Insurance 101 for PT Patients
So, your insurance “covers” physical therapy—which means you won’t have to pay anything out-of-pocket for your therapy visits, right? Not quite. The fact that your insurance plan covers PT services – or any other services, for that matter – doesn’t necessarily mean you’re off the hook as far as payment goes. In many cases, you’ll still have to pay a deductible, a coinsurance, or a copayment.
To better understand the terms of your plan, it helps to understand the terminology. Here are 5 common terms used in your insurance documents
1. What is a deductible?
This is the total amount you must pay out-of-pocket before your insurance starts to pay. For example, if your deductible is $1,000, then your insurance won’t pay anything until you have paid $1,000 for services subject to the deductible (keep in mind that the deductible may not apply to every service you pay for). Furthermore, even after you’ve met your deductible, you may still owe a copay or coinsurance for each visit.
2. What is a copay?
This is a fixed amount that you must pay for a covered service, as defined by your health plan. Copays usually vary for different plans and types of services. Typically, you must pay this amount at the time of service. Again, copay amounts are fixed—which means you will always pay the same amount, regardless of visit length. In most cases, copayments go toward your deductible.
3. What is a coinsurance?
This type of out-of-pocket payment is calculated as a percent of the total allowed amount for a particular service. In other words, it’s your share of the total cost. For example, let’s say:
- Your insurance plan’s allowed amount for an office visit is $100.
- You’ve already met your deductible.
- You’re responsible for a 20% coinsurance.
In this situation, you’d pay $20 at the point of service. The insurance company would then pay the rest of the allowed amount for that visit. Keep in mind that the coinsurance amount may vary from visit to visit depending on what services you receive.
4. What is the coinsurance for Medicare Part B?
Medicare Part B patients are responsible for a 20% coinsurance, which typically amounts to $25 per visit. If you have original Medicare as your primary insurance, but you also have a secondary insurance, the secondary payer becomes responsible for the 20%. In some cases, the secondary insurance also charges a copay, coinsurance, or deductible. We recommend contacting your secondary insurance carrier to find out.
5. What is an Out of Pocket Maximum?
This the dollar amount at which you will no longer be responsible for paying for in medical services. Plans vary greatly with out of pocket maximums.
- The deductible amount may be the same as the out of pocket maximum amount. At this time, you will no longer pay for services provided by medical providers.
- The deductible amount, plus coinsurance/copay amounts add up to out of pocket maximum amount. At this time you will no longer pay for services provided by medical providers.
- Some plans still require patients to pay copays even if the out of pocket maximum amount is met. In this case services that fall under the plan deductible will no longer be patient responsibility, but copays will always be paid by the patient.
So, how much will I owe for each visit at Physical Therapy of Melissa?
If you have not yet met your deductible, then you will typically pay around $100 per visit. We charge coinsurance as a dollar amount equal to the percentage. So, if you have a 20% coinsurance, you’ll pay $20; if you have a 10% coinsurance, you’ll pay $10. We do our best to estimate the amount to collect at time of service. You may owe any applicable coinsurance or deductible balances after we receive the Explanation of Benefits (EOB) from your insurance company if there was a difference in the collected amount. Conversely, if we find that you have overpaid, we will refund you via check as soon as possible. As for copays – these amounts rarely vary, so if your copay for physical therapy visits is $20, you will owe $20 at each visit.
What if I can’t afford to pay these amounts as frequently as I need care?
Your health is our number-one priority. As such, please let our new patient coordinator know your situation. She will discuss your treatment with one of our Doctors of Physical Therapy to find a solution. You may be able to reduce the amount of PT visits you need by doing some treatments on your own using a home exercise protocol given by one of our Doctors of Physical Therapy. In some cases, you may also be a good candidate for 30-minute treatment appointments instead of an hour.
Examples of EOBs for PT Services
Here are a few examples of Explanations of Benefits (EOBs) for physical therapy services. An EOB is a document your insurance sends to explain the various costs—including the amount you, as the patient, are responsible for—associated with your care. For definitions of the terms included in these examples, skip down to the bottom section of the page.
Insurance 1: Patient has not yet met his or her annual deductible. Therefore, the patient is responsible for 100% of the allowed amount.
| Date of Service | CPT Code | Units | Billed Amount | Adjusted Amount | Patient Responsibility | Insurance 1 Paid |
| 03/01/2017 | 97110 | 1 | 50.00 | 20.04 | 29.96 | 0.00 |
| 03/01/2017 | 97140 | 2 | 100.00 | 44.58 | 55.42 | 0.00 |
| TOTALS: | 3 | 150.00 | 64.62 | 85.38 | 0.00 | |
Insurance 2: Patient owes a 20% coinsurance for PT services.
| Date of Service | CPT Code | Units | Billed Amount | Adjusted Amount | Patient Responsibility | Insurance 2 Paid |
| 03/01/2017 | 97110 | 2 | 100.00 | 42.47 | 11.69 | 45.84 |
| 03/01/2017 | 97140 | 2 | 100.00 | 54.19 | 9.31 | 36.50 |
| TOTALS: | 4 | 200.00 | 96.66 | 21.00 | 82.34 | |
Insurance 3: Patient owes a $10 copay for PT visits.
| Date of Service | CPT Code | Units | Billed Amount | Adjusted Amount | Patient Responsibility | Insurance 3 Paid |
| 03/01/2017 | 97140 | 2 | 100.00 | 30.00 | 10.00 | 60.00 |
| 03/01/2017 | 97535 | 1 | 45.00 | 45.00 | 0.00 | 0.00 |
| TOTALS: | 3 | 145.00 | 75.00 | 10.00 | 60.00 | |
A Few Handy Definitions
Date of Service: The date of your visit.
CPT Code: The code denoting each service provided to you during your visit (e.g., manual therapy, therapeutic exercise, therapeutic activities, ice/heat, etc.). You can request a list of these codes—along with their explanations—from your insurance company or Physical Therapy of Melissa.
Billed Amount: This is the amount we billed the insurance company for that particular service. The billed amount may vary depending on the duration of the service, the facility in which the service was provided, or the state in which the facility is located.
Adjusted Amount: This amount is not a payment, but rather a write-off or “reduction.” It is based on the contract in place between your provider (us) and your insurance company. Neither you nor the insurance company pays this amount. The provider essentially writes it off (which is why it is sometimes called the provider’s responsibility).
Patient Responsibility: This column may be labeled “Deductible,” “Copay,” “Coinsurance,” or “Patient Pay.” It is the amount that you, the patient, are responsible for paying. If a secondary insurance is on file, we will forward this amount to that insurance for payment. Once we get the secondary EOB back, you will receive a bill for any outstanding balances in the patient responsibility column.
Insurance Paid: This is the amount the insurance company paid us for the services you received on that date of service.
— TIP —-
If your insurance offers an online patient portal, sign up for it! These resources typically enable you to
- check your benefits
- track your deductible
- see which providers in your area accept your particular plan
- track your claims
- compare claims to your receipts from the doctor’s office (if they don’t match up, you can then follow up on any discrepancies)
Michelle Christadoss, Business Office Manager, CFO