Frequently Asked Questions

Q. What happens during my first visit?
A. During your first visit:
1.) Arrive thirty minutes early to fill out all of the required paperwork.
2.) Remember to bring your prescription for physical therapy, a photo identification card and your insurance information and/or card.
3.) A physical therapist will then perform an examination which can include, but not limited to, a detailed medical history screening and an objective evaluation that measures and evaluates your strength, range of motion, posture, functional mobility, and neurological functioning.
4.) From the evaluation, the physical therapist can determine the problems that need to be addressed. The patient, the physical therapist, and the physician will devise a plan to help treat the problems. Treatment will promptly follow the evaluation.

Q. Will my insurance pay for treatment?
A. Most insurance plans cover outpatient therapy. Some plans require the patient to pay a co-payment for each visit. Please contact your insurance carrier for specific coverage information.

Q. Do I need to be referred by my doctor?
A. All treatment paid for by insurance carriers requires a physician referral.

Q. What information do I need to bring with me to my first visit?
A. On your initial visit, please bring your physician referral, your insurance card, photo identification card, and any other appropriate billing information.

Q. How long does each session last?
A. Each physical therapy session time is variable and dependent on your condition. However, appointments typically last between 30 and 60 minutes.

Q. I heard physical therapy is painful. Is this true?
A. In order to accomplish your goals, some physical therapy techniques can be painful. It is important that you communicate with your physical therapist so that the treatment can be adjusted accordingly.

Q. What do I wear to my physical therapy sessions?
A. You should wear loose and comfortable clothing so you can expose the area that we are evaluating and treating. If you are coming for lower-extremity treatment (i.e. knee, hip, leg, etc.), shorts and sneakers will be needed. If you have an upper extremity ailment (i.e. shoulder, elbow, etc.) please wear clothing that will expose the area to be treated. Private rooms are available to change into and out of your treatment clothes.

Q. Will I get a massage?
A. Depending on your condition, the physical therapist may incorporate massage into your treatment session.

Q. Are all physical therapists licensed?
A. All physical therapists and physical therapy assistants are licensed in the state that they are practicing.

Q. Will you communicate with my physician regarding my physical therapy care?
A. Your physical therapist is in frequent contact with your physician. After your initial evaluation, a consult summary is sent directly to your physician. Re-evaluations are conducted on a regular basis and progress notes are sent to the physician.

Q. How many times a week and for how many weeks will I have to come?
A. Frequency and duration of treatment will be determined by your physician or after the initial evaluation by your therapist. The typical frequency is 2-3 times per week.

Q. How will I handle my problem at home?
A. Your plan of care will include exercises to be performed independently at home.


BILLING & INSURANCE FAQ

It's important to understand what's included in your policy before you advance too far in any medical treatment. Some policies provide coverage for many medical treatment/procedures while others are more limited in coverage. Read your policy and benefits manual carefully and discuss any questions you may have with your insurance plan manager.

We ask that you be fully responsible for knowing the specifics of your particular insurance contract. Examples of these specifics include co-pays, deductibles, second opinions, preauthorizations, preferred providers, covered and non-covered services and preferred hospitals.

There are three typical cost sharing options:

deductibles are provisions that require the member to accumulate a specific amount of medical bills before benefits are provided. For example, if a member's policy contains a $500 deductible, the member must accumulate and pay $500 out of pocket before the insurance carrier will pay benefits. Once the patient has met their deductible, the carrier usually pays a percentage of the bill. The patient is liable for the unpaid percentage. Deductibles are yearly, usually starting in January. In an insurance policy, the deductible or excess is the portion of any claim that is not covered by the insurance provider. It is normally quoted as a fixed amount and is a part of most policies covering losses to the policy holder. The deductible must be "met", that is, paid by the insured, before the benefits of the policy can apply. In a typical automobile insurance policy, a deductible will apply to claims arising from damage to or loss of the policy holder's own vehicle, whether this damage/loss is caused by accidents for which the holder is responsible, vandalism or theft. Third-party liability coverage generally has no deductible, since the third party will likely attempt to recover any loss, however small, for which the policy holder is liable. Typically, a general rule is: the higher the deductible, the lower the premium, and vice versa. "

a flat-rate copayment, reflects a defined share of covered medical costs that the patient pays, with the insurance carrier paying an amount based on the patient's policy. For example, when the patient pays $15 of any office visit charge or $3 for any prescription, the insurance carrier is responsible for the balance. "

a percentage-based copayment, reflects a percentage share of covered medical costs that the patient pays, with the insurance company paying an amount based on the patient's policy. Examples are: 20% of the office visit charge - $10 of a $50 charge, $12 of a $60 charge, etc. Typically, this copayment arrangement includes a deductible and may have other variations.

