Understanding Your Insurance 101


Understanding your insurance

Understanding your insurance is about as easy as doing a Rubix cube blindfolded these days. There are so many terms, limitations, and policies that can affect how much you pay and what actually gets covered. We want to help you out by giving you some clear cut definitions and how to actually understand your coverage when it comes to physical therapy care.


What Terms You Need to Know:

Deductible- The defined amount needed to be met before any benefits kick in. For example, $1,000 deductible means you must pay that amount before any insurance coverage begins.

Co-Pay- Pre-determined amount a plan requires to be paid at time of visit for given specialty. For example, a $40 fee before seeing a specialist.

Co-Insurance- Percentage that insurance covers for given service. For example, if the co-insurance is 80/20 and the charge is $100 then insurance would cover $80 and you are responsible for $20.

Out of Pocket- Max amount that needs to be satisfied before insurance covers 100%. Typically this is a significantly higher amount than the deductible.

In-Network (contracted)- The healthcare company has an agreement with the given insurance company for payment of your services.

Out of Network (non-contracted)- The healthcare company does not have an agreement with the given insurance company but can still file claims.


How do I find out MY benefits?

Here is the strategy we recommend to our clients who are looking to see what type of coverage and benefits their specific plan has, this is the order of questions to ask your insurance rep. The number is typically on the back of your insurance card.

1. What are my in and out of network physical therapy benefits?

(They will give you information such as your deductible, co-pay or co-insurance and out of pocket.)

2. How much of my deductible has been satisfied so far?

(The amount that has been satisfied for both in AND out of network.)

3. How many visits am I granted per year?

(Some insurances have limitations or restrictions.)


How do I understand this all?

This infographic can help you see what in vs out of network coverage can look like for physical therapy services. This is taken from one of our recent clients.


How to determine what is best for me?

Given the coverage above, here is a breakdown to give you an idea of what we typically see from an in-network clinic versus our facility, which is an out of network clinic.

Let’s break these down…..

Number of visits- Most in-network clinics on average will prescribed 12 visits for many common diagnoses, where as our specialists on average see clients for 5 visits.

Time with clinician- In-network clinics need to fit more people in during the day so their PT usually sees a client for 15-30 mins individually before ending the session or having the patient do exercises with a PT technician or assistant. At Xcel, we do not use assistants or techs so the entire hour session is spent with our clinician.

Cost- A little math here, the in-network clinic is going to charge the $20 copay every visit, so with 12 visits you’ll have the $240 charge. Now the kicker with this plan is that they would need to satisfy the $2000 deductible before they are covered with only a copay. So, for 10 of those visits, they will be charged $200 per visit to satisfy that deductible. This is hopefully communicated to the patient, and typically comes as a bill after the care has been completed. At Xcel, we have single session price or discounted packages, so for 5 sessions our package is $925. This is the only cost we collect.

Time- Arguably the most important detail because who wants to deal with pain or injuries longer? Accounting 30 mins of travel time to and from the clinic + the 60 min session, you’re going to spend more than double the amount of time away from work, family and achieving the results you need to get back to your active lifestyle with in-network.


In Summary…

This is just an example of one individual’s coverage, so not all insurances will be like this. Some favor in-network with cost, and some do not like this situation. The biggest takeaway is for you to understand that if cost AND value of service is important to you, then do your homework. Make sure you understand your policy and coverage, so you know your expectation of costs.

Also, I truly recommend talking with one of our clinicians at the facility you’re interested in going. Ask them questions about your specific problem or symptoms and make sure you’re comfortable with them before starting your plan. Whether you go in-network or out of network, you’re still going to be spending money AND devoting your time and energy, so you want to make sure it’s with someone you’re comfortable working with.

If you have questions about insurance or want to schedule a free consultation with one of specialists, just click here and we will be happy to help you!

To your health,

Dr. Brian Campbell, PT

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