Practice News!
THE LANGUAGE OF INSURANCE (GOOD STUFF TO KNOW)
You’ve called and scheduled your first appointment with us, awesome! We cannot wait to help you! So, what do we do in the meantime to prepare for your first visit? Before we answer that question, let’s go over some insurance terms that you commonly run across when getting PT. a. Insurance verification — This is step one in the process, here we go through and verify a patient’s policy and their benefits for the services they will receive. b. Your deductible — This is the amount you need to pay before your benefits become available to pay for your medical bills. If youhave a $1000/year deductible and only have met $500, you will have to pay the next $500 out of pocket before your insurance will help pay your PT bill. c. Cost share —This is a termused to define your estimated costs for coming to PT per treatment. It is an estimated amount since cost per treatment vary at times depending on the type of treatment that day with certain insurances. d. Copay — This is your portion of the cost of treatment after your deductible has been met. It is a fixed amount per visit like $25/visit. e. Coinsurance —Similar to a copay in that it is your portion of the bill after the deductible has been met, but instead of a fixed amount it is based on a percentage of the bill, like a 20% would be 20% of the total bill and would be around $25-30 typically in PT. This is why cost share can be an estimate. f. MaximumOut-of-Pocket —Some policies have amax out of pocket with your deductible and copay or coinsurance. After that ismet, your insurance would cover 100% of the bill. This is an important benefit sincewith a severe illness or injury, you have a cap in costs for that year. g.Medical necessity —This is a confusing termbut itmeans your access to physical therapy benefits depends on whether your problem has enough complexity to require the skilled services of a physical therapist for its solution. In otherwords, are you having enough pain and functional
limitations that you need help to get it resolved? As well, as you improve the PT must determine when the patient has satisfied the medical necessity question and you are able to manage and continue to improve on your own. It is not based on the number of visits allowed by your plan but on the degree of need you have to overcome your problem which determines the quantity of PT approved. h. Explanationof benefits (EOB) —This is a report you receive in the mail or online after you receive services and it lists what was received, its charges and how much they paid and how much you are responsible for paying. Usually there is a difference in the charge and the amount paid and it relates to fee schedules and your cost share. See in-network explanation. i. Participating — This means we have a contract with this particular insurance company and agree to accept their fee schedule, this is called in-network benefits. j. In-network — This means we have an agreement with an insurance company to accept their fee schedule for payment. So, we may charge $40 for a unit of service but that particular insurance only pays $25 per unit. So, we have agreed to accept this reduction; Medicareworks this way. Youwill receive anEOBafter the insurance processes a billed treatment and the charges and the amount paid will be different because we have agreed to accept their fee schedule and so we write off the difference. k. Out of Network — This means we do not participate with a particular insurance and their fee schedule, so you would have to pay the out-of-network cost to see us. At times it is notmuch different than in-network and at other times it can be a significant difference. It depends on the insurance company and their rules. Just remember, you are potentially using PT to solve your problem and it is always good to do some research on how well a practice get results for your pain and not just decide where to go based only on costs. And, that would go for location too; convenience is not easier if you do not achieve a good
result – do your homework before you decide onwhere to go. Check on-line reviews, check their website, or call and talk to aPTabout your problemandget a feel on thequality of communication and helpfulness before you even start. So, as you can see, there is a number of terms tounderstand. When we receive your referral from your doctor, we call you and get your insurance data so we can determine if we participate and we will schedule you at that time as well. We then contact your insurance company to determine your benefits and will have them defined before your first visit. When you arrive for your first visit, we will go over your benefits so you know a close estimate of your cost share. Some insurances require authorization before we can start PT, the common ones includeBlue CareNetwork, Blue Care Network Advantage, andMedicare Plus Blue. Here iswhere medical necessity comes in and an insurance controlling a patients access to PT by defining the number of visits they will authorize initially. There are a few insurances we do not participatewhich includeMedicaid programs, andCigna but overall, we work the vast majority of the insurances used in Holland. It is common to seeplans have a visit limitwhich is usually 30 or 60 visits per benefit year. In some cases, these visit limits are combined with occupational and speech therapy and sometimes even chiropractic. Visit limits and authorizations are used by the insurance company to make sure these services aren’t being overused and/or to make sure they are medically necessary. Oncewe have all this information, we put this into your chart andhave it ready for your first appointmentwithus.We check on your policy throughout your treatment to keep track of your deductible andout of pocket costs –when youhavemet it, we will adjust your payment to the appropriate amount. If there are ever any questions about how a treatment was paid or something that is not clear, do not hesitate to ask, we are always happy to help!
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PLAY THE REFERRAL GAME! At Full Potential, we know that a referral from our patients is the biggest compliment. Let us thank you with these 3 simple steps! 1. Write your name on this coupon. 2. Give this coupon to family and friends! 3. Be sure they bring this coupon to their first appointment. 4. Receive a Meijer gift card to those that refer us a patient!
286 Hoover Blvd • Holland, MI 49423 Phone: 616.392.2172 | Fax: 616392.1726 tessa@fullpotentialpt.com | fullpotentialpt.com
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