Physical Therapy Forest Hills - Insurance

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