Insurance Information

 

Understanding Basic Insurance Terms

*Please note that as a courtesy, EverFit Physical Therapy will make every effort to verify your insurance benefits prior to your first appointment. However, it is often helpful if you have a full understanding of your benefits because the patient is ultimately responsible for this knowledge, and will be billed accordingly. If you are not sure of your physical therapy benefits, we suggest that you contact your insurance company directly.


In-Network vs. Out-of-Network

Each insurance plan provides certain coverage to a patient if he/she sees specific providers (doctor’s, physical therapists, etc.) that are listed “in the network”. As long as you choose one of these providers, you will be eligible to use your in-network coverage. Some plans will not provide any coverage if you do not choose an “in network” provider. Others do allow patients to see a provider out-of-network, but a different set of benefits will apply.

At EverFit, if you have an insurance plan that our office does not participate with, your first question to your insurance company would be, “Do I have out-of-network benefits?”. If the answer is yes, “what are they?”. If the answer is no, you are still eligible to be treated for physical therapy on a “cash” basis.

Deductible

Many plans require that a “deductible” be paid for the year before the insurance company will begin to pay for services. EverFit will bill the patient’s insurance company, and they will determine if this deductible has been met. If it hasn’t been met, the insurance company will not issue payment to EverFit, and the patient will be billed accordingly. The patient’s insurance company will keep track of the amount the patient has paid out of pocket for the deductible, and once the deductible has been met, they will begin to pay for services less the co-insurance or patient copay per patient’s benefit plan.

Copay

Many insurance plans require a copay for each visit. The amount due each visit should be listed on the front of the patient’s insurance card. Some require one amount for a visit to a primary care physician and a different amount for a visit to a specialist. A physical therapist is considered a specialist, so this would be the amount due for each visit if required by your plan. In some cases, you will be required to satisfy a deductible (see above) before beginning to pay only a copay each visit.

Co-insurance

Many insurance plans require a co-insurance to be paid out of pocket for each visit by the patient. For example, if your co-insurance is 90/10, the insurance company will cover 90% of the charges for each visit, and the patient is responsible for the remaining 10%, which usually comes out to approximately $15/visit at EverFit Physical Therapy. As with a copay, in some cases your insurance company may require you to satisfy a deductible (see above) before they will begin to make payments to EverFit. The patient will be held responsible for any remaining.

Referral

Some insurance plans, especially HMO plans, require a referral from the patient’s primary care physician to be issued before the first physical therapy appointment. You simply call your primary care office, and ask for the referral department. You will let them know you need a referral for physical therapy at EverFit Physical Therapy. Some offices require 3-5 days to process referrals, so make sure to give yourself enough time before your first appointment with EverFit.

Authorization

If your plan requires only authorization, you will not need any documentation before the initial visit to EverFit. However, after the initial visit, the physical therapist will issue a report to your insurance company, and will request a certain number of visits for treatment. Our office must then wait for approval for these visits, although the patient is still able to schedule his/her appointments. This process is often repeated several times until the point that the physical therapist can no longer justify additional treatment. The patient is not required to do anything on his/her part, but should be aware that occasionally the visits may need to be varied according to the authorization granted by the insurance company.

Visit Limit

Some insurance plans limit the number of visits allowed per year or per condition. For example, if you have a “30 visit max” for physical therapy, you will only be covered for 30 visits total for the year (or per condition), regardless of medical necessity.

Out-of-pocket max

The out-of-pocket max is often just how it sounds; the maximum amount you will be required to pay out in cash for the year in deductibles, copays, and co-insurance.

Medicare Cap

The “Medicare Cap” is the amount of money Medicare allows for payment of physical therapy per year. This CAP amount for 2008 is $1,810. This amount often covers approx 4-10 weeks of treatment. Medicare has allowed for “exceptions” to the CAP. Exceptions are based on medical necessity which will be determined by your Physical Therapist. At EverFit, we keep very close track of the dollar amount used for our patient’s treatments. When necessary, patient will be changed to our Medicare Exception list.

