Understanding Insurance

Understanding Insurance

The PT Patient’s Guide to Understanding Insurance

Insurance 101 for PT Patients

So, your insurance “covers” physical therapy—which means you will not have to pay anything out-of-pocket for your therapy visits, right? Not quite. The fact that your insurance plan covers PT services—or any other services, for that matter—does not necessarily mean you’re off the hook as far as payment goes. In many cases, you will still have to pay a deductible, a co-insurance, or a copayment. Talk about tricky.

To better understand the terms of your plan, you first must understand the terminology.

Here are a few common questions regarding insurance lingo:

What is a deductible?

This is the total amount you must pay out-of-pocket before your insurance starts to pay. For example, if your deductible is $1,000, then your insurance will not pay anything until you have paid $1,000 for services subject to the deductible (keep in mind that the deductible may not apply to every service you pay for). Furthermore, even after you have met your deductible, you may still owe a copay or co-insurance for each visit.

What is a copay?

This is a fixed amount that you must pay for a covered service, as defined by your health plan. Copays usually vary for different plans and types of services. You must pay this amount at the time of service. In most cases, copayments go toward your deductible.

What is a coinsurance?

This type of out-of-pocket payment is calculated as a percent of the total allowed amount for a particular service. In other words, it is your share of the total cost. For example, let’s say:

  • Your insurance plan’s allowed amount for an office visit is $100.
  • You have already met your deductible.
  • You are responsible for a 20% coinsurance.

In this situation, you would pay $20 at the time of service. The insurance company would then pay the rest of the allowed amount for that visit. Keep in mind that the coinsurance amount may vary from visit to visit depending on what services you receive.

What is the coinsurance for Medicare Part B?

Medicare Part B patients are responsible for a 20% coinsurance, which typically amounts to $20-25 per visit. If you have original Medicare as your primary insurance, but you also have a secondary insurance, the secondary payer becomes responsible for the 20%. In some cases, the secondary insurance also charges a copay, coinsurance, or deductible. We recommend contacting your secondary insurance carrier to find out.

*So, how much will I owe for each visit?

If you have not yet met your deductible, then you will pay out of pocket per visit until your deductible is met. You will then owe any applicable coinsurance or deductible balances after we receive the Explanation of Benefits (EOB) from your insurance company.

Conversely, if we find that you have overpaid, we will refund you as soon as possible. As for copays—these amounts rarely vary, so if your copay for physical therapy visits is $10, you will owe $10 at each visit.

*What if I can’t afford to pay these amounts as frequently as I need care?

Your health is our number-one priority. As such, we are happy to arrange a payment plan that works with your budget. That way, you can pay for your care over a timeframe that works for you. Simply ask to speak to our office/billing manager.

A Couple of Notes

  • Most insurance companies offer several different plans or subsidiaries. Thus, two patients with Blue Cross Blue Shield, for instance, may have completely different benefits, and therefore, completely different financial responsibilities. Some plans have no copays or deductibles; others may have a $10,000 deductible. Furthermore, some providers may not accept all plans from a particular insurance. This is why it is crucial that you investigate the details of your specific plan.
  • If your insurance offers an online patient portal, sign up for it! These resources typically enable you to:
    1. check your benefits,
    2. track your deductible,
    3. see which providers in your area accept your particular plan,
    4. track your claims, and
    5. compare claims to your receipts from the doctor’s office (if they don’t match up, you can then follow up on any discrepancies).

Tips for Choosing an Insurance Plan

Whether you are shopping for your own insurance or going through the benefits selection process with your employer, choosing the right plan can seem like an overwhelming task. While we cannot tell you which specific plan to choose, the following questions should help you with the selection process.

Questions to Ask Potential Insurance Carriers

What is my premium?

This is the monthly amount you pay for coverage. The lower it is, the higher your deductible will typically be. Plans with low premiums and high deductibles often are called “catastrophic” plans. Conversely, higher premium plans often feature lower deductibles, copays, and coinsurances.

What is my deductible, and what does it apply to?

This is the total amount you must pay each year before your insurance begins to pay. For example, if your deductible is $4,000, then you must pay $4,000 toward deductible-applicable services before your insurance will pay anything. If your deductible applies to PT services, then you may have to pay per visit until you meet your deductible. Once you reach your deductible, your copay or coinsurance will apply.

What is my copay?

High copays are another common drawback to low-premium plans. Remember, the copay applies even after you have met your deductible, and the copay for specialist visits—including PT visits—can be as high as $80-$100. So, if you anticipate a lot of office visits during this plan year, you will want to factor the copay into your decision process.

What is my coinsurance?

As previously noted in this document, coinsurance is another version of cost-sharing. So, you will likely have to pay either a coinsurance or a copay. However, while copays are fixed amounts—and thus, are more predictable—coinsurances are percentages. Therefore, your financial responsibility varies based on how much your provider charges for the services rendered.

Are there any restrictions on the types of providers I can see?

Some insurance plans (e.g., PPOs, HMOs, and EPOs) are limited to a certain network of providers. So, make sure you have a good selection of covered providers and facilities in your area. If you travel frequently or live in a rural area, you may want to choose a plan that has no network restrictions.

Do I have to get a referral to see a specialist?

If your insurance plan requires you to obtain a referral before seeing a specialist (e.g., a physical therapist), and you fail to do so, the insurance company may (more than likely, will) deny coverage for services rendered. So, if you do not want to go through a primary care provider (e.g., your family physician) each time you want to see a specialist, make sure your plan does not require a referral (a.k.a. prescription) for specialist services.

How many visits am I allowed each year?

Some plans place a limit on the number of covered visits per year (e.g., 20 visits), while others allow for unlimited visits. If you are athletic, have chronic joint pain, or anticipate needing a joint replacement in the near future, you may not want any restrictions on the number of rehabilitative visits allowed.

For Medicare secondary payers: Will this plan cover the entire 20% not covered by Medicare?

Medicare only pays 80% of the cost of care, so many Medicare beneficiaries seek secondary insurances to pay the other 20%. However, even those plans often feature deductibles, copays, coinsurances, or visit limitations. Thus, we recommend posing all of the above-listed questions to any secondary insurances you are considering.

The Bottom Line  

Higher-premium plans are generally better for individuals who expect to receive medical care on a regular basis. Lower-premium plans will save those individuals money monthly, but those savings will not make up for the cost-sharing portion.

The Self-Pay Option

If I do not want to use my insurance, can I just pay for services myself?

Yes! Please contact us and we will go over the details and pricing with you.


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    North Miami, FL 33181



    1000 South Dixie Highway,
    Hallandale Beach, FL 33009


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