In network versus out of Network Insurance
What does "in network" and "out of network" insurance mean when talking about visiting your physical therapist?
In network means that your physical therapist has agreed to accept a reduced rate for services from your insurance company. It also means that the provider will follow any necessary guidelines created by the insurance company such as getting pre-authorization for care, or limiting your care to a certain number of visits, or services.
Out of network generally means that the physical therapist does not accept the reduced rate, and restrictive guidelines imposed by the insurance carrier.
So which is better?
Well there's no simple answer to this, because there are a lot of variables to consider. Each situation must be examined case by case, but let's take a look at a few scenarios.
In network plans are most commonly associated with a copayment for each visit. This means that the patient will pay a set fee each visit, no matter how many services are provided for that visit. (This is not always the case, but it is the most common).
When talking about physical therapy, it is also quite common to require "preauthorization" for treatment. What this means is that you will need to visit your physical therapist for an examination, and pay a copayment for this service. The physical therapist would then have to submit the exam findings to the insurance carrier in attempt to get authorized for a certain number of sessions which may take a few days.
It is important to note that even if authorization is granted, the insurance carrier is not guaranteeing payment for these services and may still reject the claim for any number of reasons. The authorization simply states the most the insurance carrier will pay for a certain case.
The authorization is often limited to only a few sessions over a short period of time, and "by code" or individual service, such as one unit (8 minutes is the threshold) of exercise or manual therapy for example.
So, in this case, the insurance company would authorize 8 minutes of exercise per session, for which the patient would pay a set copayment.
Look at a few specifics:
GHI in network allows a maximum of 16 physical therapy visits per calendar year, before requiring pre-authorization. GHI will pay a Maximum of $27 each visit minus the copay (example if you have a $20 copay, GHI will pay $7 maximum per session). GHI will not pay anything past the first code which is met at 8 minutes.
Most other carriers like Blue Cross, Aetna, Oxford for example will require some type of preauthorization after the initial exam, carry a set copay, and limit to a maximum payment of one code per session as well (8 minutes). These carriers generally also require ongoing authorizations at least every 30 days. (some plans vary, but this is a very common scenario).
In each of this situations, the physical therapist is not going to get paid past the first 8 minutes of therapy.
I don't know of too many conditions that a patient would consult a physical therapist for that would respond well to 8 minutes of care.
So in-network may provide a slightly lower out of pocket cost for the patient in the short term, but may likely result in very limited care. Over a longer care plan, or more involved case, a patient may find it more beneficial to use out of network benefits.
Out of network plans work differently.
Typically if your insurance carrier offers out of network coverage, you can use any physical therapist you like and do not have to follow all of the restrictive guidelines of in network (although even this is changing).
With out of network plans, you will typically have a deductible (which varies widely plan to plan). The patient will pay for each visit out of pocket, and this amount paid will be applied to the deductible until the deductible is met. For ease of calculation, assume a $1000 deductible, and a visit to the physical therapist is $100. The patient will pay the physical therapist $100 each session for 10 sessions.
After the deductible is met, the insurance carrier will often cover a percentage of the physical therapy bill, typically 70% or 80%. This means the patient is responsible for the remaining percentage. In the above case of a $100 per visit cost, and 80%/20% coverage, the patient would pay $20 each session (20% of $100) after the deductible is met.
However, the physical therapist would not likely need to get preauthorization for the first visit, so the patient would be able to receive treatment that day.
Additionally, the physical therapist would not be limited to a set number of codes per session, and would often not be limited to a set number of sessions.
Let's take a look at a more detailed example.
Assume the physical therapist's fee is $100 per session, during which time he/she will provide electric stimulation with hot pack, manual therapy and therapeutic exercise. The patient's condition requires 24 visits.
The in network copayment is $30 (common) and the out of network benefit is 80/20 with $1000 deductible.
