Everything you never wanted to know about insurance*
(*But knew you should ask)
Learning about insurance coverage is less awkward but as unavoidable as squeezing into your first set of superhero tights: it’s critical to acquiring quality access and ensuring you have the appropriate coverage in place. Just as each superhero has unique abilities, each insurance plan is unique too. You, as the beneficiary, have the direct path to obtaining this knowledge.
Why is it important for me to independently learn about my insurance coverage?
Like Batman & Robin, a winning healthcare experience is a partnership. While we work to provide you with incredible therapeutic care (our superpower), we expect you to use your superpowers to keep current on your insurance benefits, notify us promptly of any changes to your coverage, and use this information to understand how your insurance plan relates to your care here at CorePhysio.
To help our community access care, we maintain insurance contracts, meaning we are in-network and preferred providers with most insurers. We are required to abide by those contracts in order to provide the community with skilled outpatient physical therapy.
Ultimately, however, your insurance company determines how your services are covered and how much you might owe.
Click on the heading of your choice below for answers to commonly-asked questions.
Why aren’t you a preferred provider for every insurance?
We are a small clinic that emphasizes the provision of quality care at a reasonable price for clients who recognize the unique value of our services, and we are proud to be preferred providers with a wide range of insurances and provider networks.
The amount of detailed information required to secure payment for medical services from numerous insurance companies with different policies is an exceptional task, as is the process to negotiate and obtain a reasonable payment contract. We try to balance this service to our clients and community with the needs and abilities of our business and staff.
If physical therapy is a “covered service,” does that mean I won’t get a bill?
A “covered service” simply means physical therapy benefits are available under your plan. Services are still subject to plan limitations such as deductibles, copays, co-insurance, etc.
You are in-network with my insurance, but I don’t want you to bill them. Can I pay out-of-pocket instead?
YES, with the exception of Medicare plans. For insurance plans other than Medicare plans, you may opt to pay for your visits using our private pay rates at time of service. Please note that choosing this option means your services will not count towards your deductible or out-of-pocket maximums for the year.
You are out-of-network with my insurance, but I want to be seen at CorePhysio. Can I choose to pay out-of-pocket?
YES, with the exception of Medicare. Please contact your insurance to see if you are eligible for out-of-network benefits, in addition to how you can apply for potential reimbursement.
Why can’t I choose to pay out-of-pocket if I have a Medicare plan?
Federal laws prohibit providers who accept federal government (Traditional) Medicare from billing Medicare clients directly. Like a supersuit, these laws were designed for your protection: taking advantage of your insurance benefits generally means you’ll owe less than if you pay out-of-pocket.
Are there circumstances where I must go somewhere else for care, even if I want to receive it at CorePhysio?
Insurance rules tell us all what to do. A very small percentage of payers, such as Humana Medicare or Medicaid plans, require their members to receive services from contracted providers only. Please contact our billing heroes if you have questions about your specific insurance plan.
Can I choose where I get my PT care?
Absolutely! We encourage consumers to research their options and make a choice based on their needs. Here at CorePhysio, you can even swing by for a tour!
Is personal training covered by insurance?
CorePhysio’s personal training powers are cash-based. Check your health savings account or specific plan to see if those charges are eligible for reimbursement.
What should I know if I have a High Deductible Health Plan (HDHP)?
A High Deductible Health Plan (HDHP) is an insurance plan that requires patients to pay a large amount of their healthcare costs out of pocket before their insurance kicks in to help lighten the load. The IRS says that a health plan is considered an HDHP if the deductible is $1600 or more for individuals, or $3200 or more for families.
It can seem daunting to dip into your pocket for care, especially when you don’t know what to expect from a cost standpoint.
The good news: getting PT early has been proven to save time, money, and unnecessary treatment down the road. Early PT can actually eliminate the need for MRIs, medications, and even surgery. CorePhysio’s therapists are specialists, not generalists, which means you get results in fewer visits, saving you time and money. We’re also well-versed in High Deductible Health Plans and have a variety of options at our disposal to ensure that you get the care you need without breaking the bank.
The bottom line? Don’t delay or avoid physical therapy due to your high deductible. We can work with you no matter your financial situation and someone is always available to talk.
What’s the difference between a referral and authorization?
A referral is a signed order by a medical doctor recommending physical therapy for treatment of your specific listed diagnoses. Think of it as your VIP ticket for accessing our rockstar physical therapy services.
