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Equinox is a physical therapy practice in Sarasota, Florida. We specialize in treating people with dizziness, vertigo, balance problems and facial paralysis.

Friday, 04 September 2015 14:49

Top 4 Questions Regarding Out of Network Outpatient Physical Therapy Services & Insurance Coverage

Money MattersMoney Matters (Selected Part of Letters from Aunt Evelyn), conceptual art by Barton Lidice Benes, 1982.


This is an article that I thought I would never write. When I first started working as a physical therapist, I worked for a big hospital in Manhattan. I never had to think about insurance, because basically the hospital accepted every type of insurance there was! In fact, these were the days when there was no such thing as a co-payment. When co-pays did come along, for many years the hospital never attempted to collect the 5 to 10 dollars per visit. But that was 17 years ago, and a lot has changed now.

Things really started to change after Obama care. I not saying that I am either for or against Obama care, I am just saying that things are very different now. For example, in order to have insurance, many families are choosing insurance where the deductible is 5 to 6 thousand dollars per year! This means that the patient has to pay the first 5 or 6 thousand dollars in medical services, thus meeting their deductible, before their physical therapy services are covered. In addition, the person usually has a co-pay required at each physical therapy session, which can be as high as 50 to 75 dollars per visit with some plans. Take the time to consider these factors when choosing your insurance needs.

At Equinox Physical Therapy, we check a patient’s insurance benefits before they even arrive for their first visit. I am a standard Medicare Part B provider for out-patient physical therapy services. That means that I accept standard Medicare Part B because I am committed to treating people over 65 years of age who have balance problems, dizziness, vertigo, falls, inner ear problems, concussion, or facial paralysis. I don’t want my Medicare patients to fall and break a hip, when I know that I can help them to enjoy their retirement in sunny Sarasota, Florida, and live a long and healthy life! Medicare pays 80% for out patient physical therapy services, and most people have a secondary insurance that covers all or part of the remaining 20% of the bill.

As far as other types of insurance, I see patients who do not have Medicare, but some other type of insurance, and in these cases I am classified as an “out-of-network” physical therapy provider. Because I am not a major hospital, I cannot accept every insurance under the sun, because it would be too much for my small practice to manage.

Why would someone come to me, an out-of-network provider, when they could see someone in-network instead? That should be your next question. The reasons are probably many. When I see a private insurance patient, they pay me, and then I give them the papers they need to submit their physical therapy bills to their insurance company. Then, their insurance company will reimburse the patient directly for whatever their out-of-network physical therapy benefits are. The patient calls their insurance company to verify their benefits before they even step inside my door. They know exactly the percentage that their insurance company will reimburse them, and the percentage that they will have to pay of the remaining bill.

Again, why would someone come to me instead of going to his or her “in-network” provider? For one thing, many of these patients have BPPV, a condition that causes vertigo and seriously interferes with their ability to work, or function properly. With this condition, it usually goes away if treated properly in 2-6 sessions. So, it is not such a big expense to come see me. If they have a big deductible, they will have to pay either way. At least if they come to see me, they know they are being seen by someone who treats this problem 3-4 times a day, as opposed to someone who has little experience, or only treats this problem occasionally. For patients with conditions that take longer to treat, they come to me because they know that their chances of having a good outcome are enhanced if they have the best possible therapist that their money can buy, because again, they still have to pay the large deductible either way. Other patients come to me because I am a specialist in treating inner ear disorders, concussion, falls, dizziness, and facial paralysis, and their “in-network” therapists are not.

Another point to consider is the co-payment. Because I am out of network, I do not collect a co-payment. For those patients whose co-payments are 50 to 75 dollars per visit, the difference between their co-payment and what they have to pay me may be the same, or not much more.

If you are considering going out of network for your out-patient physical therapy services, here are a list a questions that you should ask your insurance company to help you decide if going out of network is right for you or your loved one. One thing to remember is that you, the patient, have the right to receive services from any physical therapist you choose.

TOP 4 QUESTIONS REGARDING OUT-OF-NETWORK PHYSICAL THERAPY BENEFITS

1. Do I have out-of-network physical therapy benefits? If not, what does that mean?
2. Am I eligible to receive direct reimbursement from the insurance company for my physical therapy visits?
3. What percentage of the money I paid at my physical therapy visit will you, the insurance company, reimburse?
4. Do I have an out-of-network deductible to meet first?

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Dr. Laura Wazen

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Listen. Listening is the most important step in understanding a patient’s concern. It is the most basic beginning, and in health care today, so often undervalued. It directs understanding, direction of testing, and formulation of a plan. It is the most important step in paving the road to treatment and recovery.

Learn. My role is not only to learn from my patients, but to guide them in how to learn from me, what they should do to take back their lives and create positive change.

Live. Life is a gift. The purpose of all treatment at Equinox Physical Therapy is to restore function, independence, and freedom to clients recovering from or living with an illness.

Vertigo

Dizziness

BPPV

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