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 scaring them away. They also offered tips on how to develop and enforce a patient payment policy, clearly demonstrate to patients the value you provide, and evolve your practice’s service offerings to contend with the changing insurance landscape. Of course, there’s no way our hosts could cover everything in 60 minutes—which means we received a lot of follow-up questions from our audience. We’ve compiled them into the following massive FAQ. Feel free to scroll through the whole thing, or use the link bank below to navigate to a specific section. Don’t see the answer you’re looking for? Hit us up in the comment section at the end of the post, and we’ll do our best to get you the information you need.

Verifying Insurance Eligibility

Collecting Patient Payment

Demonstrating Value

Understanding the Current Healthcare Landscape

Incorporating Cash-Pay Wellness Services

Going Out-of-Network

The PT’s Guide to Billing - Regular BannerThe PT’s Guide to Billing - Small Banner

Verifying Insurance Eligibility

When should I verify patient eligibility?

Your office should verify benefits before the patient’s first visit—ideally at least 72 hours before that patient’s first interaction with your clinic. If you’ve been reading our blog posts for a while, you know we’ve written plenty on this topic. That’s because it’s the only way to be sure that you’ve not only collected the correct information from your patients—thus enabling you to submit clean claims—but also that you know exactly what their plans cover. And that, in turn, allows you to determine what your patients will be responsible for paying out of pocket. Without that step, it’s a guessing game, and that lack of concrete information from the get-go could put you in a tough spot with both patients and payers later. While this step has always been important, it’s even more crucial now given the explosion of high-deductible health plans in which patients are bearing the brunt of financial responsibility.

As far as when you should communicate what you’ve learned with the patient, the sooner the better. That way, patients don’t arrive for their first visit only to find out that their coverage was not what they expected it to be.

What is the best way to go about verifying benefits?

As explained here, you should request that all patients—especially new patients—bring their insurance identification card to every visit. Your front office staff should then check with the carrier to make sure the information on the card is up to date and accurate for that date of service. “This can often be accomplished by checking the insurance carrier website or calling a benefits representative,” the article explains. “If staff encounters problems with a patient’s insurance verification, policies should be in place to have the patient pay for the services in full and file the insurance claim themselves. For those with financial need, there should be an option for patients to make payment arrangements.”

Do you have any tips for streamlining the insurance verification process?

Absolutely! Check out this blog post for an in-depth discussion of insurance verification, as well as some pointers on how to optimize this process in your practice (hint: it all starts with your front office staff).

Should we have our patients sign a form that explains the benefits that we’ve verified—so we have confirmation that we’re all on the same page?

You certainly could. Office manager Asia Giuffrida says she prints out the insurance benefits and shows the patients what she’s been told by the insurance company. She then has the patient initial the document. “That way, if the benefits are wrong, the patient can see we were both misinformed and it wasn’t us trying to deceive them,” she said.

What if the insurance rep gives incorrect information when we call to verify benefits? How should we handle that discrepancy with our patients—especially when those patients also have received inaccurate information from their insurers?

Ultimately, patients are responsible for knowing their benefits. But, as we all know, patients tend to not do their homework before accessing care—which means the burden of education often falls on providers. At Heidi Jannenga’s former clinic, she and other staff prefaced any benefits conversations with a disclaimer regarding the very real possibility that the patient may have, at some point in time, received incorrect information. Your best option is to call the payer on the patient’s behalf. However, be aware that virtually every insurance company has developed a written rule about how insurance reps are not responsible for inaccurate over-the-phone quotes—and make your patients aware of that caveat, as well. Transparency is key—even when that means being transparent about the fact that benefits verification is not always an exact science.

How should we handle last-minute patients when we don’t have time to verify benefits?

This is where a patient payment policy comes in handy. It should make clear that:

  • the patient is responsible for knowing the terms of his or her coverage;
  • your practice will collect any amounts not covered by insurance at the time of service; and
  • your practice reserves the right to collect any unverified amounts upfront.

Now, demanding upfront payment as a condition of service may, in some instances, violate legal obligations, which is why we always recommend seeking the advice of a qualified healthcare law attorney prior to finalizing any type of policy in your practice. That being said, in most cases you can request payment in full at the time of service and later issue a refund based on what the insurance ends up paying. To learn more about patient refund processes and legal considerations, check out this resource.

