Insurance Reimbursement and the 35% Rule

Do you collect more than 35% of your income from one insurance company?

When was the last time you calculated the amount of money you collect from the insurance companies you bill the most?

Many chiropractors would close down if insurance didn’t exist. Making $40 per visit is not enough.

Follow this simple action plan “just in case” Blue Cross/Blue Shield, Optum, Cigna, Aetna or Medicare comes knocking on your door.

Step 1: Get pro-active.

Step 2: Review all new patient paperwork.

Step 3: Get all patient forms signed (such as the health history and review of systems forms, assignment of benefits, financial policy, informed consent, HIPAA notice).

Step 4: Review the medical policies from the insurance companies you bill the most.

Step 5: Understand “what” and “why.” Your CPT codes are “what” you’re doing and your ICD-10 codes are “why.” Make sure they’re correct and justify medical necessity or else you’ll be giving money back. For example, you’ll get audited if billing 97110 and the patient does not display any ROM deficits.

Step 6: Do a self-test on your SOAP notes. Make sure you know what to look for per insurance company.

Step 7: Find out what a medically necessary SOAP note looks like and duplicate it. Also, find out what an insurance company billing compliance plan looks like and implement as soon as possible. Insurance company audits are on the rise and are going to increase in 2019. Insurance companies know that recouping money is profitable.

Step 8: Put together a simple billing policy manual that explains what you do and why you do it. Example, explain why you adjust or mobilize full spine, but only bill 98940.

Step 9: Conduct regular meetings specifically with staff members that do your billing, especially to the insurance companies that pay you the most money. Also, do a spot check on your billing company (if you use one). Recently I’ve seen billing companies reporting fraudulent codes and the doctor did not know until the insurance company came knocking on the door.

For more info, please email Dr. John Pecora @

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