Q&A | Insurance and Physical Therapy — Let's Discuss!

If trying to figure out health insurance for physical therapy makes you want to throw your laptop across the room, you are not the problem. From deductibles to co-pays to in-network vs. out-of-network, health insurance is outrageously complicated. 

As we kick off a new year and most people grapple with a new plan, Origin’s insurance expert Anusha Sadruddin is here to explain the nitty-gritty details. “Health insurance remains a blindspot for some of the smartest people I know,” says Anusha. “I’m excited to share what I’ve learned, so people can make more informed decisions, especially when it comes to using insurance to pay for physical therapy.”

Scan below for info that’s helpful for you or read through for a mini-masterclass in no one’s favorite subject (except for Anusha’s, of course).

Does insurance cover physical therapy?

The good news is that it often does. Figuring out whether your specific insurance plan covers physical therapy (PT) and at what cost will take a little digging. PT may not be included in that 1-3 page Benefits Summary that came in your insurance welcome package. That means you might have to scan a much bigger document or call your plan to get the details. One of the nice things about being a patient at a clinic like Origin is that we verify your coverage for you.

How does Origin “verify” or check a patient’s insurance coverage for PT?

If you are using insurance, we verify your insurance benefits before your first visit. That means we contact your insurance provider directly to get the most accurate and up-to-date information about your benefits so we can give you a solid estimate of what you can expect to pay for physical therapy. We do this when you become a new patient and at the beginning of the year, when benefits reset.

Are healthcare providers required to verify patient benefits?

No, it’s not required – and it’s ultimately your responsibility to know what your benefits are — but some clinics like Origin consider it an important part of patient care. 

What does Origin’s benefits verification process look like?

When you schedule a visit at Origin and submit your insurance information, we verify benefits by calling your health insurance or using their portal. We first confirm that we’re an in-network provider for you (if we aren’t, we check for out-of-network benefits) and then see if you have a deductible to meet before your insurance benefits apply. If you do, we’ll find out if you’ve met your deductible yet.

Next, we tell your insurance company the procedure codes that we plan on using. They use these codes to estimate what they expect to cover and what you, the patient, is likely to have to pay in terms of a co-pay, co-insurance, and/or deductible. 

Finally, we send you an email with all of this information, so you’re a lot less likely to get a surprise bill.

Let’s back up and define a few of the insurance terms you’re using. What are deductibles?

Deductibles are a set amount of money that you have to pay on medical care before some or all of your health insurance benefits kick-in. It’s very important when choosing an insurance plan to look at the deductible and consider that you’ll need to pay that amount yourself before you can benefit from insurance coverage.

Individual deductibles can be as low as a couple hundred dollars or I've seen deductibles as high as $7,000 to $10,000. It depends on the type of plan you choose.

What do you mean by “individual” deductible?

Individual deductibles apply to one person. If you’ve on an insurance plan with other family members, you’ll have an individual deductible and a family deductible. 

The family deductible will be much higher. When one person meets their individual deductible, then benefits will kick in only for them. If you meet your family deductible, then insurance benefits will kick-in for everyone, even if some family members haven’t met their individual deductibles.

Another important detail about deductibles: If your plan offers in-network and out-of-network coverage, you will typically have a separate deductible for each. 

What’s the difference between in-network and out-of-network in terms of providers and benefits?

Providers who are in-network with an insurance company have signed a contract with that insurance company, agreeing to certain terms and conditions, including how much they’ll be reimbursed for the covered services they provide. It’s easier and more affordable for your insurance company to work with these providers. 

Some plans will also offer a separate set of benefits for out-of-network providers. For example, if you see an in-network provider, they might pay for 70% of your care after you meet your in-network deductible, whereas if you see an out-of-network provider, they might pay 30-50% of your care after you’ve met your out-of-network deductible. Actual numbers will vary depending on your plan.

Many plans do not offer any out-of-network benefits. That means that if you see a provider who is outside of your plan’s network, you’ll have to pay for 100% of your bill. 

What are procedure codes?

CPT or “current procedural terminology” codes are medical codes that healthcare providers have to use to bill insurance. Every medical procedure or service has an associated code that, if covered, is reimbursed at a negotiated rate. 

What is co-insurance and how is it different from a co-pay?

Co-insurance is the percentage of the cost of your care that you pay yourself (or that you pay “out-of-pocket” to use another insurance term). 

If your plan has a deductible, you’ll pay 100% of the cost of your care until you meet that deductible. After you meet your deductible, you’ll pay a co-insurance that can vary but is often 10%, 20%, or 30% of the cost of your care. The exact percentage will depend on the provider or facility or type of service you receive (check your benefits summary for details).

To make things more complicated, some medical bills that you pay will count toward your deductible and others won’t (again, your benefits summary will have the details).

Co-pays, on the other hand, are a fixed amount that you pay for a covered medical service, regardless of how much that service costs your insurance. For example, you may have a $25 co-pay when you see your primary care provider for an annual wellness visit, or a $50 co-pay when you see a specialist like a physical therapist or when you go to an urgent care clinic. 

Most plans use co-pays for some things and co-insurance for others.

When verifying benefits, does Origin find out whether you need a referral or prescription for PT?

Yes, we’ll find out if you need a referral/prescription (a signed note from an approved provider saying you need PT to address a certain diagnosis or symptom), or prior authorization in order to get covered care. 

We’ll also find out if there's any limit to the number of visits your insurance company will cover — this is a big one in the field of PT. Many plans will only cover a certain number of PT visits, regardless of how many visits you need. This is unfortunate, but it’s just the way it is right now.

What is prior authorization?

Prior authorization is an extra layer of approval. Sometimes insurance plans want to doublecheck that the visit or procedure you want to schedule is a medical necessity. So they require that you get their authorization or approval.

An authorization typically includes a date range, during which you need to receive this care. They may also say that only a certain number of visits are authorized or a certain number of “units” per CPT code. Units are often based on time, especially for PT. So if units are 15 minutes and you have a 30 minute consult, that’s 2 units of that CPT code.

What information does Origin pass on to the patient after verifying their benefits?

We send a comprehensive email explaining what you can expect to pay “out-of-pocket” and why. So we’ll let you know if Origin is an in-network or out-of-network provider for you. Then we’ll tell you if you’ve met your deductible yet and what you can expect to pay.

How often are the estimated costs that we send patients off-base?

Not often, but it can happen because insurance is tricky even for people that work in insurance. Whether we’re calling an insurance rep and asking them to interpret the data that’s available to them or our team at Origin is interpreting the data ourselves, it’s not cut and dry.

No one can 100% guarantee what you're going to pay for healthcare ahead of time. Even if you call your insurance company, they're going to give you the same warning. You’ll hear words like “any information that we provide you is an estimate” and “patient responsibility is subject to claims finalization.” 

But I can assure you that our team is well trained and doing our absolute best to give you a solid estimate. We want you to feel comfortable coming to Origin, knowing that you can afford it. To me, that’s another, equally important way of providing care to people.