

Do I need to pay my Medicare deductible?

Medicare Part B deductible is $233. As a PAR provider, we are responsible for collecting your deductible if it has not been met for the year.

Does this office bill supplemental (Medigap) or secondary Medicare insurance?

As a courtesy, we will bill your secondary insurance as well as your Medicare. Since we are out of network with major medical insurance companies, the coverage might be limited. Those insurance companies get billed first, then they relay the billing to Medicare.

Medicare will pay for Active care, but not Maintenance care

Medicare's job is to pay for care that will advance you from a painful or functionally limited status towards some sort of improvement. In order for your chiropractic care to be active care, our doctor's notes should be showing some sort of improvement along the way.

If you have a certain base level of pain that's always there, and it doesn't change during the course of chiropractic care, then that is maintenance care. If you withdraw from care, and the pain gets worse, and you start care again, and we see improvements, then it's active care.

When you get adjustments to prevent disease and promote an active quality of life, then Medicare will consider this to be "maintenance care" and they will not cover it.

(When we chiropractors bill Medicare, and we consider the treatment to be active care, we bill the codes with an AT modifier. This tells Medicare that we intend our treatment to be considered active care.)

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