Physical Therapy Visit limits, Caps, Authorizations, and Benefit periods

Common Health Insurance Terminology

Premium– The monthly or bimonthly fee you pay to have health insurance.

CPT codes– A medical code used for billing (a 5 digit number like 97110).

Allowed Amount– The maximum amount your particular health insurance plan will pay for a service.

Deductible– The amount you owe before your insurance begins to pay.

Co-insurance– A percentage of the allowed amount that you pay.

Out of Pocket– The maximum you will ever pay during your benefit period.

Copay– A fixed dollar amount you may pay for a service at the time you receive it. Many times, a copay does not apply towards your deductible. However, it will often apply towards your Out of Pocket Limits.

 

Physical Therapy Visit limits, Caps, Authorizations, and Benefit periods

Specific to physical therapy, each insurance company decides on what is the maximum amount of physical therapy the insurance company will pay for. This is done through imposing visit limits, caps and authorizations.

A visit limit is an actual number of the maximum visits that an insurance company will cover. Even if the service applied to your deductible and you paid the cost, that counts as insurance coverage and it is a visit under your limit. 15, 20, 30, 60 are common visit limit numbers.

A cap is a dollar amount that the insurance company will cover. They will only cover X dollars. If the cap is $1000, then the insurance company will only cover $1000 worth of visits. Keep in mind that this is the allowed amount, not the billed amount (See Allowed Amounts post).

An authorization is when the provider asks the insurance company’s permission before providing the service. The provider will send documentation (notes, a doctor’s prescription, etc.) to provide reason why the treatment is needed. The insurance company will provide either 1) an actual number of visits to use within a time frame or 2) an unlimited number of visits within a time frame. Example: 10 visits to use between 7/12/17- 9/12/17.

Your plan’s benefit period is the time that your plan is active. Many plans are ‘calendar year’ plans, meaning that they are active from January- December. However, they can span for any amount of months, eg. September- August; July- June. Many visit limits last during the same times as the benefit periods. So, if the plan is a calendar year plan, the visits will last from January- December also. However, rarely, there are plans that differ, in which they are July- June for a benefit period, but the visit limits were on a January- December period. They only way to know for sure is to consult your insurance handbook, call your insurance company, or speak with someone in the provider’s office.

Copays and How They Work

Common Health Insurance Terminology

Premium– The monthly or bimonthly fee you pay to have health insurance.

CPT codes– A medical code used for billing (a 5 digit number like 97110).

Allowed Amount– The maximum amount your particular health insurance plan will pay for a service.

Deductible– The amount you owe before your insurance begins to pay.

Co-insurance– A percentage of the allowed amount that you pay.

Out of Pocket– The maximum you will ever pay during your benefit period.

Copay– A fixed dollar amount you may pay for a service at the time you receive it. Many times, a copay does not apply towards your deductible. However, it will often apply towards your Out of Pocket Limits.

 

 

Copays and how they work

Sometimes the plan you sign up for will charge you a copay per service rather than a deductible. A copay is a fixed dollar amount that you pay to the provider at the time you receive the service rather than after you receive a bill. Sometimes it will apply towards your deductible; sometimes it won’t. Often it will apply towards your Out of Pocket limits.

Copay Examples (with notes from the previous blog post):

A. In this example, if you have a $25 copay for a particular service, then the provider will charge you $25 at the time of the service. The provider will then send their bill to the insurance company. Insurance Company A will receive the $200 bill from the provider and determine that your allowed amount was $70 for the service. The insurance company will send this information in the form of an Explanation of Benefits (EOB) to both you and the provider along with a check for $45 (the $70 allowed amount minus your $25 copay= $45). The EOB will show that you owe $25 (this is the copay amount that you already paid, not a new amount that you owe). The provider will adjust the $200 bill in their electronic medical records to be $70 according to the insurance’s EOB. The provider will apply the $45 from the insurance company and the $25 copay that you paid and the balance will be zero. If you did not pay your copay at the time of the service, the provider will send you a bill for the copay amount.

B. In this example, if you have a $25 copay for a particular service, then the provider will charge you $25 at the time of the service. The provider will then send their bill to the insurance company. Insurance Company B will receive the $200 bill from the provider and determine that your allowed amount was $130 for the service. The insurance company will send this information in the form of an Explanation of Benefits (EOB) to both you and the provider along with a check for $105 (the $130 allowed amount minus your $25 copay= $105). The EOB will show that you owe $25 (this is the copay amount that you already paid, not a new amount that you owe). The provider will adjust the $200 bill in their electronic medical records to be $130 according to the insurance’s EOB.  The provider will apply the $105 from the insurance company and the $25 copay that you paid and the balance will be zero. If you did not pay your copay at the time of the service, the provider will send you a bill for the copay amount.

