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Insurance Q&A

 

We understand that there can be many complexities when dealing with your insurance and making sure you have coverage for physical therapy. ProEx front desk specialists are here as a resource to you to help guide you through the process so please feel free to ask us any questions. Also of note, we are contracted with most insurance companies, including all Motor Vehicle Accidents and Worker's Compensation injuries so please contact our office for an updated list if you do not see your insurance company listed below. 

 

What’s the difference between a referral and a prescription for physical therapy?

Who is responsible for obtaining a referral?

What is a referral extension?

Is there a maximum amount (maximum benefit) of physical therapy I can receive per year? Per injury? Per lifetime?

What are your provider numbers?

What insurances do you take?

What is my financial responsibility if I come to physical therapy?

What is a deductible?

What is the difference between a co-payment and co-insurance?

What is the difference between HRAs FSAs or the HSAs?

How do I pay for physical therapy services if I have a HSA account?

How do I pay for physical therapy services if I have a HRA or FSA account? 

 

What’s the difference between a referral and a prescription for physical therapy? 

A referral is an authorization from your Primary Care Physician (PCP) referring you to an in-network specialist. Most HMO’s require a referral. A prescription is the written order for physical therapy from the referring Doctor. Please check with your insurance carrier to find out if you need a doctor’s referral or if your physical therapy prescription will satisfy your insurance plan’s requirements.   back to top

 

Who is responsible for obtaining a referral? 

As the patient, it is your responsibility to obtain a referral from your physician. If a referral is required, but not received by our office at the time of your first visit with us, you will be required to sign a form acknowledging this. Please keep in mind, you may be responsible for any charges your insurance company denies if a referral is not in place at the time of your first visit.   back to top

 

What is a referral extension? 

A referral extension is needed when your initial referral is exhausted. For example, if your initial referral is for 6 physical therapy visits and you and your physical therapist believe it’s justified to continue with treatment past 6 visits based on your progress and current status, you will have to contact your physician’s office to obtain another referral for physical therapy treatment. Depending on the number of visits your initial referral is for, it may be necessary to obtain multiple referrals for physical therapy during your time with us.   back to top

 

Is there a maximum amount (maximum benefit) of physical therapy I can receive per year? Per injury? Per lifetime? 

Many insurance plans have limitations and restrictions. It is best to call the Member Services department of your insurance company and have them tell you exactly what your plan allows for with regards to physical therapy. Our office may be able to help you understand this should you have further questions.   back to top

 

What are your provider numbers? 

Provider numbers are identification numbers issued to us by various insurance companies. Contact our office to obtain our number for your insurance plan if your PCP’s office requires it for your referral. *Please call our office for updated list of provider numbers.   back to top

 

What insurances do you take? 

We are contracted with most insurance companies, including all Motor Vehicle Accidents and Worker’s Compensation injuries – please call our office for an updated list if you do not see your insurance company listed below:

 

Massachusetts

New Hampshire

Connecticut

Aetna
BCBS of MA
BMC HealthNet Connecticare
Cigna
First Health Coventry
Harvard Pilgrim
Health New England
Mass Health
Medicare
Multiplan/PHCS
Neighborhood Health
Tricare non-HMO Products
Tufts Health Care
United Health/ACN (Optum) 

Aetna
Anthem BCBS NH
Cigna
First Health/Coventry
Harvard Pilgrim
Medicare
Multiplan/PHCS
NH Medicaid
Tricare non-HMO Products
United Health/ACN (Optum)

Aetna
Anthem BCBS CT
Cigna/Orthonet
Connecticare
First Health/Coventry
Healthnet/Orthonet
Medicare
Multiplan/PHCS
Tricare non-HMO Products
United Health/ACN (Optum)


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What is my financial responsibility if I come to physical therapy? 

Depending on your insurance plan, you may be required to provide a co-payment to us at the time of service. Your plan may also have a deductible or be supplemented by co-insurance.   back to top

 

What is a deductible? 

In an insurance policy, the deductible is a set amount of “out of pocket” expense for medical services that is the patient’s responsibility. It is normally quoted as a fixed amount and is a part of most policies covering losses to the policy holder. The deductible must be "met", that is, paid by the insured, before the benefits of the policy can apply.

Typically, a general rule is: the higher the deductible, the lower the premium, and vice versa. The type of health insurance deductibles can also vary, as there may be individual amounts and family amounts.   back to top

 

What is the difference between a co-payment and co-insurance? 

A co-payment is a payment made by an individual who has health insurance, usually at the time a service is received, to offset some of the cost of care. Co-payments are a common feature of HMO (Health Maintenance Organization) and PPO (Preferred Provider Organization) health plans in the US. Co-payment size may vary depending on the service, generally with low co-payments required for visits to a regular medical provider and higher payments for services received in the emergency room. A co-payment is not an “additional” payment to the provider but rather a portion of the visit’s payment in which the insurance company will not pay.

Coinsurance is expressed as a percentage or pair of percentages (80%/20% for example) generally with the insurer's portion stated first. The maximum percentage the insured will be responsible for is generally no more than 50%. Coinsurance indicates how an insurer and an insured will share the costs of a bill that exceeds the insurance policy’s deductible up to the policy's stop loss. Once the insured's out-of-pocket expenses equal the stop loss the insurer will assume responsibility for 100% of any additional costs.   back to top

 

What is the difference between HRAs FSAs or the HSA’s?

The common similarity of HRAs (Health Reimbursement Accounts), FSAs (Flexible Spending Accounts) or HSA’s (Health Saving Accounts) is the incentive for the subscriber to be a value conscious health care consumer. The funds can be used for qualified medical expenses as defined by the IRS. The differences mainly are; who contributes to the account and who owns the funds in the accounts. HRA funds do not accrue (build up) for the subscriber. With an FSA it is a predetermined amount of funds that a subscriber can use each year.  An HSA allows the subscriber to own the money in the account, invest the money, take the money with them if they change jobs, and have the money roll over annually. The main difference is the patient owns this account. These types of healthcare programs are new to many people and can be confusing so please make sure to let your ProEx Front Desk Specialist know if you have one of these programs so they can assist you with any questions you may have.    back to top


How do I pay for physical therapy services if I have a HSA account?

Depending on your financial institution, you can pay for copayments, deductibles or coinsurance with either HSA account checks or debit cards. In addition, you can pay with cash or credit card out of pocket and reimburse yourself for the qualified medical expenses from the HSA account. It is recommended you save your receipts for any of these transactions.    back to top

 

How do I pay for physical therapy services if I have a HRA or FSA account?

If the FSA and HRA administrator is linked to the insurance plans and offer automatic rollover claims processing then the insurance carrier/administrator processes your physical therapy claims in accordance with plan of benefits.  If there is a patient responsibility then the claim payment system automatically looks to the FSA and/or HRA for available funds.  If funds are available then they “pull the money” and send it along w/the underlying claim reimbursement to the provider.  The patient gets an EOB (“Explanation of Benefits or EOP (Explanation of Payment) showing the monies used to pay the providers. If the FSA or HRA does not have the funds to cover the patient responsibility then the balance is billed by ProEx and is your responsibility.   We strongly encourage you to check with your specific plan before starting physical therapy so that you are fully informed on your benefit as these plans will vary from patient to patient.    back to top

Please note, these FAQ’s are meant to educate you on general guidelines as they may pertain to your physical therapy treatment. You should contact your insurance company for specific answers to these questions, as your plan may change from time to time.