Your physician has referred you to physical therapy for an evaluation and treatment. Does your insurance company require that you have an authorization to be seen? The referral and authorization issue can be confusing.
The referral comes from the specialist or treating doctor and they will give you, or fax to our facility, a prescription that will document the diagnosis and recommended treatment along with their contact information. The authorization is issued by your insurance company that reviews the diagnosis, recommended treatment and contributing factors and determine that the treatment is medically necessary. The authorization is requested typically by your primary care physician, also referred to as your gatekeeper. Some insurance companies allow the specialist to request an authorization. Your primary care physician, the insurance customer service or your policy documents can advise you as to the starting point for your individual plan. Our office will help you navigate the authorization questions that you may have and we work closely with the primary care office by providing them with insurance procedure codes and diagnoses they need to obtain the authorization.
Insurance companies are all different and within each company is a collection of plans and policies. To say that this is confusing is quite the understatement. Terms you will hear frequently are:
Deductible: The deductible is the amount your policy requires be paid by the insured prior to services being covered. Some policies have high deductibles and others have lower deductibles. There are even policies that the deductible is waived depending on the type of service. For example, if you have a $1000 deductible, you will need to receive services which you have paid or will be paying for that offsets the $1000.
Out of Pocket: Out of pocket refers to the amount of money you will pay for deductible, co-pays, and co-insurance during the year. Once you have met the amount the policy has determined, then your insurance will pay future claims at 100%.
Co-pay: Co-pays are specific amounts, determined by your policy, that are paid at each visit.For example, if you have a $45 co-pay, you would need to pay that for each day that you come in for therapy. Co-pays can be different for your primary care physician, for specialists and for physical therapy.
Co-insurance: This amount is a percentage of the allowable. The allowable is the fee your insurance company has agreed to pay for physical therapy services. The most common co-insurance percentage is 20%. For example, if the charge for your therapy is $200.00 but the insurance has contracted with us to pay $164.99, we will make an adjustment of $35.01 and your 20% would be $33.00. The confusing part of this is that each procedure (therapeutic exercise, manual therapy, therapeutic activities, neuromuscular re-eduction, vasopneumatic) has a different value assigned to it. While we use our best guess based on historical data and typical charges to estimate your 20%, we don’t know exactly what that 20% will be until the claim is processed by your insurance company. Sometimes our estimate of the co-insurance can be a little low or a little high. If your account is overpaid, we will issue you a refund check. If your account is underpaid, we will send you a bill showing the amount still due.
One other issue that you should be aware of is whether or not your insurance policy has a maximum dollar amount or visit limit per calendar year. Our staff will check your benefits before or at the time of your first visit. At that time, based on the information received from your insurance company, we will advise you of your deductible, what has been met and is remaining, your out of pocket, what has been met and is remaining and any visit limits.
Financial Responsibility – Payment is due at time of service. We do use tools (website, provider customer service, historical data, etc.) to predict closest financial responsibility. Payment plans are available to assist you with working this financial cost into your budget.
We work with you, your physicians, and your insurance to help you navigate the insurance and financial questions you will have. Keep us advised of any policy, company, or personal data that changes during the course of your treatment so that we can assist you to the best of our abilities.