 

This copay payment continues until you have reached your Out of Pocket limit (OOP). The OOP is the maximum amount that you will pay during a benefit period. Sometimes the deductible or copays apply to the OOP and sometimes they don’t; it varies per plan.

Out of Pocket Examples (continued from above):

A. In this example, if you have a $25 copay for a particular service, then the provider will charge you $25 at the time of the service. The provider will then send their bill to the insurance company. Insurance Company A will receive the $200 bill from the provider and determine that your allowed amount was $70 for the service. However, you have accumulated enough medical expenses to have met your $4000 Out of Pocket limit (OOP), so now the insurance will pay 100% of the service cost. The insurance will send this information in the form of an Explanation of Benefits (EOB) to both you and the provider along with a check for 100% of $70, which is $70, to the provider. The provider will adjust the $200 bill in their electronic medical records to be $70 according to the insurance’s EOB; they will note the account as paid in full by the insurance by $70. You will not receive a bill. If you paid your $25 copay at the time of service, the provider will issue you a refund.

B. In this example, if you have a $25 copay for a particular service, then the provider will charge you $25 at the time of the service. The provider will then send their bill to the insurance company. Insurance Company B will receive the $200 bill from the provider and determine that your allowed amount was $130 for the service. However, you have accumulated enough medical expenses to have met your $4000 Out of Pocket limit (OOP), so now the insurance will pay 100% of the service cost. The insurance will send this information in the form of an Explanation of Benefits (EOB) to both you and the provider along with a check for 100% of $130, which is $130, to the provider. The provider will adjust the $200 bill in their electronic medical records to be $130 according to the insurance’s EOB; they will note the account as paid in full by the insurance by $130. You will not receive a bill. If you paid your $25 copay at the time of service, the provider will issue you a refund.

Copays and Deductibles together?

There are some insurance companies that will charge a copay for a service, such as a therapy, but also apply the remaining balance of the initial visit to the patient’s deductible. This may be why, even though you pay your copay in full for each visit, you also receive a bill from the provider’s office. It is best to call the office and inquire about the bill so you will know if this is the case or if a billing error has occurred.

 

On to the next topic:  More to learn about what you need to know. Stay tuned for Physical therapy visit limits, authorizations, and benefit periods.

Deductibles, Co-insurance, & Out of Pocket limits

Common Health Insurance Terminology

Premium– The monthly or bimonthly fee you pay to have health insurance.

CPT codes– A medical code used for billing (a 5 digit number like 97110).

Allowed Amount– The maximum amount your particular health insurance plan will pay for a service.

Deductible– The amount you owe before your insurance begins to pay.

Co-insurance– A percentage of the allowed amount that you pay.

Out of Pocket– The maximum you will ever pay during your benefit period.

Copay– A fixed dollar amount you may pay for a service at the time you receive it. Many times, a copay does not apply towards your deductible. However, it will often apply towards your Out of Pocket Limits.

 

Deductibles, Co-insurance, & Out of Pocket limits

Once the insurance company has determined the allowed amount of the service based on their fee schedule, they consult your particular healthcare plan. Each insurance company offers different levels of plans and the coverage of those plans are all different. The amount you pay for the service provided to you is based on the plan you chose. If you have a Deductible and Co-insurance type of plan, then the allowed amount for the service is applied to your Deductible first.

Deductible Examples (with notes from the previous blog post):

A. In this example, Insurance company A received the $200 bill from the provider and determined that your allowed amount was $70 for the service. If you have a $2000 deductible, then they apply $70 to your deductible, leaving you with a remaining deductible of $1930. The insurance company will send this information in the form of an Explanation of Benefits (EOB) to both you and the provider. The provider will adjust the $200 bill in their electronic medical records to be $70 according to the insurance’s EOB and will mail you a bill for $70.

B. In this example, Insurance company B received the $200 bill from the provider and determined that your allowed amount was $130 for the service. If you have a $2000 deductible, then they apply $130 to your deductible, leaving you with a remaining deductible of $1870. The insurance will send this information in the form of an Explanation of Benefits (EOB) to both you and the provider. The provider will adjust the $200 bill in their electronic medical records to be $130 according to the insurance’s EOB and will mail you a bill for $130.

 

Once you have met your Deductible, the allowed amount of the service will then apply to your Co-insurance. Your Co-insurance is a split where you pay a percentage of the fee for the services and the insurance company pays a percentage of the fees. It is usually written as a fraction with the insurance’s portion first like this, 80/20, which means the insurance company pays 80% of the service costs and the member (you) pay 20% of the service costs.