Who at our practice is ultimately responsible for knowing about and having conversations with patients about insurance benefits?

Everyone at your clinic should be fully fluent in all things insurance-related. Now, it makes sense for your front office staff to be exceptionally prepared and well-versed in having these often ambiguous conversations; after all, patients typically have their first interaction with—and ultimately remit payment to—these employees. But honestly, your entire staff should be comfortable having these conversations, because you never know when the topic of insurance will come up.

What’s a coinsurance, co-pay, and deductible?

To learn more these terms, check out this article written by WebPT President Heidi Jannenga.

Collecting Patient Payment

When should I discuss the cost of treatment with my patients?

Whatever you do, don’t wait to discuss the cost of treatment until a patient completes that first session and you send out a bill. If you do, there’s a good chance you’ll end up with an unhappy patient who either won’t pay or won’t see you again. He or she may even take out some frustration on your billing department—or worse, on social media, telling other potential patients that he or she felt ripped off or taken advantage of.

I’ve had patients adamantly refuse to provide their insurance information—because they know that they have a high deductible they’ll never meet—and request to pay cash instead. Is it legal for me to accept cash from these patients?

Knowingly doing this could get you into legal trouble—particularly with Medicare and your in-network insurances. Dr. Jarod Carter explains why in this blog post. So, if you opt to accept cash from patients who are insured, just make sure you aren't violating any contract terms or legal obligations.

Is it legal to discount copay amounts—or provide waivers?

You must be very careful about providing discounts and waivers. Generally speaking—and this goes for both in-network and out-of-network insurances—you are putting your practice at risk legally by routinely waiving or discounting patient charges. Now, in some cases, you may be able to make exceptions for financial hardship, but the criteria around what constitutes "hardship" are typically fairly strict. To learn more about establishing a hardship policy, check out this resource.

What are the criteria for waiving copays, coinsurances, or deductibles on the basis of financial hardship?

Because the therapy services you provide are valuable, you should make every attempt possible to collect patient copays and deductibles on a routine basis. However, there are times when patients simply cannot afford to pony up. That’s why, according to this resource authored by compliance expert Tom Ambury, it’s important to establish a procedure that patients must use to demonstrate a financial hardship—and document it. (For more details on how to define and document financial hardship in your practice, check out this resource.) You can also protect your practice by making sure the patient signs an acknowledgement indicating that he or she has a financial hardship.

But, that doesn’t mean you should automatically waive a patient’s copay or deductible when he or she claims to be unable to pay the full amount; after all, your practice should be able recoup something. In these circumstances, ask the patient, “What can you afford to pay each visit?” Then, work with the patient to create a payment plan that suits his or her budget.   

What’s the best way to handle a situation in which a patient has already met his or her deductible—as a result of a recent surgery, for example—but the insurance company hasn’t processed that payment yet and says we’re responsible for collecting payment?

As a commenter in this thread suggests, simple honesty may be the best policy in this case: "I would suggest that when you get the EOB from the insurance company showing that amounts were applied to the patient's deductible to call the patient before sending the bill and explaining that their insurance company processed your claim BEFORE the physician's claim and that their physician will almost certainly be refunding an amount to them because of it. That way, they will at least know what happened and that the deductible amount ended up being owed to your office instead. Most times patients just need a little information to help them feel more comfortable about insurance and how it works. We understand it because we deal with it every day, but it gets confusing to them sometimes."

Is consistently waiving a patient’s coinsurance, copay, or deductible considered a HIPAA violation?

According to this Medical Economics article, providers who waive copays can expose themselves to greater HIPAA violations because, essentially, the provider is misstating his or her charge to the commercial plan. For example, assume a $100 total charge where the patient has an 80/20 plan. If the provider waives the patient’s obligation to pay 20%, then, arguably, the commercial plan owes only 80% of $80—not 80% of $100.

How can we ensure our office is consistently collecting patient payments?

Establishing a policy—and sticking to it—regarding the payment of coinsurances, copays, and deductibles is a great first step. However, keep in mind that different insurance contracts may have different provider obligations for handling patient financial responsibility. Thus, we recommend reviewing your major contracts and forming your office’s policy accordingly.

