Understanding Health Insurance

• Health insurance can be used for physical therapy services that are deemed medically necessary.    
• Washington is a “direct access” state, which means you can go directly to a physical therapist without the need of a prescription or referral from another provider.  However, each insurance carrier has its own rules and may require a current prescription, referral or prior authorization.  Stride will identify whether or not your plan requires this and if so, may ask for more information from you.
• Insurance Demystification

Understanding insurance and the real cost of health care is often confusing and frustrating.  At Stride Physio, we want to be as transparent and clear around what we charge for our services and what you see on your bill.  The more you understand how insurance works and how providers bill for their work the more empowered you can be in making choices around your care.  We believe the services we provide are of high value at a low cost in both the short and long run. Physical therapy keeps you out of pain, reduces your reliance on medications, prevents the need for and/or improves the outcome of surgeries, minimizes lost days at work and staves off long term disability. Don’t let insurance be the barrier to you getting the best care for your movement system.

• • Billing Insurance:  The amount an insurance plan will pay or release to the patient per visit averages around $130 for follow ups and $230 for initial evaluations but can fluctuate depending on CPT codes billed. CPT codes are numbers (i.e 97112, 97140) that define what service was provided for the insurance company to process accordingly.  Stride Physio bills the same rate for each CPT code to all insurance companies.  Since we are a small business, the insurance plan sets the rate of pay, giving us little to no room to negotiate.  As providers, we bill for the type of service using “CPT codes” and the time it took for that service using “Units”. One unit is between 8-22 minutes of time spent.  Currently the charge for an initial evaluation is $180.  All other skilled services are billed at $60.00 to $80.00 per unit.  What this means is that the average amount Stride bills for the initial evaluation (first visit) for an hour of service is $480.00. The average amount Stride bills for follow up visits for an hour of service is $300. These amounts can fluctuate depending on the CPT codes billed. This is not the amount we will get reimbursed or a patient will be responsible for. Per our contract with each insurance company they decide the amount to pay per unit and CPT code billed. This is the “adjusted” rate or “allowable” you will see on your Explanation of Benefits (EOB) from your insurance carrier. For our level of education as Doctors of Physical Therapy, this remains one of the lowest reimbursement rates in all of healthcare.  

• • Self pay rates:  Because of contractual language with insurance providers, we cannot charge a different rate to people who pay out of pocket versus those who pay with insurance for the same services (despite insurers paying substantially lower than what we charge).  However, we can give a discounted rate if you pay out of pocket the day of the service because we are not contracted with your insurance or your insurance deems your visit not medically necessary. See self pay rates above.

• • Understanding your bill:  Most insurance policies have deductibles, co-pays and co-insurance (see below for these definitions).  You will get an EOB from your insurance carrier, which is NOT a bill.  You will then get an invoice from Stride Physio for any amounts owing for deductible, co-pay or co-insurance.  In general, Stride asks that you pay your co-pays at each date of service.  Should you not understand or agree with the bill we sent, we are more than happy to go over it with you for further clarification.

Glossary of health insurance terms

• • Deductible: this is a set amount that each individual must pay before their insurance benefit will start covering the cost of healthcare services.  For PT, if we bill your insurance $240.00 for your visit, and your insurance states the allowable (set rate by insurance company) amount is $120.00, then you will pay $120.00 toward your deductible.  Once your contracted deductible is paid, then your insurance covers the bulk of the service and you cover the co-pay and/or any co-insurance which is going to be a percentage of the allowable on the visit.  Stride is happy to look up your plan for you to find out your particular deductible.

• • Co-pay: this is a set amount you are required to pay every time you have an appointment with your provider.  Many plans consider physical therapy a “specialty” service so they require you to pay a higher amount.  Stride asks that you pay your co-pay on the day of your appointment.

• • Co-insurance: once you have paid your deductible, many insurers require that you pay a percentage of the service amount, up to a set maximum out-of-pocket amount.  For example, if you have 20% coinsurance on an adjusted bill of $120.00, and your deductible is met, Stride will bill you a total of $24 for coinsurance.

• • Visit Limit:  Most insurance plans have a set number of visits for all “rehab” services, including physical therapy, chiropractic, occupational therapy and massage therapy.  Once you have reached the visit limit number, then all future visits will have to be paid in full by the client.

• • Prior authorizations: Many plans now require a separate authorization process in order for you to receive services.  These prior authorizations have an expiration date and/or a visit limit.  These authorizations pre-determine the amount of care you can receive, regardless of the stated number of visits (or dollar amount) in your plan. 

• • Medically necessary:  This term is used to either accept or deny an insurance claim billed by a provider. It is defined as healthcare services and supplies that are justifiably reasonable, necessary and/or appropriate to diagnose or treat an illness, injury, disease or its symptoms.  Your practitioner AND your insurance provider determine what is medically necessary.  If you are denied coverage based on lack of medical necessity, your therapist at Stride will appeal this if that does not comport with our clinical judgment. 

• • HMO: This is a term for health maintenance organization.  These plans keep their costs down by keeping all the work in house.  With many of these plans you can still see a provider out of their network, if you are willing to incur greater out of pocket expense.

• • PIP: this stands for “personal injury protection” and is part of auto insurance coverage.  In the event of an auto accident, your auto policy will cover your medical bills, up to a specified dollar limit, if you chose to have PIP as part of your policy.  PIP claims require a referral for physical therapy. Once the PIP amount is used up, then the claim becomes “3rd party.  Stride does not accept 3rd party claims.  However, once the PIP is used up you are able to use your health insurance for further services needed and/or pay self pay.

• • L & I: Labor and Industry claims is employer insurance for on-the-job injuries.  These claims require referral from another provider in order to receive physical therapy.  You will also be asked to provide a claim number, the date of the injury and a case manager name and number.