Co-insurance Examples (continued from above):

A. In this example, Insurance Company A received the $200 bill from the provider and determined that your allowed amount was $70 for the service. If you have a $2000 deductible, but have accumulated enough medical expenses that you have met your $2000 deductible for the benefit period, then $70 is applied to your co-insurance amount. If you have an 80/20 co-insurance amount, meaning that the insurance will cover 80% of the service costs and you will cover 20% of the service costs, then the insurance will send this information in the form of an Explanation of Benefits (EOB) to both you and the provider along with a check for 80% of $70, which is $56, to the provider. The provider will adjust the $200 bill in their electronic medical records to be $70 according to the insurance’s EOB, they will note the account as partially paid by the insurance by $56 and will mail you a bill for $14.

B. In this example, Insurance Company B received the $200 bill from the provider and determined that your allowed amount was $130 for the service. If you have a $2000 deductible, but have accumulated enough medical expenses that you have met your $2000 deductible for the benefit period, then $130 is applied to your co-insurance amount. If you have an 80/20 co-insurance amount, meaning that the insurance will cover 80% of the service costs and you will cover 20% of the service costs, then the insurance will send this information in the form of an Explanation of Benefits (EOB) to both you and the provider along with a check for 80% of $130, which is $104, to the provider. The provider will adjust the $200 bill in their electronic medical records to be $130 according to the insurance’s EOB, they will note the account as partially paid by the insurance by $104 and will mail you a bill for $26.

This co-insurance split continues until you have reached your Out of Pocket limit (OOP). The OOP maximum is the maximum amount that you will pay during a benefit period. Sometimes the deductible or copays apply to the OOP maximum and sometimes they do not; they vary per plan.

Out of Pocket Examples (continued from above):

A. In this example, Insurance Company A received the $200 bill from the provider and determined that your allowed amount was $70 for the service. You have a $2000 deductible, but have had enough medical expenses that you have met your $2000 deductible for the benefit period. You also have an 80/20 co-insurance amount, meaning that the insurance will cover 80% of the service costs and you will cover 20% of the service costs. However, you have accumulated enough medical expenses to have met your $4000 Out of Pocket limit (OOP), so now the insurance will pay 100% of the service cost. The insurance will send this information in the form of an Explanation of Benefits (EOB) to both you and the provider along with a check for 100% of $70, which is $70, to the provider. The provider will adjust the $200 bill in their electronic medical records to be $70 according to the insurance’s EOB; they will note the account as paid in full by the insurance by $70. You will not receive a bill.

B. In this example, Insurance Company B received the $200 bill from the provider and determined that your allowed amount was $130 for the service. You have a $2000 deductible, but have had enough medical expenses that you have met your $2000 deductible for the benefit period. You also have an 80/20 co-insurance amount, meaning that the insurance will cover 80% of the service costs and you will cover 20% of the service costs. However, you have accumulated enough medical expenses to have met your $4000 Out of Pocket limit (OOP), so now the insurance will pay 100% of the service cost. The insurance will send this information in the form of an Explanation of Benefits (EOB) to both you and the provider along with a check for 100% of $130, which is $130, to the provider. The provider will adjust the $200 bill in their electronic medical records to be $130 according to the insurance’s EOB; they will note the account as paid in full by the insurance by $130. You will not receive a bill.

 

On to the next topic: When do Copays apply instead of a Deductible? Can you have both? Stay tuned for Copays and how they work.

Common Health Insurance Terminology

 

Premium– The monthly or bimonthly fee you pay to have health insurance.

CPT codes– A medical code used for billing (a 5 digit number like 97110).

Allowed Amount– The maximum amount your particular health insurance plan will pay for a service.

Deductible– The amount you owe before your insurance begins to pay.

Co-insurance– A percentage of the allowed amount that you pay.

Out of Pocket– The maximum you will ever pay during your benefit period.

Copay– A fixed dollar amount you may pay for a service at the time you receive it. Many times, a copay does not apply towards your deductible. However, it will often apply towards your Out of Pocket Limits.

 

 

Allowed Amounts: What are they and why is one bill different from another?

Each insurance company has a document called a fee schedule that lists the maximum amount that company will reimburse for a particular service. The bill that the doctor sends has one or more CPT codes on it. An insurance representative finds each of those codes on the fee schedule so they will know how much to pay for that service.

Examples:

  1. If a provider sends a code to Insurance Company A and it is $200 on the bill, but the fee schedule says that the insurance pays $70 for that service, then $70 is what is paid for that service.
  2. If a provider sends a code to Insurance Company B and it is $200 on the bill, but the fee schedule says that the insurance pays $130 for that service, then $130 is what is paid for that service.

