Insurances vs. Cash in Obamacare

My last post on the new health care reform (entitled “Congress Has Done It, Now What?“), caused quite a few comments. Mostly the feedback was good. One lady called me a right wing nut and we gladly accommodated her request to be removed from the email list. I guess in today’s politically correct world, stating the obvious (that our taxes will go up and it will be more work on our practices) makes you a right wing nut.

A few concerned doctors emailed me trying to persuade me to see the “bright side of things”.  They argued things were not so bad, after all the ACA or ICA (depending on which one you ask) was responsible for getting anti-discriminatory language in the bill. While I commend both organizations for fighting hard for chiropractic, I’m not so sure the gain of anti-discrimination language will justify the huge stack of problems the bill will cause.

Of course if your patients are mostly Muslim, Amish, American Indian or a Christian Scientist you will likely continue on as if nothing has changed.

As for everyone else, this type of government action brings up the age old chiropractic question, “cash or insurance?”

First off, I must state I do not agree with the mentality that has been perpetuated for years by many chiropractic coaches: “we must do cash because all insurance is evil” . There are good reasons not to take insurance, some of which are philosophical, but this type of rhetoric mentioned above is usually just a cop-out for those are are scared and don’t know how to bill insurance. Trust me, I know because this was me for the first 2 years in practice!

So with that said, let’s look at a the biggest reasons some doctors abandon insurance for an all-cash practice.

What the Proponents of an All-Cash Practice Say:

1. Insurance is too restrictive of the services you provide.

Many chiros do away with insurance hassles because of the burden it puts on their practice. They do not like to be told what they can and can not do with their patients. If most of their insurance patients are carrying these types of restrictive plans, they will choose to convert to an all-cash practice. Do you think Obamacare will make insurance more restrictive or less for chiropractic? (Leave your comments below.)

One medical doctor sent a letter to her patients stating she will not comply to the new laws Obama has enacted.

Of course the doctor who takes insurance will rebut this argument when applied broadly to the whole United States. His reply would be that “just because there are some bad insurance pockets, or even whole states, does not justify saying all insurance is bad and only pays for 12 visits anyway, so we might as well go all-cash.”

2. Insurance is too much work.

Other doctors choose not to bill insurance because they say it is too much work. They have to submit reams and reams of paperwork just to make $30 on a visit. Exams and x-rays require even more notes and paperwork. They’ll have to hire another staff person just to figure out all the billing codes and how to do chiropractic insurance appeals.

What does the non-cash chiropractor say to this? He would likely reply that “while some insurance plans and contracts require an insane amount of work, this does not mean that all insurance plans do. I simply do not participate in the ones that are bad.” He would also argue that whether cash or insurance, we all must have documentation. He would likely also add that many cash practices give the patient a superbill, which is essentially doing everything an insurance practice would do, except fight denials.

3. They do not pay special services.

A few doctors choose not to bill insurance because their practice is very specialized and insurance in their area does not pay chiropractors for these services. These include spinal decompression, weight loss, nutrition, cold laser, deep tissue laser, etc.

On the other side, many chiropractors will still implement these uncovered services, but also continue to offer chiropractic adjustments and therapy. So they will bill insurance for those services that are covered and do cash for those services not covered like decompression treatments, etc.

So which side of the fence do I stand on?

Neither. At the current time (and this may change in the future), I do not paint with a broad brush when it comes to this subject. Some states and areas are great with insurance, with plans giving 80-100 visits per year. I’ve even seen a few that allow unlimited visits to chiropractors per year. Other areas are so bad you’d have to be crazy to bill insurance there.

In my Decompression Marketing Elite program, there is one client grossing a million per year as an all cash practice. Another client has a mostly insurance practice and is doing nearly the same amount. Other clients have more of a 50/50 mixture, doing cash for decompression plans and insurance for other services.

You see, whether you choose cash or insurance, you should choose wisely. And once you make that choice, it all comes down to one thing — marketing. Insurance companies won’t bring you many new patients, if they bring any at all. Simply switching your practice to all cash won’t make people flock to you either.

I think too many people sit around thinking the grass is greener on the other side, when in reality they are not reaching their potential because of poor marketing choices.

What do you think about all this? Leave your comments below.

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  1. I guess I’m with you in that I’m a right wing nut. Mostly, from a BUSINESS standpoint, I can’t imagine the “new plan” being good for us. There are still many unknowns. This makes business strategies hard to predict. I agree one can’t say “all cash” or “all insurance.” The way you bill have to be congruent with your business philosophy and ability to position yourself and sell the product. From a HEALTHCARE/CLINICIAN standpoint, I want to help people. But I want to do it in a manner that doen’t compromise my method or the patient’s well being. I wonder if Chiropractic fits into the “preventitive care services” portion that will take place in a few years?

  2. Dr. Beck,

    Great post, my office does take insurance for those services that are covered and a cash system for those services (spinal decompression) that are not covered. I think another arguement that you could discuss if you do take insurance, should you be in in-network vs. out of network. My office is out of network so it reduces some the insurance paperwork and restrictions but you still get paid well at $80-90 per visit and the patient can use their insurance for covered therapies.

    Todd P. Sullivan

  3. Micah Carter, D.C. at

    I can tell you that running a cash practice was way more work for me than running a 50/50 practice has been. Accepting insurance has made some aspects of my practice easier and others more difficult. One important thing I learned when adding insurance to my practice was that the standards are the same whether I accept insurance or not. The medical necessity and documentation rules are the same either way. Of course we have to spend some extra time collecting from some insurance companies but it has also improved patient compliance from day one. Our average office visit went way up as well, for many reasons. Now we are about 50/50 and plan to stay that way. Thanks Dr. Beck for sharing and I don’t think you are a “right wing nut,” just a nut 😉 Be Blessed!


  4. These days we face some challenges we didn`t 20-30 years ago, however the paradigm of the cash vs ins practice models for chiropractic remains remarkably similar to what many leading consultants in those days deliberated about. In those days some of the most successful leaders in that field said insurance as we knew it would be gone by 2000, yet we still see coverage with medicare, medpay and in most states some form of PPO coverage. As Mike states it all boils down to where you are and what you prefer, we all know that. The liberal media paints a drastically different picture from the conservative, and this right wing left wing talk is childish in my opinion.The trick is what`s the best approach to stay in business. Truthfully, it would be ideal if we could simply gain equality from medicare for all services we render including therapys, in line with reimbursement for PTs and MDs. $87 per visit for 4 PT units plus a 98941 would go a long way to making us all healthier financially. And medicare patients need the care arguably more than anyone . Yet I know practices that won`t treat medicare patients, because they can`t afford to. Whether equality will occur or not time will tell, but regardless, we can`t stay in practice without effective marketing, and that Mike provides exceptionally well. Whatever “wing ” that`s on, sign me up. We did all sign on to help folks.

  5. J Chipley, DC at

    Just a question after reading the last two blogs and the ACA paper about the potential benefits of the anti-discrimination legislation contained in the bill signed into law. Would this anti-discrimination legislation affect Medicare??? Or will it only affect the private sector insurance companies??? I would appreciate any insight if anyone has reserched this. Thanks.

  6. drbeck at

    Dr. Chipley, I’m not sure anyone knows that answer yet. But my guess would be no, it is going to be separate from Medicare.

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