Understanding Your Insurance Benefits - Kinetic Edge Physical Therapy
by Lisa Vos & Chasidy Ryan of the Kinetic Edge Insurance Team

Insurance… just the word can be intimidating!  Most people are unaware of their insurance benefits and don’t know where to start when asking questions.

Here is a guide for what you need to know for physical and occupational therapy coverage.

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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 therapy services 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, co-insurance, or a copayment.

To better understand the terms of your plan, you first must understand the terminology. Here are a few common questions regarding insurance lingo:

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 co-insurance for each visit.

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.

What is a co-insurance?

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 for different services.

What are my costs if I have Medicare?

If you have Medicare, that doesn’t mean you won’t have any cost. You need to meet your Medicare deductible (for 2022 this is $233). If you have secondary insurance, they might cover this deductible amount, but NOT all plans do. You will need to check with your secondary insurance to find out.

If you do NOT have a secondary insurance, you are responsible for a 20% coinsurance (which the secondary will otherwise cover). This will come to $11-25 per visit.

What are my costs if I have Medicaid / Iowa Total Care / Amerigroup?

If you have Medicaid, you will not have any out of pocket cost. You are required to have a referral from your primary physician. We are also required to request authorization for your care.

So, how much will I owe for each visit?

If you have not yet met your deductible, then you will pay $50 per visit towards your deductible. If you have coinsurance, we collect $10 per visit towards your co-insurance. You’ll then owe any applicable coinsurance or deductible balances after we receive the Explanation of Benefits (EOB) from your insurance company and we will send you a bill for the balance. 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 $30, you will owe $30 at each visit.

Here are a Few Handy Definitions:

  1. Date of Service: The date of your visit.
  2. CPT Code: The code denoting each service provided to you during your visit (e.g., manual therapy, therapeutic exercise, self-care instruction, therapeutic activities, etc.).
  3. Billed Amount: This is the amount we billed the insurance company for that particular service based on our fee schedule.
  4. 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.
  5. Allowed Amount: The contracted amount agreed to between the provider (us) and your insurance company.
  6. 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.
  7. Insurance Paid: This is the amount the insurance company paid us for the services you received on that date of service.

Are there any restrictions on the types of providers I can see?

Some insurance plans (e.g., PPOs, HMOs, and EPOs) are limited to a certain network of providers. There are times that Kinetic Edge is not in your network. We work to let you know that. If we are out of network with your plan, you have the option to self pay.

Do I have to get a referral to see a specialist?

If your insurance plan requires you to obtain a referral before seeing a specialist (e.g., a physical therapist), and you fail to do so, the insurance company may deny coverage for services rendered. So, if you do not want to go through a primary care provider (e.g., your family physician) each time you want to see a specialist, make sure your plan does not require a referral (a.k.a. prescription) for specialist services.  Most insurances do not require a referral in Iowa, but there are some that do. Please check with your insurance.

How many visits of “X” am I allowed each year?

In this case, “X” represents a specific type of service (e.g., physical therapy, occupational therapy, or chiropractic). Some plans place a limit on the number of covered visits per year (e.g., 20 visits), while others allow for unlimited visits. Some plans have a hard visit limit and others we can request additional visits. We try and communicate that to you on the payment policy you receive at your first visit.

Our insurance benefits support team will also monitor your number of visits throughout your care. If you are able to receive additional visits for your plan, we will cover this requesting step for you. Some insurance companies will also give a date range for those visits.

Do I need to have prior approval (authorization) to attend therapy?

You do not need prior approval to start your care, as we can get you in for an evaluation without authorization. We will then use that evaluation from your physical and/or occupational therapists and will reach out to your plan and get authorization to continue your care.  Each insurance company has a different processing time for approvals. You are able to continue your care during this pending authorization stage, but if approval is denied you will be responsible if there is additional cost.

So, If I don’t want to use my insurance benefits, can I just pay for services myself?

The self-pay rate for all follow-up visits at Kinetic Edge Physical Therapy is $70- $110. Because an insured client with a deductible may have to pay $75 or more for the same service, many insured clients ask if we can essentially “pretend” they are uninsured. If we are contracted with your insurance company, we are obligated to honor that contract—which means we must bill your insurance for services rendered. These contracts also prohibit us from providing discounts or waiving client financial responsibility (e.g., copays or coinsurances). If we do not contract with your insurance, or if you have exhausted your benefits for the year, then you may be eligible to receive services on a cash-pay (i.e., self-pay) basis.

A Couple of Notes

  • Most insurance companies offer several different plans. Thus, two clients with Blue Cross Blue Shield, for instance, may have completely different insurance benefits, and therefore, completely different financial responsibilities. Some plans have no copays or deductibles; others may have a $10,000 deductible. Furthermore, some providers may not accept all plans from a particular insurance. This is why it is crucial that you investigate the details of your specific plan.
  • If your insurance offers an online patient portal, sign up for it! These resources typically enable you to:
    • check your insurance benefits,
    • track your deductible,
    • see which providers in your area accept your particular plan,
    • track your claims, and
    • compare claims to your receipts from the doctor’s office (if they don’t match up, you can then follow up on any discrepancies).

Kinetic Edge offers a free insurance benefits check so that you will be able to understand financially what therapy will cost. Ultimately, it is your responsibility to know your plan, but we do everything we can to check accurately. We welcome questions and will do what we can to help. If you would like to inquire about your insurance coverage for physical therapy or occupational therapy, please reach out online or call 866-588-0230.