About Billing & Insurance of Your Office Visits
Patients have the option to use their medical insurance for coverage of their physical therapy benefits or pay out-of-pocket. We accept most PPOs, Worker’s Compensation and Medicare. Individual benefits are dependent upon your individual health plan and you should understand your PT benefits prior to starting care.
How to Check Your Insurance Benefits
In order to check your individual physical therapy benefits, you should call the customer service phone number located on the back of your insurance card. Some things to ask your insurance company are:
- What is your Deductible? Your deductible is the amount of money you agree to pay before your health insurance policy begins to pay.
- What is your Co-Pay? This is a fixed amount you pay for physical therapy. This is different from a co-insurance.
- What is your Co-Insurance? This usually translates into the insurance company paying a certain percentage of your physical therapy bill, while you pay the remaining percentage. The percentage is dependent upon your insurance plan.
- What is your maximum PT benefits? This is the total amount of physical therapy visits you can have in a calendar year.
Insurances We Accept (Most PPOs)
- Blue Cross
- Blue Shield
- Health Net
- Medicare Part B
- United Health Care
- Worker’s Compensation
Insurances We Do NOT Accept
- HMO plans, including Kaiser
- Medi-Cal including Alameda Alliance, Community Health Center Network
How a Physical Therapy Claim is Created
A physical therapy claim (i.e., bill) is created at each attended appointment by your Physical Therapist. Your PT will bill according to the time spent performing each intervention which may include modalities, therapeutic exercise, neuromuscular re-education, gait training, and/or manual therapy. Due to the variability that occurs during each session, your PT claim will have a lot of variability as well – therefore the cost of each session will often be different.
How A Physical Therapy Claim is Processed
At the end of each session, the bill is completed by your PT and then processed within our internal billing department, lastly it is sent out to your insurance company for review and processing. Once received by your insurance company, your insurance company will review the billing claim and process it within their department and determine the amount that is covered. The amount covered is determined by your individual PT benefits in which the remaining balance is billed to you later.
When Will I Receive My Physical Therapy Bill?
Every insurance company processes billing at a different time schedule. Due to the nature of this process, you will expect a delay in receiving your statement balance from ESPT. Along with your ESPT statement, you should receive an Explanation of Benefits (EOB) sent to you by your insurance company. This document may be sent to you by your insurance company several weeks or months after you had a healthcare service that was paid by the insurance company (or after a claim was filed, even if the full cost was applied to your deductible and deemed your responsibility). You should get an EOB if you have private health insurance, a health plan from your employer, or Medicare.
If Your Insurance is Out-of-Network
We are in network with certain insurance companies only, however if our clinic is out-of-network, you still have the option to continue PT care with ESPT. The billing process is the same, EXCEPT your financial responsibility will be higher according to your out-of-network benefits which is determined by your individual benefits plan.
Advantages to the Out-of-Network Payment Model
In order to maintain a high quality of care and a greater amount of time spent with our patients, ESPT has chosen to be out-of-network with certain insurance companies due to low/unfair reimbursement rates received when we are considered “in-network”. Some clinics may choose to accept all insurances, however, they increase the amount of patients they see per hour in order to receive the needed amount of reimbursement to cover their overhead. By increasing the amount of patients they see, the direct amount of time spent with each physical therapists is greatly reduced. Often times this means the average time spent with the PT is 5-7 minutes only – this is according to our patients who have experienced care elsewhere. We average 20 minutes of direct time with our patients. By choosing to continue treatment at ESPT with your out-of-network benefits, you will choose to maximize the time you spend getting better through efficient and effective methods practiced by our physical therapists.
If you do not have medical insurance, or your medical insurance plan is not accepted at our facility, you have the option to pay out-of-pocket for your physical therapy care. There are definite advantages to this model which include: an expected flat rate for physical therapy visits, no delay or confusion of billing from the insurance company, you choose how many and how often to have your treatment sessions.
Advantages to Out-of-Pocket Payment Model
Your insurance plan often determines what clinic you can go to and whether your visits are authorized or not. For patients who are not satisfied with their available in-network physical therapy clinics or have maxed out their benefits, physical therapy is still accessible to you at a clinic of your choice. By paying out of pocket, you will have financial control of your physical therapy visits, not your insurance.