Last week, WebPT’s Brooke Andrus wrote a post explaining why patient confusion about insurance coverage can translate into problems for your clinic—everything from angry and frustrated patients to unpaid balances. According to PJ Cloud-Moulds—author of this Physicians Practice post—“there is a huge gap between reality and what the patient thinks happens with their insurance plan.” That’s why—whether it should fall on providers’ shoulders or not—many PTs, OTs, and SLPs are stepping up their educational game to ensure their patients not only understand the differences between copays, coinsurances, and deductibles, but also know what to ask potential insurance carriers before selecting a plan. And practices are providing that education before patients even receive services in their offices—in many cases, via a handout embedded in their website, as part of their patient intake paperwork, or in appointment confirmation emails. Some therapists are even going so far as to offer their patients an explanation of benefits sample—like the one you can find here—so there are no surprises come billing time.

In the words of Cloud-Moulds: “Take it easy on your patients, and find it in your heart to spend the necessary time with [them to help them understand their insurance benefits]; remember this [is] likely someone's dad, mom, sister, or brother.” With that in mind, read on to learn what we recommend passing on to your patients to help them get the most out of their insurance plans—and thus, the most out of your services:

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What Patients Should Know About Potential Insurance Plans—and Why

1. The Premium

A premium is the monthly amount your patients pay for insurance coverage. In most cases, the lower the premium is, the higher the deductible will be. Plans with very low premiums and very high deductibles often are called “catastrophic” plans. According to this eHealth article, catastrophic plans—which are usually only available for individuals under 30 and those who are experiencing financial hardship—“are designed to protect [the beneficiary] in a worst-case scenario; for example, if you get into a medical emergency and your medical costs total thousands of dollars.”  Until the beneficiary reaches that high deductible, he or she will most likely pay all health expenses out of pocket. Conversely, higher premium plans often feature lower deductibles, copays, and coinsurances.

2. The Deductible (and the Services to Which it Applies)

The deductible is the total amount that a patient must pay each year before his or her insurance begins to pay. For example, if a patient’s deductible is $5,000, then he or she must pay $5,000 toward services that are applicable to the deductible before insurance will pay anything. If that deductible applies to PT, OT, or SLP services, then he or she may have to pay the full cost of your services. Once a patient reaches his or her deductible, the copay or coinsurance will apply.

3. The Copay

Many low-premium plans also have high copays. And because copays apply even after a patient has met his or her deductible—and the copay for specialist visits, including PT, OT, and SLP sessions, can be as high as $80—patients who anticipate a lot of office visits during a plan year should definitely factor the copay amount into their decision process.

4. The Coinsurance

Coinsurance is another type of cost-sharing; patients will likely have to pay either a coinsurance or a copay. While copays are fixed amounts, coinsurances are percentages. Therefore, patients with coinsurances will have varying financial responsibility based on what you charge for your services.

5. The Network

Some insurance plans limit beneficiaries to a certain network of providers, which is why it’s imperative that patients not only ensure they have a good selection of covered providers and facilities in their area, but also choose a plan that includes their preferred providers (or be willing to pay out-of-network rates). Furthermore, patients who travel frequently or live in rural areas may want to consider a plan with no network limitations.

6. The Referral Rules

Patients with insurance plans that require them to obtain referrals—a.k.a. prescriptions—from their primary care physicians before seeing a specialist such as a PT, OT, or SLP have to jump through a few more hoops in order to receive your care. Plus, failing to obtain that referral may lead the insurance company to deny coverage.

7. The Visit Limitations

Some plans place a limit on the number of covered visits beneficiaries may receive per year. Certain types of patients—like athletes or people with chronic joint pain (especially those who anticipate needing a joint replacement in the near term)—may benefit from a plan that doesn’t limit the number of rehabilitation limits they’re allowed.

Want to help your patients choose the best insurance plans for their individual needs? Give them a free copy of the PT Patient’s Guide to Understanding Insurance.

While you can’t tell your patients which specific plans to choose—even if you want to—you can help them be better informed and, thus, better able to navigate the often confusing world of health insurance. By doing so, you’ll not only be providing them with an extremely valuable resource with benefits that extend beyond your practice, but also reducing the insurance coverage confusion that can wreak havoc on your business. Now, that’s what I call a win-win.

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