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:

The Data-Driven Practice: 10 Stats to Track in Your Therapy Organization - Regular BannerThe Data-Driven Practice: 10 Stats to Track in Your Therapy Organization - Small Banner

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.

  • Collection Objection: Overcoming Patient Excuses for Why They Can’t Pay Image

    articleApr 19, 2017 | 5 min. read

    Collection Objection: Overcoming Patient Excuses for Why They Can’t Pay

    If collecting patient payment at the point of service was important before, then it’s mission-critical now—especially as reimbursements continue to shrink. That’s because—as we’ve mentioned here , here , and here —only 21% of patient balances that aren’t collected at the point of service are ever recovered. That’s a lot of cash you’re leaving on the table if your patient collection strategy is not on point. So, in addition to implementing a solid payment policy, successful providers …

  • The Case for Care Cost Transparency in Your Practice Image

    articleApr 26, 2017 | 6 min. read

    The Case for Care Cost Transparency in Your Practice

    Back in the day, the notion of healthcare providers discussing the cost of treatment with insured patients was relatively unheard of. After all—aside from a nominal patient copay—insurance usually footed the bill. That’s not the case today. As Fair Health President Robin Gelburd writes in this Physicians Practice article , the insurance industry has evolved to place greater financial responsibility on patients—hello, high-deductible health plans (HDHPs). As a result, patients want to know the cost of the …

  • The PT Patient's Guide to Understanding Insurance Image

    downloadApr 3, 2017

    The PT Patient's Guide to Understanding Insurance

    Patients are shouldering a greater portion of their healthcare costs than ever before. But when they don’t know the specifics of their coverage, they can end up with much bigger bills than they bargained for—and that often leads to unpaid balances and unfinished treatment plans. Bring them up to speed—and improve your practice’s collections and patient retention—with this guide. Patients will learn: What it means for a service to be “covered.” How to define common insurance terms. …

  • 4 Keys to Keeping a Steady Cash Flow Image

    articleMay 18, 2016 | 5 min. read

    4 Keys to Keeping a Steady Cash Flow

    As a private practice clinic owner, you’re probably familiar with the cold sweat-inducing struggle to keep a steady cash flow. Claims management muck-ups, inefficient processes, staff issues, and lack of insight into your clinic’s financial health can leave you feeling like you’re riding a revenue rollercoaster. So, whether you’re trying to maximize reimbursements , combat employee theft , or optimize patient payments , these four keys to maintaining a steady cash flow will help you even out …

  • Death to Denials: 4 Strategies for First-Pass Claim Payment Image

    articleMay 1, 2017 | 4 min. read

    Death to Denials: 4 Strategies for First-Pass Claim Payment

    Claim denials are the worst. You provide your patients with exceptional therapeutic intervention—and bill their insurance companies to recoup payment for those services—only to find out that the payer has no intention of actually doing any paying. Womp, womp. While you could—and should—implement a process to correct and rebill denied claims, wouldn’t it be even better to stop them from happening in the first place? After all, it costs providers an average of $25 to rework a …

  • Founder Letter: 3 Ways Your Practice is Losing Money Image

    articleMay 5, 2016 | 7 min. read

    Founder Letter: 3 Ways Your Practice is Losing Money

    Much like the patients you treat, your practice can appear healthy on the outside despite significant internal issues. And when those issues are money-related, the consequences can be deadly. If your practice already is in the red, you know you’ve got some pretty serious cash flow problems. But even if you’re in the black every month, you may still be washing dollars down the drain. While there are myriad ways your practice might inadvertently be losing revenue, …

  • 3 Common Rehab Therapy Credentialing Mistakes Image

    articleJul 18, 2018 | 6 min. read

    3 Common Rehab Therapy Credentialing Mistakes

    Proper credentialing is a crucial step in running a successful physical therapy clinic. If your clinic and therapists aren’t properly credentialed with insurance providers from the get-go, your bottom line might suffer. And it’s not just new clinics that are susceptible to making credentialing mistakes; in fact, any clinic that has gone through a change in ownership, rapid growth phase, or any other transition might find itself mired in credentialing headaches. But before we get to the …

  • Suppressing Sticker Shock: How to Handle Your Patients’ High-Deductible Health Plans Image

    webinarFeb 23, 2017

    Suppressing Sticker Shock: How to Handle Your Patients’ High-Deductible Health Plans

    Copayments, coinsurances, unresolved balances—oh my! Any one of these can cause headaches for healthcare providers, but as healthcare reform efforts shift more and more financial burden to insurance beneficiaries, today’s practitioners are increasingly facing all three. And these challenges are not only hurting their patient acquisition and retention rates, but also their bottom lines. Tired of spending time verifying benefits only to lose those patients to copay sticker shock? Stuck in a constant cycle of pursuing past-due …

  • Common Questions from Our Patient Sticker Shock Webinar Image

    articleMar 31, 2017 | 33 min. read

    Common Questions from Our Patient Sticker Shock Webinar

    From copays and deductibles to payer contracts and benefits verification, understanding all the nuances of third-party insurances is tough enough for healthcare providers—let alone their patients. In WebPT’s most recent webinar— Suppressing Sticker Shock: How to Handle Your Patients’ High-Deductible Health Plans —co-hosts Heidi Jannenga, PT, DPT, ATC/L, the cofounder and president of WebPT, and WebPT CEO Nancy Ham provided a lot of great advice on how to have productive conversations about healthcare costs with your patients—without …

Achieve greatness in practice with the ultimate EMR for PTs, OTs, and SLPs.