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: 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. After we receive an insurance response, we will send a statement to the patient containing their responsibility for service or "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 become patient responsibility once a claim is controverted/closed.
Member Rights and Responsibilities
Rights Each member has the right to:
actively participate in decisions about their health care
talk with their physicians and providers about options for medical treatment, regardless of cost or benefit coverage
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
be treated with courtesy and respect
have their privacy respected when they receive health-care services
have medical records and other information kept confidential
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
give accurate and complete information to their physicians and providers
cooperate with physicians and providers by following their treatment guidelines
educate themselves about the terms and limitations of their program
use health-care services prudently and appropriately
follow their clinic’s procedures--including those for appointment cancellations and obtaining after-hours care
fulfill their financial obligations to their physicians and providers
show respect and courtesy to their physicians, providers, and insurance claim representatives
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.
Coinsurance After the member has paid their deductible, coinsurance is the portion (usually a fixed percentage) of financial responsibility they have for eligible services rendered.
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, their copay may be reviewed.
Deductible A predetermined dollar amount of eligible expense that is designated by the subscriber’s contract. The member must pay the deductible each year from his/her own pocket before the plan makes a payment for eligible benefits.
Dependent Any individual(s) who is/are included on the policy coverage.
Insurance Administration 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, the member should 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 their insurance begins to pay 100% of eligible benefits.
Premium This is the amount the member/subscriber pays to have an insurance policy/plan. It may be paid weekly, biweekly, monthly, semi-annually, or annually. The plan 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.