Money Matters (Selected Part of Letters from Aunt Evelyn), conceptual art by Barton Lidice Benes, 1982.
This is an article that I thought I would never write. When I first started
working as a physical therapist, I worked for a big hospital in Manhattan. I
never had to think about insurance, because basically the hospital accepted
every type of insurance there was! In fact, these were the days when there was
no such thing as a co-payment. When co-pays did come along, for many years the
hospital never attempted to collect the 5 to 10 dollars per visit. But that was
17 years ago, and a lot has changed now.
Things really started to
change after Obama care. I not saying that I am either for or against Obama
care, I am just saying that things are very different now. For example, in
order to have insurance, many families are choosing insurance where the
deductible is 5 to 6 thousand dollars per year! This means that the patient has
to pay the first 5 or 6 thousand dollars in medical services, thus meeting
their deductible, before their physical therapy services are covered. In
addition, the person usually has a co-pay required at each physical therapy
session, which can be as high as 50 to 75 dollars per visit with some plans.
Take the time to consider these factors when choosing your insurance needs.
At Equinox Physical Therapy, we check a patient’s insurance benefits before
they even arrive for their first visit. I am a standard Medicare Part B
provider for out-patient physical therapy services. That means that I accept
standard Medicare Part B because I am committed to treating people over 65
years of age who have balance problems, dizziness, vertigo, falls, inner ear
problems, concussion, or facial paralysis. I don’t want my Medicare patients to
fall and break a hip, when I know that I can help them to enjoy their
retirement in sunny Sarasota, Florida, and live a long and healthy life!
Medicare pays 80% for out patient physical therapy services, and most people
have a secondary insurance that covers all or part of the remaining 20% of the
bill.
As far as other types of insurance, I see patients who do not have Medicare,
but some other type of insurance, and in these cases I am classified as an
“out-of-network” physical therapy provider. Because I am not a major hospital,
I cannot accept every insurance under the sun, because it would be too much for
my small practice to manage.
Why would someone come to me, an out-of-network provider, when they could see
someone in-network instead? That should be your next question. The reasons are
probably many. When I see a private insurance patient, they pay me, and then I
give them the papers they need to submit their physical therapy bills to their
insurance company. Then, their insurance company will reimburse the patient
directly for whatever their out-of-network physical therapy benefits are. The
patient calls their insurance company to verify their benefits before they even
step inside my door. They know exactly the percentage that their insurance
company will reimburse them, and the percentage that they will have to pay of
the remaining bill.
Again, why would someone come to me instead of going to his or her “in-network”
provider? For one thing, many of these patients have BPPV, a condition that
causes vertigo and seriously interferes with their ability to work, or function
properly. With this condition, it usually goes away if treated properly in 2-6
sessions. So, it is not such a big expense to come see me. If they have a big
deductible, they will have to pay either way. At least if they come to see me,
they know they are being seen by someone who treats this problem 3-4 times a
day, as opposed to someone who has little experience, or only treats this
problem occasionally. For patients with conditions that take longer to treat,
they come to me because they know that their chances of having a good outcome
are enhanced if they have the best possible therapist that their money can buy,
because again, they still have to pay the large deductible either way. Other
patients come to me because I am a specialist in treating inner ear disorders,
concussion, falls, dizziness, and facial paralysis, and their “in-network”
therapists are not.
Another point to consider is the co-payment. Because I am out of network, I do not collect a co-payment. For those patients whose co-payments are 50 to 75 dollars per visit, the difference between their co-payment and what they have to pay me may be the same, or not much more.
If you are considering going out of network for your out-patient physical therapy services, here are a list of questions that you should ask your insurance company to help you decide if going out of network is right for you or your loved one. One thing to remember is that you, the patient, have the right to receive services from any physical therapist you choose.
TOP 4 QUESTIONS
REGARDING OUT-OF-NETWORK PHYSICAL THERAPY BENEFITS
1. Do I have out-of-network physical therapy benefits? If not, what does that
mean?
2. Am I eligible to receive direct reimbursement from the insurance company for
my physical therapy visits?
3. What percentage of the money I paid at my physical therapy visit will you,
the insurance company, reimburse?
4. Do I have an out-of-network deductible to meet first?