In network authorizes 10 visits. In this case the patient will be allowed 10, 8-minute sessions (hot pack for example) for $300. The next 14 would be paid out of pocket (since not authorized) for an additional cost of $1400 (14 X $100). Total cost: $1700
If the patient utilized the out of network benefits, he/she would likely be able to receive full treatment day one, and therefore likely finish the care plan sooner. This patient would pay $1000 for the first 10 sessions, then $280 for the next 14 ($20 X 14). Total cost: $1280.
In this case the out of network is not only less expensive, but would allow significantly more comprehensive treatment that the in-network plan.
Although this is not always the case, the patient with out of network insurance will often find that they will be able to receive more care, at a similar cost to the in network benefit when it comes to physical therapy especially for more involved cases, and cases requiring longer term care.
It is important to discuss your benefits with your physical therapy billing specialist and compare the long term costs of in versus out of network before beginning a physical therapy program.
For more information about your specific insurance benefits give us a call today at (888) 595-7282. We will be happy to verify and discuss your insurance benefits prior to starting care.
Forest Hills Rehabilitation
108-14 72nd Ave, 4th Flr
Forest Hills NY 11375
(888) 595-7282
(718) 520-8480
http://www.ForestHillsRehab.com
Thursday, May 17, 2012
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Tuesday, May 8, 2012
Physical Therapy Forest Hills Post
How To Get The Most From Your Physical Therapy Appointments
An appointment with a physical therapist is an excellent step towards improved function and injury prevention. To make the best use of your time, please use the following guidelines:
Wear comfortable clothes. Jeans or long sleeves are not advisable during your initial evaluation since the therapist may need to evaluate your joint stability.
Make sure to arrive on time or a few minutes prior to your appointment in case you need to fill out some forms.
Elaborate on the things you are unable to do, or the level of function you would like to achieve with the physical therapist. This will help the therapist to serve you as effectively as possible.
Provide information about when the pain started, the nature of pain (sharp or dull), what caused it, and what aggravates it.
Remember that you and your physical therapist are part of a team with a common goal - to get you better as quickly as possible. Do your home exercise program exactly as instructed and try not to miss any appointments in an effort to reach that goal.
Preparing for Physical Therapy
When you visit a physical therapist for the first time, we understand that you may not know what to expect. Here are some things to consider before you seek physical therapy:
Ask your physician about your condition and if physical therapy is right for you.
Talk to your friends and ask if they have worked with a physical therapist and what their experience was.
If you have health insurance, contact your provider and educate yourself about your benefits and physical therapy coverage.
Become familiar with your medical history and medications and discuss them with your physical therapist during the first appointment.
If possible, try and define your goal. Ask yourself what you want to accomplish and share them with your therapist.
Remember, a physical therapist is an expert on strength and mobility so if you have any questions related to aches and pains, it's likely that your physical therapist may be able to assist you quickly and effectively.
Physical Therapy Instead of Surgery?
There are several conditions in which physical therapy is a good treatment option, and knee osteoarthritis is one of them. Individuals who experience knee osteoarthritis respond well to physical therapy, especially in the early stages. A well planned physical therapy program has been shown to improve the body's ability to function by improving strength and coordination. This may reduce the need for surgery.
The President of the American Physical Therapy Association, Scott Ward, PT, PhD has said, "Physical therapy is effective and should be considered not only by patients themselves, but also the primary care doctors and orthopedists that are treating them."
Physical therapists recognize and correct abnormal movement patterns, and create a comprehensive treatment approach each patient.
This was just one example of what physical therapy can do for you. For more information on how we can help treat bones and joints (and improve wellness), please contact us. We'll answer any questions you have about what physical therapy can do for you, and if you need to come in, we'll see you as quickly as possible.
If you or someone you know is considering surgery, ask your physician if physical therapy is right for you. In some cases, physical therapy can indeed be a viable alternative to surgery.
Forest Hills Rehabilitation
108-14 72nd Ave, 4th Flr
Forest Hills NY 11375
(888) 595-7282
http://www.ForestHillsRehab.com
Sunday, May 6, 2012
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