Where can I find a sample patient payment policy?

You can find a sample policy, as well as guidance on how to implement it, here.

When should we collect payment from patients?

You should be collecting patient payments—whether that be a patient’s copay or outstanding balance—at the time of service at least 90% of the time. Don’t wait to send a bill later. After all, as Erica McDermott explains in this blog post, only 21% of patient balances that aren’t collected at the point-of-service are ever collected. To stack the deck in your financial favor, you’ve got to collect patient payments when the patient is in your office. To make things easier, consider using the phrase, "How would you like to pay today? Credit card, cash, or check?," rather than "Would you like to pay your copay today?" According to the APTA, clinics attained much better collection rates using the former phrasing. You may also want to consider developing an incentive program for front office staff based on their collections—after all, the increase in collections will more than offset the costs of an incentive program.

When providers put their patients on a payment plan, are they allowed to keep their payment information on file and bill the first of each month, instead of waiting for the patient to pay his or her bill?

More and more providers are adopting automated payment programs to help ensure consistent patient payment collection. If you opt to keep a patient’s payment information on file, make sure the patient is aware of when he or she will be charged. This process should also be documented in your practice’s payment policy. You may also want to consider sending patients automated phone calls or emails to alert them when a payment is about to be processed.

Some of our insurances won’t let us collect anything until we’ve received the EOB. Is there a way around this rule—for example, by providing refunds?

First, we’d recommend carefully looking over your contracts with these insurances. According to one commenter in this AAPC thread, “it is well within MOST insurance contracts between the insurance company and the provider for a collection of a patient's estimated deductible/coinsurance/copayment. What is usually not allowed is a blanket requirement of a deposit without an estimation of benefits being performed.” That being said, as another commenter stated, “there are plans that do not allow this. And if the plan does not allow it, then the provider has no choice but to bill the patient.”

We’ve been told by a third-party payer that we cannot request patient payment for a service we provided without authorization. Is that true?

This may depend on the specific agreement you have with your insurance carrier. Please reference your contract and reach out to your insurance representative for a definitive answer.

Can I collect the 20% coinsurance from Medicare patients at the time of service?

Yes. As noted here, you can collect the patient responsibility upfront from Medicare patients. However, you must “refund as promptly as possible any money incorrectly collected from Medicare beneficiaries or from someone on their behalf.”

If we’ve sent a patient multiple past-due balance notices and he or she still has not paid, can we write that amount off, or do we have to send the patient to collections?

As we mentioned above, providers should always try to collect these amounts on a routine basis, and in many cases, it is illegal for providers to waive copayments or deductibles. Now, if you’ve been unable to collect past-due balances despite repeated attempts—and the patient has not demonstrated a financial hardship—then you have the choice of either sending the patient to collections or writing off the unpaid balance. As explained here, both options come with caveats to consider. For example, the collections process may “send the patient into crisis or cause the patient to take legal action against the doctor.” And write-offs are not always possible—or legal—per individual payer contracts. Thus, before you resort to either option, we recommend exhausting all other strategies—including offering to put the patient on a payment plan (as explained above).

If we misquote the patient’s financial responsibility and it ends up being more, can we—or are we required to—waive the difference?

No. As we have already mentioned, it is ultimately the patient’s responsibility to know the terms of his or her coverage, and we’d suggest prefacing any estimates you provide with the fact that they are just that—estimates (this is also something you could include in your patient payment policy). If the patient ends up owing more than you originally projected, in most cases, you must bill the patient for the difference. On the flip side, if you discover that the patient has overpaid, you must refund the difference. For more information on patient refunds, check out this resource.

Can I charge interest on past-due balances?

