If you are currently a client undergoing physical therapy or likely will require physical therapy in the future, I would be willing to bet that you have likely been reminded by your job or insurance provider about electing coverage for your health needs. Often forgotten, many physical therapy clients focus on their in-network benefits but seemingly forget about their out-of-network benefits.
Current and prospective physical therapy clients tend to underestimate their needs and often continue with their current benefits for the upcoming year. I pose these questions. What happens if you need additional care given outside the allotted physical therapy visits? Or what if you choose to go to an out of network provider because a close friend referred them?
Here are some things to look for when electing your new coverage and ensure complete coverage for you and your family’s needs.
1. Out of Network Deductible
Typically higher than your in-network deductible, your deductible is the amount that you pay for eligible out of pocket medical expenses in a calendar year before the insurance pays their portion. After the deductible is met, you either pay nothing or you share the cost with your company up to a certain limit. The maximum out-of-pocket limit for any individual marketplace plan for 2015 can be no more than $6,600 for an individual plan and $13,200 for a family plan. Ideally, you want a plan that has a very low out-of-network deductible so you can seek care out of network if necessary.
For example, let’s say that in January you tear your ACL, complete surgery and start physical therapy. You expect anywhere from 6-8 months of rehab. You first choose to use your in-network benefits to cover your medical expenses.
· After 10 visits you’ve paid $1000
· Your insurance paid $0
· Your in-network deductible is met
You continue with therapy through February and March and are limited to a total of 20 visits for rehab.
· During the 10 visits, you’re paying your copay/coinsurance
· Your insurance picks up the rest of the bill
However in April, you need to continue with rehab to get back to running marathons and your insurance informs you that you’ve reached your visit maximum and your therapy will no longer be covered. What do you do?
· Either you choose to pay all expenses out of pocket, or now choose to continue with therapy out-of-network, using your out-of-network benefits.
The key here is if you have a lower out-of-network deductible, the less you will have to pay towards your new deductible and the more likely you will continue with rehab to full recovery.
2. Reimbursement
After reaching your deductible, you participate in cost sharing/coinsurance. Cost sharing is the part of the covered service that you pay for. (E.g. you pay 20% of physical therapy charges while your plan pays 80%). Typically, a rate of 80% or greater is on the higher end of reimbursement while 50-60% is on the lower end. Ensure you will be reimbursed as much as possible by shopping around for plans where its customary to reimburse for rates on the higher end of the spectrum. Another option; prior to initiating physical therapy always contact your insurance provider and find out about your plans reimbursement policy.
3. Be familiar with your visit limit
Contrary to most beliefs physical therapy is not unlimited in the insurance world. Most insurance companies limit the amount of time your able to receive treatment. You can appeal to get more treatment, but it’s an arduous process at best, and there’s no guarantee that you’ll win. At times if they do approve more visits they likely will only allow 5 additional visits at most. The Idea here is to shop around seeking plans with higher visit limits but also looking for a physical therapy practice with good patient outcomes that can maximize your visits. Such a practice like Theralution, which focuses on direct one on one care and has total treatment times no less than 1.5 hours. This helps to maximize patient visits by increasing client treatment times therefore decreasing the length of therapy and avoiding reaching visit maximums set forth by the insurance companies.
4. Pre-authorization
Be aware! Only a few insurance companies currently require this but this can easily foil your plans for reimbursement. This sometimes can stand between clients and the care that they require. Essentially, pre-authorization is prior approval required for certain services before you receive them. This can delay necessary care ultimately prolonging the healing process. Here is a good rule of thumb. Do not choose a plan, which requires pre-authorization! It’s that easy.
5. Filing claims
Whether you’re using in-network or out-of-network benefits, some companies are known to make you jump through hoops in order to get an appropriate reimbursement. A good company understands your needs and will attempt to reimburse you in an appropriate time frame. Typically you should expect reimbursement between 15 to 30 days from the initial date of care. Submitting your claims on a weekly basis saves time and helps to keep track of your reimbursements as well.
Now that you’ve learned about these important aspects of your benefits, the key is to find the perfect combination that suits your families needs. Being knowledgeable and acting now helps you maximize your benefits while avoiding disappointment in the long run. Be an intelligent consumer and get complete and great care on your terms. Have additional questions? Feel free to visit us and ASK A PT .