Insurance
Each policy is different. Within each insurance company, there are several policies. That is why our experienced staff verifies individual policies, benefits, and eligibility prior to treatment. Even then, it is not a guarantee of coverage. If we find any limitations for Physical Therapy on a policy, we will be sure to let the patient/guarantor know. If information is not provided when requested, we are not liable for withheld or missing information and the verification process is not a guarantee of payment.
How patients are billed
We can provide an estimate of patients coinsurance based on the information provided when verification of benefits and eligibility is completed. Copays are expected to be paid at each visit. Deductibles, out of pocket maximums, and non-covered services are the responsibility of the patient. We do not know the actual amount of the patient’s responsibility until the insurance responds to our claims. Once we receive a response from the insurance and if any amount is patient responsibility, we will send a statement to the patient which shows the amount due. If a patient, insured or uninsured, chooses to pay in full at each visit, we will give a 10% discount. Workers Compensation claims are the responsibility of the patient unless the claim is controverted/closed at which time it then becomes the responsibility of the patient.
Glossary
Claim: A descriptor assigned to a date of service or group of services rendered and then billed to the insurance plan. This is also a descriptor or classification for a work-related injury or a motor vehicle accident. It will be numerical or a combination of alpha-numeric digits.
Co-insurance: The portion of covered health-care costs for which the member has a financial responsibility, usually according to a fixed percentage of the allowed amounts for services rendered. Co-insurance often applies after first meeting a deductible requirement.
Copayment (Copay): A predetermined dollar amount a member pays for a specific service (ex: $20 for an office visit). Typically, copayments are fixed amounts for office visits, prescriptions or hospital services. Copays should be collected at the time of service from the member. If the member is admitted to the hospital from the emergency room, copay may be reviewed.
Deductible: A predetermined dollar amount of eligible expense, designated by the subscriber’s contract that the member must pay each year from his/her own pocket before the plan makes a payment for eligible benefits.
Dependent: Any individual(s) who is included on the policy coverage.
Insurance Administration: This is a company that processes the insurance claims sent to them from the insurance carrier. This company may also be referred to as the Payment Center.
Insurance Carrier: The name of the insurance company through which the policy/plan resides and to whom the premium is paid.
Liability: The designated individual or group who is accountable or responsible for the terms of the plan.
Member/Subscriber/Beneficiary: The individual whom the policy belongs to; the policy holder.
Non-covered Services: Members are responsible for the payment of services not covered by their plan/policy. Non-covered services can vary. To verify if a service is covered, contact member services/customer services to inquire. If a service is not covered and the member decides to proceed with a non-covered service, the member should sign a consent form agreeing to their financial responsibility before the service is provided.
Out of Pocket Maximum: A predetermined dollar amount a member pays out of his/her own pocket before the plan begins to pay at 100% of the allowed amount of eligible benefits.
Premium: This is the amount the member/subscriber pay sot have an insurance policy/plan. It mey be paid weekly, biweekly, monthly, semi-annually, annually. It may be paid in full or partially by an employer or it may be paid in full by the member.
Third Party: A generic legal term for any individual who does not have a direct connection with a legal transaction but who might be affected by it.
Co-insurance: The portion of covered health-care costs for which the member has a financial responsibility, usually according to a fixed percentage of the allowed amounts for services rendered. Co-insurance often applies after first meeting a deductible requirement.
Copayment (Copay): A predetermined dollar amount a member pays for a specific service (ex: $20 for an office visit). Typically, copayments are fixed amounts for office visits, prescriptions or hospital services. Copays should be collected at the time of service from the member. If the member is admitted to the hospital from the emergency room, copay may be reviewed.
Deductible: A predetermined dollar amount of eligible expense, designated by the subscriber’s contract that the member must pay each year from his/her own pocket before the plan makes a payment for eligible benefits.
Dependent: Any individual(s) who is included on the policy coverage.
Insurance Administration: This is a company that processes the insurance claims sent to them from the insurance carrier. This company may also be referred to as the Payment Center.
Insurance Carrier: The name of the insurance company through which the policy/plan resides and to whom the premium is paid.
Liability: The designated individual or group who is accountable or responsible for the terms of the plan.
Member/Subscriber/Beneficiary: The individual whom the policy belongs to; the policy holder.
Non-covered Services: Members are responsible for the payment of services not covered by their plan/policy. Non-covered services can vary. To verify if a service is covered, contact member services/customer services to inquire. If a service is not covered and the member decides to proceed with a non-covered service, the member should sign a consent form agreeing to their financial responsibility before the service is provided.
Out of Pocket Maximum: A predetermined dollar amount a member pays out of his/her own pocket before the plan begins to pay at 100% of the allowed amount of eligible benefits.
Premium: This is the amount the member/subscriber pay sot have an insurance policy/plan. It mey be paid weekly, biweekly, monthly, semi-annually, annually. It may be paid in full or partially by an employer or it may be paid in full by the member.
Third Party: A generic legal term for any individual who does not have a direct connection with a legal transaction but who might be affected by it.
Links
Cobra Coverage: dol.gov
Flexible Spending Account (FSA): healthcare.gov
Member Rights and Responsibilities
Rights: Each member has the right:
Responsibilities: Each member has the responsibility:
- to actively participate in decisions about their health care
- to talk with their physicians and providers about options for medical treatment, regardless of cost or benefit coverage
- to receive information about their health plan, the services provided, the physicians and the providers providing the care, the basis for health-care decisions, and the terms and limitations of their program
- to be treated with courtesy and respect
- to have their privacy respected when they receive health-care services
- to have medical records and other information kept confidential
- to voice complaints and appeals about the quality of their care and the administration of their program
Responsibilities: Each member has the responsibility:
- to actively participate in the decisions about their health care
- to give accurate and complete information to their physicians and providers
- to cooperate with physicians and providers by following their treatment guidelines
- to educate themselves about the terms and limitations of their program
- to use health-care services prudently and appropriately
- to follow their clinic’s procedures, including those for appointment cancellations and obtaining after hours care
- to fulfill their financial obligations to their physicians and providers
- to show respect and courtesy to their physicians, providers and insurance claims representatives