While it’s certainly not common practice for healthcare professionals to charge interest on past-due balances, it may be within your rights—if you include a detailed explanation of the penalties associated with late payments in your patient payment policy. According to the American Medical Association—as quoted in this Physician’s Practice article—“Although harsh or commercial collection practices are discouraged in the practice of medicine, a physician who has experienced problems with delinquent accounts may properly choose to request that payment be made at the time of treatment or add interest or other reasonable charges to delinquent accounts. The patient must be notified in advance of the interest or other reasonable finance or service charges by such means as the posting of a notice in the physician’s waiting room, the distribution of leaflets describing the office billing practices, and appropriate notations on the billing statement. The physician must comply with state and federal laws and regulations applicable to the imposition of such charges...Physicians who choose to add an interest or finance charge to accounts not paid within a reasonable time are encouraged to use compassion and discretion in hardship cases.” Before going forward with this practice, we recommend thoroughly reading your state practice act and reaching out to a healthcare attorney for further guidance.

If the patient's secondary insurance comes back and says the 20% coinsurance is over its allowable rate, do we have to bill the patient?

This depends on whether your practice contracts with both payers. Additionally, by law, if you contract with both payers, you’re not allowed to bill the patient anything other than his or her responsibility.

Should we be having payment conversations within earshot of other patients?

Absolutely not. In fact, all conversations regarding a patient’s health and financial situation should be kept confidential, which may mean creating a separate area within your office for confidential conversations or, at minimum, keeping your voice low when discussing this type of information with a patient. Speaking of confidential information, it’s also prudent to have these discussions directly with the patient—whether that be in-person in the office or over the phone as opposed to via email or voicemail (unless the patient has provided you with express written permission to do otherwise).

Most of our insurance companies require prior authorization and/or a prescription from a physician before they will reimburse for physical therapy services. So, how do we provide preventive care?

In most cases, preventive care would fall under the category of wellness services, which most third-party payers view as non-covered services. According to Ann Wendel, because “wellness is not a covered service, [it] would be an out-of-pocket expense for the client.” That being said, you can verify whether a client is eligible to receive reimbursement for wellness services by checking with that client’s insurance company. Wendel says that “some clients may be able to use their health savings account (HSA).”

How should we collect copays if our therapists are going to see patients at an assisted living facility? We always bill, but it just doesn’t seem feasible for our therapists to collect money at the time of service.

In some situations, it might not be feasible to collect copays at the point of service. However, you may want to consider keeping a form of payment on file for each patient to automatically charge at each visit—if PCI guidelines and your payer contracts allow for it.

We’re a nonprofit PT facility, and many of our patients simply assume that because of this we should be able to waive their copays. How do we explain to patients that this isn’t the case?

Honesty is the best policy. Simply explain to patients that although your organization does not make a profit, you still must earn enough money to keep your doors open—and, because you’re contracted with their insurance company, you are legally required to collect copays.  

Demonstrating Value

How can I amp up my customer service game?

You can use stellar customer service to show value by ensuring that:

  • your waiting room is attractive and comfortable;
  • check-in is friendly and efficient;
  • your therapists are on time for appointments, so that patients spend minimal time in the waiting room;
  • therapy progresses at an appropriate pace; and
  • your patients are out the door on time so they can back to work or life.

Also, be sure your staff is well-versed in customer service best practices, so everyone on the team greets patients by name and with a smile—and handles challenging conversations with poise.
It also doesn’t hurt to consider the little things, like providing complimentary water and cold towels, sending out handwritten birthday cards, or even putting out fresh flowers and playing soothing or motivating music. Ultimately, the better the environment you can provide for your patients to heal, the better. And, of course, this all comes on top of providing unparalleled clinical care.

How do we ensure patients actually show up to their first appointments—even after learning about the cost of services?

If you’re noticing that patients aren’t showing up for their first visits after learning about the cost of treatment, then this advice is for you: consider adjusting your phone script to promote the value you provide for each patient’s specific condition. For example, if your patient is experiencing low back pain and your clinic happens to have exceptional outcomes data demonstrating your skill in treating this condition faster and better than other therapy providers, you could relay that information—or provide a comparison as to how patients typically fare when receiving PT for low back pain versus more invasive interventions.

What else can our front-office staff do to effectively communicate the value of therapy services before the patient even sees the therapist?

Your front-office staff can start by helping the patient understand what physical therapy actually is—after all, this may very well be that patient’s first time receiving therapy. This may entail allaying fears, concerns, and apprehensions—as well as describing how therapy services positively impact specific conditions or injuries (see the question and answer above). Your front office staff could also provide logistical support—such as clear directions and accurate information about available parking—set clear expectations regarding visit length, and provide additional education and/or resources that will help the patient prepare for his or her first appointment.

