How to Determine Your Insurance Benefits for Physical Therapy

Grit Mobility Concepts  –  Dr. Ann Phillips

Although we are credentialed with some insurances, we are considered Out of Network (OON) for others. However, understand that…

OON simply means that there is no middle man. Why let insurance dictate your care? In Grit’s healthcare model, WE (you and I) decide what is best for you, not someone looking at diagnosis codes and dollar signs. Consider this…

  1. What if we could optimize the time we have together with uninterrupted, self-directed, therapeutically rich content in the convenience of your home?
  2. What if we could get better functional outcomes with less visits?
  3. What if having uncompromising and convenient care was actually more cost effective than going to a clinic?

Do your research on OON benefits: [see the “How To Determine Your Insurance Benefits For Physical Therapy”]

  • Do you have OON Physical therapy benefits? What are they? (sometimes it’s the same as In-network)
  • What’s your deductible? = your out of pocket responsibility before insurance will “incur liability” for remaining charges
  • What’s your co-insurance? = your part (%) of the charge for a covered service
  • What’s your co-pay? = your part ($ amount) of a covered service with every visit
  • A lot of times, your HSA or FSA can be used for OON PT services
  1. Call the toll free # for customer service on your insurance card. Select the option that will allow you to speak with a customer service provider, not an automated system.
  2. Ask the customer service provider to quote your physical therapy benefits in general. These are frequently termed “rehabilitation benefits” and can include occupational therapy, speech therapy, and sometimes massage therapy.
  3. Make sure the customer service provider understands you are seeing a non-preferred provider/out- of-network provider.

What YOU need to know:

Do you have a deductible? Yes/No        If yes, how much is it? ___

How much has already been met? ___

What percentage of reimbursement do you have? (60%, 80%, 90%, are all common) _____

Does the rate of reimbursement change because you’re seeing a non-preferred provider? Yes/No

Does your policy require a written prescription from your primary care physician? Yes/No

If yes, will a written prescription from any MD/physician or a specialist your PCP (primary care physician) referred you to be accepted? Yes/No

Does your policy require pre-authorization or a referral on file for outpatient physical therapy services? Yes/No       –     If yes, do they have one on file? Yes/No

Is there a $ or visit limit per year? Yes/No     –       If Yes, What is it? ______

Do you require a special form to be filled out to submit a claim? Yes/No

How do you obtain it?

What is the mailing address you should submit claims/reimbursement forms to?

Is there an online website where you can submit the claim? Yes/No

What is the address?

  1. What this information means:

  • A deductible must be satisfied before the insurance company will pay for therapy treatment. Submit all bills to help reach the deductible amount.
  • If you have an office visit co-pay, the insurance company will subtract that amount from the percentage they will pay. This will affect the amount of reimbursement you will receive.
  • The reimbursement percentage will be based on your insurance company’s established “reasonable and customary/fair price” for the service codes rendered. This price will not necessarily match the charges billed; some may be less, some may be more.
  • If your policy requires a prescription or referral from your PCP you must obtain one to send in with the claim. This is usually not difficult to obtain if your PCP sent you to a specialist for help with your condition. If the referral from a MD or specialist is all you need, make sure to have a copy to include with your claim. Each time you receive an updated referral you’ll need to include it with the claim.
  • If your policy requires pre-authorization or a referral on file and the insurance company doesn’t have one listed yet, you’ll need to call the referral coordinator at your PCP’s office. Ask them to file a referral for your physical therapy treatment that is dated to cover your first physical therapy visit. Be aware that referrals and pre-authorizations have an expiration date and some set a visit limit. If you are approaching the expiration date or visit limit you’ll need the referral coordinator to submit a request for more treatment.

This worksheet was created to assist you in obtaining reimbursement for Physical Therapy services and is not a guarantee of reimbursement to you.

Please contact us if you have any further questions or would like help understanding your benefits.