Understanding Insurance

The Patient’s Guide to Understanding Insurance

So, your insurance “covers” physical therapy—which means you won’t have to pay anything out-of-pocket for your physical therapy visits, right? Not quite. Just because your insurance plan covers physical therapy services—or any other services, for that matter—doesn’t necessarily mean you’re off the hook as far as payment goes. In many cases, you’ll still have to pay a deductible, a co-insurance, and/or a copayment.Here are a few common questions regarding insurance terminology:

What does it mean to verify your benefits?

This is when your insurance benefits are obtained from your insurance company based on the plan you selected. Such as, you may have a deductible, a co-pay, co-insurance, or require authorization. It is important to understand that verifying your benefits is not a guarantee for payment. Your insurance company determines payment when a claim is received.

What is a deductible?

This is the total amount you must pay out-of-pocket before your insurance starts to cover your physical therapy services. For example, if your deductible is $1,000, then your insurance won’t pay for your physical therapy services until you pay $1,000 for the services subject to the deductible. Keep in mind that the deductible may not apply to every service you pay for. Additionally, even after you’ve met your deductible, you may still owe a copay or co-insurance for each visit.

What is a co-pay?

This is a fixed amount that you must pay for a covered service, as defined by your health care plan. Copays usually vary for each plan and type of service, such as PCP or Specialist.  You must pay this amount at the time of each service. Again, copay amounts are fixed—which means you will always pay the same amount, regardless of the visit length. In some cases, copayments go toward your deductible.

What is coinsurance?

This type of out-of-pocket payment is determined by taking a percentage of the total allowed amount for a particular service. In other words, it’s your share of the total cost. For example, let’s say: Your insurance plan covers $100 for each office visit and you’ve already met your deductible. You’re then responsible for the coinsurance, as defined by your health care plan.

So, how much will I owe for each visit?

After verifying your benefits, if you have not yet met your deductible, our office policy states that we are to collect an estimated $70 per visit until the deductible is met. Once we receive the Explanation of Benefits from your insurance company, any applicable coinsurance or deductible balances after that will be billed to you and payable within 30 days of the statement date. Conversely, if we find that you have overpaid, we will refund you via check as soon as possible.

What if I can’t afford to pay these amounts as frequently as I need care?

Your health is our number one priority and we understand how annual deductibles can be a scary thought and cause financial hardship in the first few months of each calendar year. Therefore, we ask our patients to pay for a portion of the services rendered at each visit, so that their final bill at the end of their treatment is lower.