What’s the best way to set appropriate expectations with patients who want to know how many visits it will take to reach their goal?

In some cases, you may have an idea of how many visits it usually takes to address a specific condition. However, it’s imperative that you tell patients that there is no guarantee; each individual is unique, as is each injury or condition. This may also be a good time to discuss the importance of remaining engaged in their care and complying with all home exercise prescriptions—as that will surely enhance recovery time.

How can we keep patients engaged in their care?

Patient-reported outcomes data can be an absolute game-changer when it comes to improving patient engagement. Patient satisfaction information empowers you to not only identify—and address—potential problems before patients bail on their treatment, but also engage your patients in the treatment process. In fact, the act of collecting and discussing patient-reported outcome measures (which translate into patient progress) is a great way to foster patient engagement.

How important are engaged patients?

Engaged patients typically achieve better outcomes. It’s a wonderful cycle. After all, these patients:

  1. Are proactive vs. reactive about their health;
  2. Are invested in their treatment;
  3. Recognize that their actions outside of treatment impact their health outcomes; and
  4. Understand the value of their treatment with regards to their overall health. (In other words, they see a direct connection between their treatment and their health status—in both the short and long term.)

That’s why it’s so important to fully explain conditions to patients (in terms they can actually understand), involve them in the creation of their care plans, and highlight improvement as they progress toward their goals. It’s also crucial to explain that if patients don’t complete their therapy, they run the very real risk of incurring additional costs associated with treating their unresolved issues, such as pain medications, ER visits, repeat MD visits, and imaging—not to mention the pain and frustration that go along with an untreated condition or re-injury. In other words, be sure your patients are fully aware that your services are a great investment—both for their health and their pocketbooks.

How else can outcomes data help us demonstrate our value?

With a solid outcomes data collection game plan, you’ll know exactly how your clinic is stacking up to the national average for each outcomes test. Then, you can use that data—which essentially conveys how much time and money your patients save by receiving treatment in your clinic instead of anyone else’s—to better market yourself to potential patients and referral sources. And even if you don’t land at the top of the heap, you’ll know exactly where you have room for improvement—and that can be a huge motivator for you and your staff to kick it into gear. You could also use this information strategically: for example, if you see that your therapists are knocking it out of the park for low back pain patients—but are barely reaching par for treating shoulder injuries—then you could concentrate your marketing efforts on bringing in more low back pain patients while simultaneously working to improve your shoulder programs. Now, that’s what we call leveraging your strengths.

Which outcome measures should I be using to show my value?

You should be using outcome measures that are broadly applicable—thus allowing you to make comparisons both inside and outside of the therapy realm. Furthermore, your OMTs should be risk-adjusted. That way, you can ensure your comparisons are accurate despite differences in patient demographics or case complexity. And as Charlotte Bohnett explains here, this allows you to provide an accurate representation of the quality of your care—regardless of the complicating factors associated with any one case. This blog post covers some of the top outcome tools that fit the bill on those fronts.

Is there an outcomes tracking software you recommend?

We highly recommend WebPT Outcomes, as it not only features measures that meet all of the above criteria, but also provides a suite of data analysis tools to help you distill your data into meaningful, actionable information. Plus, all of the OMTs are built into the documentation piece of the software, making it easy for you to enter scores as you complete your notes. Check out this page to learn more and see WebPT Outcomes in action.

Understanding the Current Healthcare Landscape

What’s going on with HDHPs?

To give you an idea of just how much of a brunt patients are having to bear with high-deductible health plans, a CNBC story reported that the average deductible for a bronze plan from the federal healthcare exchange in 2015 was $5,181 for an individual and $10,545 for a family. Silver plans—which, according to CNBC, are “by far the most popular plans sold on those exchanges”—had average deductibles of almost $3,000 for individuals and $6,000 for families. And the growing popularity of high-deductible plans (or HDHPs) isn’t limited to the federal exchanges at all: according to Becker’s Hospital Review, in 2015, “more than 24 percent of individuals participating in employer-sponsored coverage chose HDHPs, up from 20 percent in 2014.” The article also notes a study showing that “44 percent of employers are expected to offer HDHP as the only benefit option for employees within the next three years.”