Now we know that the allowed amounts are set by the insurance companies and that they list all of their chosen amounts in a document called a fee schedule. Each company has their own list and, while they may be similar, they are not the same.

On to the next topic: Who will be paying for the service now that the price is determined? That will depend on the particular plan that you signed up for. Stay tuned for Deductibles, Co-insurances, and Out of Pocket Limits.

What is Direct Access

Direct Access is exactly what it sounds like: Patients having direct access to physical therapy services without a doctor’s referral. A direct access license is available to physical therapists in Pennsylvania and many other states. There are five elements to the Direct Access model of care including examination, evaluation, diagnosis, prognosis, and intervention. Once your initial examination/evaluation is completed, our physical therapists will develop a Plan of Care for your treatment. This will be submitted to your doctor for their review.

Who can use Direct Access?

Most insurances will cover treatment without a referral as long as the physical therapist has his/her direct access license. Medicare, Medicare replacement plans (Security Blue, for instance), and government issued insurance plans usually will not reimburse direct access treatment. If you have any questions about your insurance plan, please contact your local Panther Physical Therapy office for more information.

Why choose a Physical Therapist with Direct Access?

Direct Access extends consumer’s choice and eliminates barriers to entry. This decreases the time it takes to start treatment. It improves access to a profession that promotes prevention and wellness. Early access to physical therapy has many benefits including decreased medical costs, enhanced recovery, and decreased use of sick time. Direct Access helps the patient see positive functional results, feel confident in their recovery, and experience reduced pain as they progress. It is dynamic and comprehensive care.

Picking the right physical therapy office can be daunting. By choosing a physical therapist with Direct Access, it allows you to begin treatment sooner since you do not have to wait for an appointment with your physician. Therapists can provide their patients with the quality of care that they need, when they need it, and in a manner that best suits them- No Prescription Necessary.

How to Get the Most Out of Physical Therapy

Check Your Insurance

Prior to starting therapy check with your insurance provider to determine your therapy benefits. Find out if you have a visit limit and how many visits are allowed. Check if you have a copay, co-insurance, and / or deductible that must be met. By knowing what to expect with these details up front, it will minimize surprises down the road.

Arrive Early

Try to arrive early for your scheduled appointments. During your initial appointment, you may want to arrive up to 15 minutes early to allow time to fill out the required paperwork. Arriving early will allow you time to change if necessary and be ready for the start of your appointment to maximize time with your therapist.

Openly Communicate

If you have questions or do not understand something, do not hesitate to ask your therapist, especially if it pertains to your home care. If at any time you experience increased pain, it is important to let your therapist know. Some pain is natural with therapy but your therapist will know if it is normal and expected or something that needs to be addressed.

Discuss Your Goals

Determine what you personally want to accomplish with your therapy program and discuss your goals with your therapist during your initial session. Therapy programs are established based on each individual’s needs. Your goals should be part of the process in determining your program.

Dress Comfortably

If you are going to therapy straight from work, take a change of clothes with you. Some of your therapy goals will involve improving your range of motion and flexibility. You will need to be able to move through a full range of motion which is difficult in tight fitting, restrictive clothing. Also bear in mind that your therapist may need to expose the injured area for certain types of treatment.

Maintain an Open Mind and Positive Attitude

The mental aspect of therapy can be every bit as important as the physical component. Committing fully to your therapy program will impact the speed and quality of your recovery.

Focus on Your Treatment

Do not bring friends or family to therapy sessions unless it is a necessity. Turn off your cell phone during your appointments. Schedule your sessions at times in which you will not be rushed. Doing your program accurately and at the appropriate speed will affect your outcomes. It is difficult to focus on the task at hand if you have constant distractions. Your progress will be limited if your therapist has to shorten your session because of time constraints.

Stay Hydrated

Drink plenty of water and stay well rested throughout your rehabilitation. Proper hydration and rest is important when recovering from any injury.

Complete Your Home Exercises

Your therapist will prescribe a home exercise program for you. Create a schedule to do your home exercises and be faithful with completing it. Your home exercise plan is every bit as important as your scheduled therapy appointments and should be a daily priority. Take your home exercises seriously and do them as prescribed, including the appropriate number of repetitions and daily frequency.

Challenge Yourself

As you get stronger throughout your therapy, increase your resistance and/or repetitions with your exercises. Your therapist will periodically progress your program. If your exercises begin to feel too easy, speak up about adding resistance, repetitions, or extra sets.

Discuss After-Care

Consult with your therapist about your after-care when formal treatment has concluded. In many instances, you will continue with your home exercise program for several more months.