Truth: Physical Therapy is an investment in your quality of life. What does that mean to you?

While most people I meet express their dissonance with how our country’s healthcare system is being administered, there are ways that you can prepare and educate yourself on what you do have available to you in terms of medical and physical therapy benefits. As with anything that is worthwhile and of value, physical therapy is not free. However, it does not have to be a bank breaker, either.

Prepare.

Prepare yourself by understanding your benefits. Do you understand the difference between a deductible and an annual out-of-pocket maximum? No? That’s okay, really. But now is a great time to learn and gain a deeper knowledge so there’s no surprise when your statement comes.

Educate.

Call your insurance company and ask for your physical therapy benefits. (See the bottom of this article for a glossary of terms to know!) By educating yourself on your insurance coverage, you not only set your expectations and goals for the financial side, but you can also manage the treatment side through Shared Decision Making with your provider.

Evaluate.

Once you have a clearer picture of the financial aspect of your care and are feeling more confident in how you want to proceed, call us! We can schedule an initial evaluation of your condition with one of our licensed Doctors of Physical Therapy. Our clinic providers will spend around 30 minutes of this hour-long visit assessing your diagnosis and getting tests and measures of your starting place of care. The second portion will be the start of treatment for your condition.

Communicate.

Communication with your provider throughout the entirety of your episode of care is key. If something changes with your financial or physical well-being, tell us! We can’t adjust to what we don’t know.

One thing we tell people often is, “We have options!” Through your communication with us on your needs, we are confident that we can find common ground between provider and patient. Opening a dialogue is essential to finding what best suits your circumstance.

We look forward to helping you maximize your benefits and gaining back a healthier you!


Glossary of Insurance Terms to Know:

Co-insurance: Co-insurance is a cost-sharing feature of many plans. It requires a member to pay out-of-pocket a prescribed percentage (%) of the allowed amount or billed charge owed to a provider. The defined co-insurance that a member must pay out-of-pocket is based upon his or her health plan design. Co-insurance usually applies after a deductible is met in a deductible plan, such as deductible HMO, preferred provider organization (PPO), point-of-service (POS), and indemnity plans.

Contracted Provider: A medical provider that has an agreement with a health plan to accept their patient at a previously agreed upon rate for payment.

Contracted Rates or Contractual Allowances: These are the amounts that health insurance companies will pay to healthcare providers in their network for services. These rates are negotiated and established in the insurers’ contracts with in-network providers.

Co-payment or Co-pay: A form of medical cost sharing in a health insurance plan that requires the member to pay a fixed dollar amount for each visit to a doctor or for a specific service (for example, $15). This fee is pre-set and is specified in the health insurance policy of the patient and also may be listed on your insurance card.

Deductible: A set dollar amount which must be satisfied within a specific time frame before the health plan begins making payments on claims.

Direct Access: Refers to the ability for patients to be evaluated and treated by a physical therapist without being referred by a doctor or other healthcare practitioner or to self-refer, based on health plan requirements.

Explanation of Benefits (EOB): A summary of the payment made by a health plan to the medical provider that is sent to the patient. Usually a copy is sent to the provider as well, but may be called an Explanation of Remittance. The EOB will include a detailed explanation of how your insurer/administrator determined the amount of reimbursement it made to your provider or to you for a particular medical service. The EOB will include information on how to appeal or challenge your insurer’s reimbursement decision. Note that patients may not receive an EOB for care that you have received from a provider or facility that is in your insurer’s network if there is no required payment from you for those services.

Maximum Out-of-Pocket Expense: The maximum dollar amount a member is required to pay out-of-pocket during a year. Until this maximum is met, the plan and member share in the cost of covered expenses. After the maximum is reached, the insurance carrier pays all covered expenses.

Out of Network (OON): Usually refers to physicians, hospitals, or other healthcare providers who are considered non-participants in an insurance plan, i.e., they are not contracted providers. Depending on an individual’s health insurance plan, expenses incurred by services provided by out-of-network health professionals may not be covered, or covered only in part by an individual’s insurance company when the patient’s plan has OON benefits.

Out-of-Pocket Costs, Expense or Patient Responsibility: Your expenses for medical care that aren’t reimbursed by insurance. Out-of-pocket costs include deductibles, co-insurance, and co-payments for covered services plus all costs for services that aren’t covered.

Prior Authorization: Prior authorization is a check run by some insurance companies before they will agree to cover certain prescribed medications or medical procedures. There are a number of reasons that insurance providers require prior authorization: determining medical necessity, the availability of a generic alternative, or checking for drug interactions. A failed authorization can result in a requested service being denied.

Referral: A recommendation for a patient to be seen by another provider typically issued by Primary Care Provider (PCP) depending on the health insurance plan. PCP is acting as the “gatekeeper” for health care. Referrals may be required by a health plan in order to ensure covered benefits are paid, and may need to be approved by the health plan prior to services being rendered.