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Insurance Resources

We get it—health insurance today can be confusing. There are many complex terms to remember and when it comes to providing coverage, every plan is different. At the same time,  high-deductible health plans, legislation changes and rising costs have led to an increase in patient financial responsibility, making it all the more important to understand your policy and how it works.

Below are a few resources that can help to explain some of the standard insurance terms, conditions and processes.

POST Physical Therapy bills to a variety of insurance companies and plans. We urge you to contact your insurance provider so that you understand the specific coverage details in your policy, and we recommend reviewing the following terms:

Benefit Year

The annual cycle of your health insurance plan. At the beginning of your benefit year, the health insurance company may alter plan benefits and update rates. Some benefit years follow the calendar year, renewing in January, whereas others may renew the month you became a member.

Example:  You have a plan through work that has a benefit year starting April 1st. Your physical therapy benefits are a $30 copay and 30 visits per year. When April 1st comes the plan resets and here are a few scenarios about what can happen 1) Everything is the same 2) You now have a $50 copay 3) New insurance altogether

Coinsurance

Shared costs between you and the health insurance plan. For example, you have a 20% coinsurance and your visit to the doctor cost $100. You will pay $20 and insurance will pay $80. These percentages vary from plan to plan. Meeting a deductible first and then being responsible for a coinsurance is common.

Copay

Shared costs between you and the health insurance plan. For example, you have a 20% coinsurance and your visit to the doctor cost $100. You will pay $20 and insurance will pay $80. These percentages vary from plan to plan. Meeting a deductible first and then being responsible for a coinsurance is common.

Deductible

The amount you have to pay yourself for specified medical expenses before your health insurance plan begins to pay each plan or calendar year. Insurance companies provide the rates for these services and you’ll pay that rate. The scenario with the doctor’s visit would then be you paying the total cost.  After you have met your deductible your insurance will cover up to 100% for services. If your insurance covers 80% of the cost after the deductible is met that means you are responsible for a 20% co-insurance.

Explanation of Benefits (EOB):

This is not a bill. Most insurance companies will send an EOB to you about the claim the company is or is not paying. If you do not understand it or have questions, call your insurance company as soon as possible.

HMO

An HMO, or a “Health Maintenance Organization,” gives you access to certain doctors and hospitals within its network. A network is made up of providers that have agreed to lower their rates for plan members and also meet quality standards. But unlike PPO plans, care under an HMO plan is covered only if you see a provider within that HMO’s network.

Limitations

A term referring to any maximums that a health insurance plan imposes on specific benefits. Specifically physical therapy visits per plan year or per condition.

Medical Necessity

A standard set by health insurance companies to determine if medical services should be covered.

PPO

PPO means “Preferred Provider Organization.” You will probably not be required to coordinate your care through a single primary care physician, as you would with an HMO, but it’s up to you to make sure that the healthcare providers you visit participate in the PPO. Typically a referral is not needed.

Preauthorization

“preauthorization” and “precertification” refer to the process by which a patient is pre-approved for coverage of a specific medical service. Health insurance companies may require that patients meet certain criteria before they will extend coverage for some services. In order to pre-approve such service, the insurance company will require that the doctor submit notes documenting the patient’s condition and treatment history.

Prescription

An order by a physician for the administration of a treatment. A prescription is always required in case your insurance performs a medical review of your case and is different than a referral.

Referral

For HMO plan members. Insurance referral is generated and submitted by their primary care physician to a see a specialist for the diagnosis or treatment of a specific condition.

If you change insurance, please notify us as soon as possible with a copy of your new insurance card(s) and the effective date of the new policy.
We will only send you a statement of balances that are your responsibility. If you have questions about our statements, please call us. We may be able to re-bill your insurance company, but since some insurance companies have strict filing limits, we need to deal with any problems as soon as we can.