Sarah: Ah, the holidays. A time for family, festivities, and…insurance resets? Looking through different terms and dollar amounts can be overwhelming, especially with the jargon involved. One of the services we provide at AMTA is a benefits check for each patient before they come in for their first appointment, as well as a new quote at the beginning of their plan year. Over the years we’ve received feedback from patients who were pleasantly surprised to have their benefits explained to them before they began treatment and stated their other medical offices didn’t offer that sort of information. We get a patient’s insurance information when scheduling their initial evaluation, make calls to each patient’s insurance companies to get a quote of in-network benefits, and explain said benefits upon check-in at their first appointment, so each patient has an idea of what to expect, billing-wise.
Each of our front desk staff members is trained on insurance terms and the basics of billing insurance claims. Explaining benefit details to patients involves knowing the different types of cost shares for a patient, as well as authorization processes and limits placed on PT in particular.
Crystal: When I was learning how to verify patients’ benefits for them, the first thing I committed to memory was that a medical insurance deductible works the same as that of car insurance: it’s an amount that must be met by paying the contracted amount to all covered medical services combined before the insurance provider starts to pay a portion of the cost along with the patient’s portion, referred to as the cost share. That’s the part that got confusing. The cost share could be a copay or coinsurance. Yikes! What do those even mean?!
The copay is a set amount that will not fluctuate for the same service, for example: Physical Therapy. The coinsurance on the other hand is a percentage and is based on the procedures performed at a PT visit. The coinsurance can fluctuate from one visit to the next by a moderate amount, which we can estimate based on your plan and our contract with your provider.
Sarah: Typically, if a plan has a deductible for medical services, there’s a coinsurance percentage to be paid after the deductible is met. This coinsurance can be as little as 5% of what you would pay towards your deductible each visit or upwards of 50% of the amount. As Crystal stated above, the actual dollar amount for that coinsurance can vary per visit, depending upon what insurance you have. We check your claims before each visit to see how they have processed and will keep you updated should you end up with a credit or balance. In addition to a deductible (if your plan has one for medical services), your plan may also have an out-of-pocket maximum.
Crystal: I bet you’re thinking “I thought I was already paying out of pocket?!” That’s insurance lingo for you; any patient responsibility is going to come out of ‘your pocket’, but the out of pocket maximum is a dollar amount notated in your insurance plan.
Sarah: Should you meet your out of pocket (OOP) for your plan year, your insurance will then cover 100% of covered services for the remainder of your plan year. The amounts you are responsible for in regards to deductible, copay, and coinsurance payments will typically apply to your OOP; however this can vary from plan to plan. During the benefits call we make to your insurance company, we ask for any deductible, coinsurance, or copay information, as well as the amount you have paid towards your deductible and OOP. This way we can accurately determine an estimate of your responsibility for physical therapy services at our clinic. The example I like to use for deductibles and OOPs when training is that of a person swimming. When you’re paying towards your deductible, you’re swimming on your own in a lake. When you meet your deductible and owe a portion of the charges, insurance has given you a life jacket: you’re still swimming, but you’ve got a little help on the way. Meeting your OOP is akin to insurance giving you a boat; you no longer have to swim and it’s smooth sailing (at least until your plan year resets). In some cases, your deductible and OOP amounts may be the same, so if you meet your deductible, you’re covered at 100% for the remainder of your plan year!
Crystal: Physical therapy can be limited to a set number of visits or a dollar amount worth of physical therapy services. Sometimes, insurances require authorization for PT services. If an authorization is required, we do the leg-work and initiate the authorization, as well as request extensions when necessary. Your insurance may send you written correspondence regarding your authorization. If you have any questions regarding your authorization, feel free to call or bring the letter in and we’ll be happy to go through it with you.
Sarah: Insurance can be a pain, and on top of physical pain, can leave you feeling overwhelmed and out of your element. Our administrative staff is trained on the insurance processes listed above, as well as claims processing and billing, and are always available during business hours to answer any questions you may have. Give us a call at (512) 832-9411 and we will help you get started on the road to recovery!
Sarah Urias, Front Office Manager | Crystal James, Patient Care Coordinator