How is the ACA impacting the current healthcare landscape?

As it stands now, under the ACA, insurers must provide patients with a three-month grace period for premium payments. So, if a patient misses a premium payment, the insurer is legally required to keep the coverage active for three months from the date of the missed payment. The catch? Well, the insurer is only required to pay benefits during the first month of premium delinquency. After that, while the patient is still technically “covered,” the insurer is allowed to:

  • Hold off on paying claims until the patient pays the premium owed, and
  • Deny all claims for services provided during the second and third months of delinquency (if the patient never pays the balance owed to the plan).

At that point, providers can seek payment from the patient directly, but if you have any experience with collections, you know how much of an uphill battle that can be. Perhaps the craziest part of the deal: patients who fail to pay outstanding balances with their insurers can enroll in new plans as soon as the next open enrollment period begins.
That means it pays—literally—to be extra vigilant about streamlining and optimizing your entire billing process, from the moment a patient calls to schedule an appointment to the minute you send a claim out the door. Specifically, we recommend developing a patient payment policy—and then communicating and strictly enforcing it.

What specific solutions are PTs using today to deliver telehealth—or telemedicine—services?

It’s tough to comment on the specific solutions that PTs are using on the telehealth services front, mainly because Medicare and many private payers don’t include PTs, OTs, and SLPs on their current lists of approved telehealth providers. This, of course, prevents therapists from easily billing for these services, because there are no specific, PT-focused CPT telehealth codes on the books. To learn more about the use of telehealth in rehab therapy, check out this blog post.

Incorporating Cash-Pay Wellness Services

Should we start providing cash-pay wellness services now?

Providing cash-based services is a great way to counteract the effects of weaker insurance plans. For information on pricing, I'd recommend checking out this blog post from Dr. Jarod Carter. Just be sure to reach out to a healthcare attorney who’s familiar with your state practice act before adding cash-pay services into your repertoire.

Are PTs well positioned to provide wellness services?

Yes! Because rehab therapists are dedicated to helping their patients restore optimal function and improve their quality of life, therapists are perfectly positioned to pivot toward—and capitalize on—health and wellness services. Fitness-related programs, holistic health interventions, dry needling, wearables, and telehealth all integrate seamlessly into the spectrum of rehab therapy services. And—even better—patients are willing to pay cash for these services. In fact, it’s a $34 billion market.

What is the APTA’s stance on wellness services?

The APTA is totally on board with PTs offering these kinds of services. In fact, the organization released a statement affirming that it “recognizes that physical therapists are uniquely qualified to assume leadership positions in efforts to prevent injury and disability, and fully supports the positive roles that physical therapists and physical therapist assistants play in the promotion of healthy lifestyles, wellness, and injury prevention.” The APTA also encourages PTs to “act as advocates for physical education, and for physical conditioning and wellness instruction.”

Is there anything else I should know before providing wellness services in my practice?

Before you add these kinds of services to your repertoire, you should absolutely speak with your malpractice insurance carrier to ensure you have adequate coverage. You should also consider reaching out to several different experts—including an accountant, attorney, and insurance professional—who know your state’s laws to make sure you understand which wellness services fall under the scope of practice allowed in your state and which services fall under your practice’s scope of competence. In some cases, you may need to create a separate limited liability company to run your wellness programs.

Can we accept cash payments from commercially insured patients who have exhausted their benefits?

You may. Now, as to whether or not you still need to submit a claim to that patient’s insurance company, that depends on the terms of your contract.

How should I go about providing and pricing cash-based services for in-network patients?

As Dr. Jarod Carter explains here, “There are certain things that must be kept in mind to ensure you are not violating your contracts with insurers, and possibly breaking state laws.” We recommend reviewing Carter’s full post to ensure you cross all your t’s and dot all your i’s before providing self-pay services to any in-network patients.

In terms of Medicare patients, once services are deemed not medically necessary or the patient reaches the therapy cap ($1,960) but wants to continue care, are we able to charge less than the Medicare fee schedule rates? Can we discount charges at this point?

