Complete Game Physical Therapy Answers 5 Common Insurance Questions
If you’ve visited the Complete Game Physical Therapy clinic in our new and expanded location in North Chelmsford, MA, you’ve interacted with either Bonnie or Jill at the front desk when checking in. As part of the patient check-in process, we check insurance, submit claims for our patients, and also answer questions that people have about this sometimes complicated subject.
We know how frustrating it can be when you’re in pain and just want to get some relief as quickly as possible. Insurance coverage should be the last thing that you need to worry about.
Based on feedback from our patients (and also Bonnie and Jill) we’ve created this blog to answer five of the most frequently asked questions that we receive in the clinic. We also have created a helpful downloadable pdf of these questions for you to use a resource as you navigate your insurance policy information.
DO I NEED TO SEE MY DOCTOR BEFORE I GO TO A PHYSICAL THERAPIST?
In Massachusetts you do not need to see your doctor first. Massachusetts is a direct access state, which means you can go directly to a physical therapist. We are the providers of choice to restore function and movement for those with conditions affecting muscles, joints, bones and nerves.
Your insurance may require you to see a doctor before seeing a physical therapist, however. Some policies require a doctor’s referral (see question 2) and some do not. Generally speaking, HMO plans require referrals for PT, and PPO plans do not, but this can vary. It’s best to contact your insurance company directly to find out what your plan requires.
WHAT IS A PRESCRIPTION? A REFERRAL? AN AUTHORIZATION?
These terms can be confusing and are often mistakenly used interchangeably. They are, however, very different.
Prescription: A prescription is a note from the doctor to the physical therapist which usually includes information on what the doctor thinks is wrong, general guidelines for treatment, and, in some post-surgical cases include more specific protocols. In Massachusetts, a prescription is not required to see a physical therapist.
Referral: A referral is a signed order from the doctor (usually a primary care provider or pediatrician) sent to the insurance company ordering physical therapy. A referral may be required by your insurance company and they will not pay for PT until one is received.We can help you determine if you need a referral. Your doctor may need to know the name of our clinic, our fax number, and our NPI (National Provider Identification) number. We can provide this information so that you are prepared when you call.
Authorization: An authorization comes from the insurance company and is the number of PT visits that the insurance company has approved. Some policies require an authorization and some do not. We can help you determine how many PT visits your insurance has authorized, and usually more can be requested as necessary.
The number of visits a doctor or physical therapist requests may not always be the same number authorized by insurance. Be sure to check with us to see how many sessions were authorized.
WHAT IS THE DIFFERENCE BETWEEN A DEDUCTIBLE, COINSURANCE AND A COPAY?
It’s important to understand these terms, as they will determine how much you are required under your insurance to pay out of pocket.
Deductible: Your deductible is the amount you pay for health services before your insurance kicks in. For example, if you have a $1500 deductible, you must pay that amount before insurance will pay. Typically physical therapy works against your deductible.
Coinsurance: Coinsurance would kick in after you have met your deductible and is a percentage of the health care cost that you share with insurance. For example, after reaching your deductible, your insurance may cover 90% of healthcare service cost and you are required to pay the remaining 10%.
Copay: Your copay is a fixed cost you pay for health care service. For example, you could have a $30 copay for physical therapy due at time of service. This varies by insurance plan and type of service, but you could have a copay before your deductible has been reached or along with your coinsurance.
These items all vary depending on your insurance plan. It’s imperative to contact your insurance company or we can help you determine your out-of-pocket cost for PT.
HOW MANY PHYSICAL THERAPY SESSIONS DOES MY INSURANCE COVER?
The number of PT sessions will depend on your specific insurance plan. When we do an initial insurance verification process, we will be able to tell you how many sessions are covered under your policy. This does not necessarily mean all sessions are approved. If there is a denial,you will need to call the insurance company directly to request more visits (sometimes they are nicer to you than they are to us!).
CAN I PAY OUT OF POCKET FOR PHYSICAL THERAPY?
With rising costs of deductibles, copay, and coinsurance, we are sometimes asked if it is possible to just pay out of pocket for physical therapy. The answer is generally yes, but there are some cases where we are contractually required to bill insurance. Medicare, for example, requires us to bill them for any physical therapy provided to their subscribers unless they have used up their benefit or it is for a service they do not cover. Again, the clinic you work with should be able to give you the answer to this question along with their self pay fees. For reference, our self pay fee is $120 for the initial evaluation and $80 for follow up visits.
We are here to make things easier for our patients and pride ourselves on our ability to do so. Contact us to schedule an appointment, check your insurance benefits, and to ask any questions you might have. We welcome all patients whether they are athletes, active older adults, those rehabbing from surgery or injury, or anyone dealing with some nagging pain issues. If you are in the Lowell, Andover, Tewksbury, Chelmsford, and North Chelmsford area how can we help you this year?