Most individuals come in wanting to use their medical insurance, but they don’t necessarily understand the process of how it works. Although insurances can be complex, we want to make your experience as simple and convenient as possible. Here are a few breakdowns of what you should know regarding your insurance:
About Deductibles.
If the insurance policy has a deductible, then the card holder is responsible for paying that amount before the insurance begins to cover the desired services. At Core Performance PT, we have received estimations from each insurance company of what to charge the patient during each session. This payment amount depends on the insurance company and if the patient is coming in for an initial evaluation or a follow up appointment. After the patient satisfies the deductible, then their insurance will kick in. The patient will now be responsible for their policy’s copay or coinsurance. If deductible does not apply for their policy, then they will be responsible for just their copay or coinsurance.
What is the difference between a Copay and Coinsurance?
A copayis a set dollar amount that will be owed for each session.
A coinsuranceis a percentage rate. For example, the insurance company will cover 80% where the patient is responsible for 20%. We determine the coinsurance charge by the estimations that we receive from each insurance company.
The copay and coinsurance is different for each policy.
Are prescriptions always required?
Most insurance companies require a prescription from a medical doctor in order for the services to be covered. This depends on the insurance company and the policy. Our billing department sends the physical therapy documentation a long with the prescription to the insurance company. The insurance will then respond saying if they deny or cover the services.
Although the patient’s physician provides a treatment plan on the prescription, the insurance company ultimately determines how many visits will be approved based off of the physical therapy notes and medical prescription.
We will still bill and treat our patients even if they do not have a prescription. However, the patient will be responsible to pay our cash rates if their insurance does not cover their visits.
How many visits are allowed for Physical Therapy?
Patients will either have a visit limit or it will be based on medical necessity. In other words, if the physical therapist thinks it is necessary for the patient to continue treatment, then the insurance will approve those visits. If there is a visit limit, it will either be a soft cap (additional visits may be approved) or a hard cap (cannot get additional visits). Our receptionist will call your insurance company for additional visits when needed.
Medicare overview in one paragraph.
Medicare operates a bit differently than most PPO insurances. Medicare provides a dollar amount opposed to a visit limit. We allow up to a $3000 maximum which we estimate to be about 30 visits. All Medicare patients must have a prescription to be treated for physical therapy. Medicare covers 80% of the services while the secondary insurance will cover the remaining 20%. If the patient does not have a secondary insurance, then they will be responsible for paying what Medicare does not cover (the remaining 20%). We do not have estimations of what that charge will be as it depends on how the therapist bills and how Medicare processes the billing.
What happens when I exhaust my $3000 limit for Medicare?
There are 2 options when a Medicare patient exhaust their benefits.
- Continue physical therapy with us and pay out of pocket as a cash patient.
- Sign up for personal training with one of our skilled trainers and pay cash for 12- or 24-session packages. Learn more here.
Insurance companies can be complex, but we at Core Performance PT want to make your journey as easy and simple as possible. Keep in mind that we do not determine the prices for physical therapy, the insurance companies do. We hope that these tips will help you better understand your insurance.
If this article didn’t answer your question, please contact us at:
IRVINE: (949) 861-3416
NEWPORT BEACH: (949)759-1840
or refer to our FAQ page here.
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