If you feel your services are no longer medically necessary, but the patient wishes to continue therapy, then you can provide therapy to the patient on a self-pay basis (i.e., have the patient pay out-of-pocket). However, you must first issue the patient an ABN—as explained in this blog post—and submit the claim to Medicare with the GA modifier. This should prompt Medicare to deny the claim, at which point you can collect payment directly from the patient. You will need to apply this modifier for every visit (i.e., each time you submit a claim). With regard to pricing, non-covered services (i.e., prevention, wellness, or fitness services) can be priced at whatever level the market will support. However, if you’re continuing skilled therapy care on a “maintenance” basis, you should not drop the pricing too far below the Medicare fee schedule, as doing so may put your practice at greater risk of an audit. That being said, if you choose to do so, it’s probably best to provide these reductions as same-day payment discounts.

Going Out-of-Network

When should I drop a payer?

It can be a very tough decision to drop a payer—and it’s certainly not something that should be done without a plan, because that could cause a dip in revenue. But if you’re accepting patients from a payer that isn’t paying you enough to cover the clinical costs associated with seeing those patients, then you’re losing money every time you see that payer’s patients. Often, providers will try to make up the cost difference by either increasing the volume of patients they see or reducing total patient treatment time or care episodes, but none of those decisions are based on what’s best for patients; instead those providers are making concessions to their treatment plans that essentially reduce the quality of the care they’re providing for all of their patients.

When is becoming an out-of-network provider a good idea?

Becoming an out-of-network provider is often a better solution in situations where you’re not receiving enough money from your payers to cover the costs associated with a patient visit. That way, you’ll have more freedom to negotiate with the patient—which you don’t have when you’re under a payer contract—to reach a fee that works for the patient and brings in a profit above the cost of a visit. Plus, when we look at the bigger picture, it’s better for our profession to not lower the price tag on the services we provide. In order to demonstrate our value to our patients and the rest of the healthcare community, we first must own it for ourselves.

How do we convince out-of-network patients to stay?

Clinics may adopt their own strategies on this front, but ultimately it comes down to demonstrating your value—and not being reticent about marketing that value—using outcomes data. That way, you’ll have verifiable proof to show patients that you provide better outcomes at a lower cost. Bottom line: Sell yourself with confidence and with data.

Can you treat out-of-network patients the same way you treat self-pay patients?

Not exactly. Your self-pay rates should only be used for individuals who have no insurance or for those who have exhausted their benefits. For out-of-network patients, you must adhere to the parameters that are set by the insurance carrier, which means you must still be familiar with that insurance carrier’s contract. That being said, as an out-of-network provider, you typically have a lot more room to play in terms of what you can charge overall—and therefore what your out-of-network patients and payers will end up paying.

How does coinsurance work for out-of-network providers?

According to HealthCare.gov, coinsurance for out-of-network providers is “the percentage (for example, 40%) [patients] pay of the allowed amount for covered health care services to providers who don't contract with [their] health insurance or plan. Out-of-network coinsurance usually costs...more than in-network coinsurance.”

We’ve heard that some of our patients’ insurance companies call our patients to tell them not to use an out-of-network provider. How do we combat this?

The best way to ensure your patients are committed to receiving your care—regardless of your network status—is to consistently demonstrate your value by providing exceptional clinical care and a wonderful patient experience. That way, should one of your patients receive a call from his or her insurance company, the patient will be well equipped to explain why he or she has no intention of seeing anyone but you. You can also check out this FAQ to learn how cash-based PT Ann Wendel responds to clients who tell her they want to use in-network therapists.

As an out-of-network provider, may I charge the patient the entire cost of their visit and then bill their insurance company so the patient receives reimbursement? If so, how do I determine what to charge?

According to Ann Wendel, “As an out-of-network provider for third-party payers, you can charge whatever the market bears in your town/city.” Each insurance company will reimburse the patient according to its own fee schedule, and each insurance company has a “different rate of reimbursement for different codes.” Thus, what the patient receives from his or her insurance company will differ depending on his or insurance policy. Wendel notes that “as a provider, you do not have control over what the insurance reimburses, only over what you bill/receive as payment from the patient.”


Wow—talk about insurance information overload. Still scratching your head? Leave your question in the comment section below, and we’ll do our darndest to answer it.

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