An authorization is a document from your insurance company agreeing to cover a given number of visits for a specified date range. If a referral is a ticket, an authorization tells you for how long the ticket permits access.
Do I need a referral or authorization?
Different insurers have different requirements. In order to use your insurance benefits for physical therapy, your insurance company may require you to have a referral, an authorization, or both.
Obtaining a referral is always in your best interest, whether or not your insurance requires one. For instance, a referral can help to demonstrate medical necessity in the event coverage is denied, provide us with a medical history to prepare for your visit, as well as keep your care coordinated with your physicians.
Contact your insurance company to confirm whether your plan requires you to team up with a physician for a referral and/or authorization.
We are your Authorization Advocate!
1. (If pre-auth is required) Your referral request is submitted by your doctor’s office initially. Your insurance company will then grant or deny services.
2. When the number of authorized appointments is almost reached, our insurance coordinator applies for additional visits. For a few insurance companies, your doctor may have to apply for additional or new authorization for continued care.
3. We wait for your insurance to review our authorization request. This can take days to weeks depending on the payer and their needs for support of medical necessity.
4. If approved, we continue your care.If denied, we appeal the denial and advocate for additional visits.
Why can’t you tell me how much I’ll owe before I’m seen if I’m using my insurance? I just want to know!
We would love to be able to do that! But, even if we could, it would mean we decided your plan of care before you were seen. One of the benefits of choosing CorePhysio is the one-to-one appointments you’ll receive with an expert clinician. Want to describe in detail the epic bail on Galbraith that resulted in your PT visit? Give us all the details! Your PT will create a custom-tailored plan to get you back to doing what you love.
We do wish we had the superpower to know, in advance, how much of your deductible will be met by the time your insurance processes each claim. Your payment responsibility is determined by your insurance’s contracted rates and your specific benefit usage at the time the claim is received by your insurance.
Why did I get a bill?
• If you have not yet met your deductible (a yearly amount you must pay before insurance starts paying for services), your insurance may apply your patient responsibility (bill) to your deductible.
• Your plan may require a copay (a fixed amount due at the time of service for each visit that may apply before or after deductible) and/or a coinsurance (a percentage of the visit cost billed to you after your insurance has processed the claim).
• Any payments you make count towards your out-of-pocket maximum (the maximum yearly amount for which you would be responsible for services covered under your plan). Once your out-of-pocket maximum is reached, you will no longer be responsible for bills from CorePhysio for that year. **This is why your patient responsibility may change depending on the time of year and other health insurance claims you have made that year.**
• A breakdown of the cost of services and payments made by the insurance company can be found in an Explanation of Benefits (EOB) sent to you by your insurance company.
In general, how long should I expect to wait before receiving a bill?
If you are paying privately, you will pay for your visit at time of service. If you are using insurance coverage, here is an overview of the timeline from attending your PT appointment to receiving a bill from CorePhysio.
Billing Timeline
1. Day of visit If your plan requires a copay, or you are paying out of pocket, payment will be collected at time of service.
2. 1 to 3 DAYS + Completed billing is submitted to your insurance.
3. 10 to 90 DAYS + Primary insurance notifies us they have paid.
4. 1 to 3 DAYS + Any remaining balance is billed to applicable secondary insurance.
5. 30 to 90 DAYS + Secondary insurance notifies us they have paid.
6. 1 to 30 DAYS + After auditing to ensure the payments are correct, any remaining balance is billed to you through a monthly statement.
You see people one-to-one; are you more expensive than other PT clinics?
No. Hospitals and physician-owned offices are the most expensive places to receive PT because they are paid different rates and fees. Like all PT clinics, we bill medically necessary care for the time we spend with you and the specific treatment interventions.
Questions to ask your Insurance Company
Inquire to see what benefits are available to you for physical therapy. Your benefits should be listed in your plan documents, which will tell you about your deductible, your copay and/or co-insurance, the number of visits allowed under your plan, and whether your plan requires a referral and/or authorization.
Ask your insurance plan for—and review—your explanation of benefits (EOB) after each visit. This will show you how your benefits are being used.
How do I contact my insurance company?
Reaching out to your insurance company isn’t as simple as throwing up the Bat Signal, but each plan has its own hotline. Call the member number on your insurance card, just like calling for reinforcements. Many insurers also offer online accounts and apps to stay updated on your benefits.
I still have questions about insurance that I’m hoping CorePhysio can answer.
In brightest day, in blackest night, during standard business hours–our billing and insurance superheroes are here for you! Please give us a call at (360) 752-2673.
