Health insurance is something that everyone needs but very few people understand. As physical therapists, we see patients for a wide range of reasons, which include work injuries, car accidents, ailments related to aging, and more. Each patient falls into one of six insurance categories: Medicare, Medicare Advantage, Private Insurance, Auto, Workman’s Comp, or Cash Payer. The type of insurance you have will determine what kind of physical therapy coverage you have available in regards to costs and the number of sessions. Below is an overview of common health insurance terms and a brief explanation of how each health plan works.
Defining Common Insurance Terms
A patient’s upfront out-of-pocket expense they have agreed to pay before their insurance coverage is responsible for any fees. This is applicable to both health and auto insurance.
A patient pays a percentage of their claim in accordance with their insurance company’s contracted rate with the provider. Example: Your insurance company has agreed to pay your provider $50 a visit. Your co-insurance rate is 15%. You would pay the provider $7.50 per visit.
Also called a copayment, this is the amount a patient has agreed to pay a provider in addition to what their insurance company will pay. The rate is established by their insurance company and is charged for each visit to the provider.
The monthly rate a patient pays to their insurance company to purchase their coverage plan. This is applicable to both health and auto insurance.
Depending upon the health insurance plan, some patients will have direct access. That means that they do not require a referral from their primary care provider in order to see a specialty provider. As long as a provider accepts the patient’s health plan (also called ‘in-network’), the patient can see them for care. Pennsylvania is a Direct Access State and all Cawley Physical Therapy therapists have Direct Access. What does this mean for you?? This means NO referral and NO doctor prescription is necessary for you to be seen in our facilities for up to 30 days.
How Does My Insurance Coverage Work?
Medicare: This is government-provided insurance that is available for individuals over the age of 65. While Medicare has many rules under which it operates, it does cover 80% of provided service, leaving the patient responsible for the remaining 20%. Supplemental policies can be purchased to cover the remaining 20%.
Medicare Advantage/Replacement Plans:
These plans work like private insurance but they are much more affordable, sometimes even having no monthly premium for qualified patients. Unlike traditional Medicare, these plans usually have a copay and deductible. Patients may incur greater out-of-pocket expenses with these plans.
This is a traditional insurance plan that people generally purchase via their employers. Some of the most common private insurance companies are BlueCross, BlueShield, Highmark, Geisinger, Aetna, Cigna and many others. Private insurance generally offers more plan options dependent upon how large of a deductible and premium a patient is willing to pay. In general, these plans have a yearly deductible, copay or coinsurance, and a monthly premium. These rates can vary depending on the employer and available plans.
Auto insurance is used for medical care only when a patient has sustained an injury from an automobile accident that has been documented by their auto insurance company. The assigned claims adjuster from the auto insurance company will provide the patient with an assigned claim number. This claim number can be used by the patient in place of their regular health insurance plan in order to receive care. However, most auto insurance plans have a cap on medical expenses. You may be required to provide your private health insurance information or pay out of pocket for any care needed after your cap has been met.
This state-run program works similar to auto insurance in that there will be a claim number associated with your medical care. Typically, your care is overseen by an assigned case manager and physician who are in charge of the care related to your injury. It’s important to know that you must see the doctor and medical experts assigned to you, but you have the right to seek a different medical expert for a second opinion.
Cash Payer: Just as it sounds, this option is for patients without medical coverage. Patients will pay the full rate to receive treatment from the provider for each visit. The patient is responsible for the entire cost of their care.
Still Have Questions?
Contact Cawley Physical Therapy and Rehabilitation at (570) 208-2787 and speak to our billing department to learn more about your bill and payment options. Remember: If you have specific questions about what your insurance plan covers, you should call your insurance company directly.
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