Knowing the ins and outs of your insurance is your right and responsibility. There are lots of ways to find out and educate yourself. There are booklets that should be available and even online versions of those booklets. On your insurance card there is a number for “patients” that can answer ALL your insurance questions and even specific to Physical Therapy and coverage.
As a courtesy to our patients in our clinic we check on benefits for outpatient physical therapy such as how many visits you are authorized to have per year “Allowable Visits”, visit time frames and other even deductibles and out of pocket maximums all information that the patient needs to know even if they aren’t curren’t being seen for anything medical. It is again the patients right and responsibility to know what their benefits are.
Allowable visits– Insurance companies set a number for therapy visits you are allowed per injury of even per year. This is something the company you work for or yourself agree and settle upon when they contract with the insurance company. 95% of insurance companies combine all therapy (speech, occupational and physical therapy) for the plan year. Most insurance companies set up a hard limit (Example 20 visits per calendar year, this is not per condition it is for all conditions combined) and this can vary upon insurance companies and the plan the patient is enrolled in. Some insurance has a certain number of visits than need authorization, (Example first 10 visits are approved and then any additional visits need authorization, which requires us to send in proof that the condition still persists.) In this example the plan does not have a hard limit of visits as long as it’s medically necessary.
When we say we request authorization from insurance companies, most of the time this service is hired out to a third party. Insurance companies have third parties do authorizations for them. This means we request more visits after your initial visit, and the third party employs a doctor or a nurse to read our documentation and determine if more visits are necessary or not. (Example insurance company A allows 30 visits per calendar year but authorization needs to be done after the first visit (evaluation). This will be sent to the third party that is contracted with Insurance A. Third party will come back with a # of visits, a time frame to be done in and guidelines on billing.) This can be confusing for the patient to understand. Our office tries to make it easier and more understandable for our patients and their insurance coverage for visits for the year. And we usually explain the best we can. We have also put into a play an insurance verification form that the patient signs on their first visit with us.
**Now on the note of allowable visits this does not mean that your insurance COVERS the visits at 100%. This is decided on the benefits for therapy that is on your plan. This could take into consideration your deductible and/or your out of pocket maximum.**
