Insurance is naturally confusing. Therefore, I am going to simplify it for you. You either have a copay, deductible, or coinsurance...or more than one!
A copay is a fixed amount you must pay for a covered service at the beginning of your treatment as defined by your health plan. For example you might have a $30 copay. Depending on if you've satisfied your deductible, you may or may not owe more money for that treatment. This is where we need to learn what a deductible means!
A deductible is an amount of money that needs to be satisfied or paid off (by the patient) in order for the insurance company to start paying for the service. For instance, if you have a $2000 deductible, you (the patient) are responsible to pay the $2000. Your insurance company will not pay anything until you have paid the deductible, but there will be a "negotiated rate" for the service.
After your deductible has been met, you may have to pay a copay or coinsurance (and in some cases both) for each visit. A Coinsurance is when you have met your insurance plan’s deductible, and you are responsible for a percentage of the payment. For example some people have 20% coinsurance; this means the patient is responsible to pay 20% and the insurance company will pay the 80% of the claim.
A Claim is the patient’s visit. All claims have codes which help to identify what is wrong with the patient and what is being done to help treat them. One set of codes are called ICD-10 codes, which stands for the international classification of diseases, in the United States version of the code book. For example, M54.5 is back pain. There are also CPT codes, which stands for Current Procedural Terminology. For instance, 97140 is Manual Therapy.
There are also visit limitations for physical therapy. You might have a limited number of visits you are allowed per year. Some people have plans where they are allowed 20, while others might be allowed 120 visits. How many visits you have are permitted depends on your health plan.
Just to summarize! Copay means you pay a specific amount in the beginning of your treatment. Deductibles mean the patient has to satisfy that amount of money in order for insurance to start paying (and the patient may be responsible for the entire visit amount). Coinsurance means that a percentage of the claim is paid for by the patient. However, even after you’ve met your deductible you may still owe a copay or coinsurance for each visit.
Additionally, when an office says that your insurance will cover it, they mean that the insurance company will process the claim. However, that doesn't mean that the insurance will pay for all of the visits.
Even after reading this, you may still be confused about insurance and claims. Call the office and let our billing department walk you through the process, and get all the information for you!
If you would like to learn more visit the link below: https://docs.wixstatic.com/ugd/464fe8_5951638b8f3444038a1b27179d97c32a.pdf