Understanding Medicare

*The staff at EverFit will do everything they can to help you understand your Medicare coverage, and to use this coverage to offer you the best care possible.

Do I need a prescription from my doctor to attend physical therapy if I have Medicare coverage?

You may technically attend your initial evaluation for physical therapy without a prescription from your doctor. The physical therapist will send a report to your doctor after your initial evaluation, and will need it returned and signed in order for Medicare to approve payment to our facility. This is why we recommend that you notify your physician prior to your first visit and make sure they are aware and approve of your need for physical therapy.

How much will Medicare cover for each visit? Will I have to pay anything?

After your annual deductible has been satisfied, Medicare will cover 80% of the Medicare Fee Schedule. However, if you have secondary insurance, they will often cover most if not all of the balance not covered by Medicare. You should always be aware of your secondary insurance coverage, and whether or not it covers the deductible, as well as how much of the 20% remaining charges it covers.

Is there a limit to the length of time I can attend physical therapy throughout the year?

There is a limit on the amount Medicare will cover for each calendar year, which currently stands at $1,810 for 2008. This amount can cover anywhere from 4-10 weeks of treatment, depending on the condition treated There are some cases where the physical therapist may request an exception to this limit, and continue treatment when deemed “medically necessary”.

How will I know if I have reached this limit?

You should always alert EverFit Physical Therapy if you have already had physical therapy at some point during the calendar year. The staff at EverFit will verify your coverage with Medicare, and will document the amount of physical therapy you have already used. We will carefully track your usage from that point on, and will alert you when approaching the limit.

I am currently being treated in home care, but I know I will be ready for out-patient physical therapy in the next week or two. Can I schedule my appointment now?

You may schedule your appointment with EverFit as soon as you are certain you are about to be discharge by your home-care physical therapist. You must be signed out of home-care, and Medicare must be alerted before they will begin to cover out-patient physical therapy.

Understanding Workman's Compensation
and Auto Accident Coverage


*EverFit will work closely with your case manager to ensure you receive the necessary care to improve or resolve your condition, and return you to work or daily activities.

We will need to know your case managers name, phone number and fax number. We will also need to know the name, address, phone number and contact name of your Employer. After you have been injured in an accident, you know you need to notify your auto insurance company. In the State of New Jersey, when renewing your auto insurance policy you chose your medical or auto insurance company to be your primary or secondary insurance. This is why we always need not only your auto insurance information, but also your medical insurance information. When you make your appointment, we need you to inform us which company you chose as your Primary Insurance Company and which you chose as your Secondary Insurance Company. Make sure you understand your auto insurance policy. You may have picked a higher deductible or co-insurance to help keep your auto rates lower. If you did, remember, this amount would not be covered by your auto insurance until you satisfy your plan. We are able to bill your personal medical insurance for remaining balances not paid by your auto insurance. Depending on your personal medical insurance, this may supply you with additional medical

 

Insurances Accepted @ EverFit

Aetna (Out-of-network only)
AmeriHealth Administrators
AmeriHealth Casualty
AmeriHealth, Inc.
Bankers Life & Casualty
Blue Cross/Blue Shield
Cigna
Consolidated Services Group
CHN PPO
CHN Managed Workers
Compensation
CHN PPO Auto
Federal Employee B/C B/S
First Managed Care Options
GEICO Companies
Health Net
Highmark Blue Shield
Horizon
Horizon Casualty
Humana Medicare		 Independence B/C B/S
Intergroup Network
Liberty Mutual
Medicare
Medrisk
Motor Vehicle Insurance–
(we always call to verify)

National Education Association
OrthoNet– Cigna Open Access Plus
Oxford
Personal Choice
QualCare
Railroad Medicare
Travelers
Tricare
United Healthcare
US Department of Labor

Workman’s Compensation -
(we work closely with your case manager)




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