Understanding Basic Insurance Terms
Please note that as a courtesy, FIT Rehab will make every effort to verify your insurance benefits prior to your first appointment. However, it is often helpful if you have a full understanding of your benefits because the patient is ultimately responsible for this knowledge, and will be billed accordingly. If you are not sure of your physical therapy benefits, we suggest that you contact your insurance company directly.
In-Network vs. Out-of-Network
Each insurance plan provides certain coverage to a patient if he/she specific providers (doctor’s, physical therapists, etc.) that are listed “in the network.” As long as you choose one of these providers, you will be eligible to use your in-network coverage. Some plans will not provide any coverage if you do not choose an “in network” provider. Others do allow patients to see a provider out-of-network, but a different set of benefits will apply.
At FIT Rehab, if you have an insurance plan that our office does not participate with, your first question to your insurance company would be, “Do I have out-of-network benefits?” If the answer is yes, “what are they?” If the answer is no, you are still eligible to be treated for physical therapy on a “cash” basis.
Many plans require that a “deductible” be paid for the year before the insurance company will begin to pay for services. FIT Rehab will bill the patient’s insurance company, and they will determine if this deductible has been met. If it hasn’t been met, the insurance company will not issue payment to FIT Rehab, and the patient will be billed accordingly. The patient’s insurance company will keep track of the amount the patient has paid out of pocket for the deductible, and once the deductible has been met, they will begin to pay for services. In addition some patients will still be responsible for a co-insurance or copay. Please read below for more information.
Many insurance plans require the patient to pay a copay for each visit. The amount due each visit should be listed on the front of the patient’s insurance card. There are different requirements based on care whether it is for a primary care physician or a specialist. A physical therapist is considered a specialist, so this would be the amount due for each visit if required by your plan. In some cases, you will be required to satisfy a deductible (see above) before beginning to pay only a copay each visit.
Many insurance plans require a co-insurance to be paid out of pocket for each visit by the patient. For example, if your co-insurance is 90/10, the insurance company will cover 90% of the charges for each visit, and the patient is responsible for the remaining 10%, which usually comes out to approximately $15/visit at FIT Rehab. As with a copay, in some cases your insurance company may require you to satisfy a deductible (see above) before they will begin to make payments to FIT Rehab. The patient will be held responsible for any remaining.
Some insurance plans, especially HMO plans, require a referral from the patient’s primary care physician to be issued before the first physical therapy appointment. You simply call your primary care office, and ask for the referral department. You will let them know you need a referral for physical therapy at FIT Rehab. Some offices require 3-5 days to process referrals, so make sure to give yourself enough time before your first appointment.
If your plan requires only authorization, you will not need any documentation before the initial visit to FIT Rehab. However, after the initial visit, the physical therapist will issue a report to your insurance company, and will request a certain number of visits for treatment. Our office must then wait for approval for these visits, although the patient is still able to schedule his/her appointments, this process is often repeated several times until the point that the physical therapist can no longer justify additional treatment. The patient is not required to do anything on his/or her part, but should be aware that occasionally the visits may need to be varied according to the authorization granted by the insurance company.
Some insurance plans limit the number of visits allowed per year or per condition. For example, if you have a “30 visit max” for physical therapy, you will only be covered for 30 visits total for the year (or per condition), regardless of medical necessity.
The out -of-pocket max is often just how it sounds; the maximum amount you will be required to pay out in cash for the year in deductibles, copays, and co-insurance.
The “Medicare Cap” is the amount of money Medicare allows for payment of physical therapy per year. This CAP amount for 2011 is $1,860. This amount often covers approx 4-10 weeks of treatment, Medicare has allowed for “exceptions” to the CAP. Exceptions are based on medical necessity which will be determined by your Physical Therapist. At FIT Rehab, we keep very close track of the dollar amount used for our patient’s treatments. When necessary, patient will be changed to our Medicare Exception list.