Your benefits administrator will be able to explain these points to you. Be certain that all patient financial responsibilities are understood before starting any medical treatment. If you can calculate your costs based on the terms of your insurance plan, there will be no misunderstanding later of your obligation.

Q. What does "contracted" insurance and allowables mean?
A. "Contracted" insurance means that we have agreed to accept that particular insurance company's fee schedule for payment of our services. Allowable is another term used for this. Although we accept the insurance allowable, there is usually a portion, percentage, deductible or co-pay for which the patient has financial responsibility.

Q. What's the difference between "in network" and "out of network" providers?
A. Many managed care plans (HMOs and PPOs) pay different levels of coverage for healthcare services, depending on whether a healthcare provider is considered in network or out of network. The managed care company will pay a higher percentage of the costs for an in-network hospital or physician. If you choose to receive care from a provider that is out of network, your managed care insurer will pay a lower percentage of the costs and you may be responsible for a higher amount of out-of-pocket payment. We recommend checking with your insurer for the specific requirements of your insurance plan.

Q. Who is responsible for payment and follow-up with the insurance company?
A. If you are 18 or over, you are legally responsible for your own account, regardless of who you live with, who has the contract with the insurance company or who claims you as a tax deduction. If the patient is under 18, BOTH parents, despite divorce or other separating agreements, or the legal guardian are responsible for payments.

Q. What is the difference between an HMO, PPO, POS, and EPO?
A. HMO stand for Health Maintenance Organization. An HMO is a group that contracts with medical facilities, physicians, employers and occasionally individual patients to provide medical care to a group of individuals.

PPO stands for Preferred Provider Organization. As a rule, you must select a primary care physician (PCP) who is under contract with the PPO. If you choose a doctor not under contract, you pay more. Like an HMO, you usually pay a small amount known as a co-pay each time you visit your PCP or health-care facility. Unlike an HMO, if you choose to see a doctor who is not contracted with the PPO, the plan might pay a percentage of the medical bills (out-of-network benefits). However your cost will probably be higher than if you choose a caregiver that is in the plan's network.

Point of Service (POS)/Tiered Plan - Health coverage that allows the patient to utilize a variety of benefits associated with different level/tiers of coverage. The following is an explanation of the common tiered POS coverage. "

Tier 1 Level Benefits (HMO Coverage): members are assigned or chose a PCP; the PCP must manage the care. Physiotherapy Associates must obtain authorization for specialty services. Typically, patients are only responsible for their co-pays. "

Tier 2 Level Benefits (PPO Coverage): the patient may self-refer to any in-network-contracted provider without obtaining authorization from their PCP but authorization is often required from the insurance company. Patients are responsible for a deductible and a percentage of their medical costs. "

Tier 3 Level Benefits: coverage for medical care provided to POS members from non-contracted provider. Insurance payment amount is dependent on the benefit offered by the plan. Services may be denied by the insurance company as not covered and the patient is responsible for 100% of all charges. Typically the patient is responsible for a larger share of the charges.

Care provided to POS members without the required authorization from their health plan will result in the patient being financially responsible for 100% of the charges.

EPO stands for Exclusive Provider Organization, and there are two types of EPO plans:

The current industry standard requires that a patient select a Primary Care Physician (PCP) (some patients may only have to choose a medical group) and when needed obtain authorization from that PCP to receive specialty services. A patient must stay within the contract network and only use preferred providers. There typically is a lifetime policy maximum with this type of plan. In the event a patient goes out of network (OON) they may be responsible for the entire balance that is not paid by the payer associated with the services provided. "

The other type of EPO is one where the benefits are those of a PPO but the provider panel from which members obtain care is smaller than a PPO panel.

Q. What does "assignment of benefits" mean?
A. The transfer of the right for reimbursement directly to the provider of plan benefits from the insured person to a health care provider. Transferring rights allows the insurer to mail any benefit payment directly to the provider.

This legal statement is usually in the initial paperwork requested by the health care provider and may be signed by the insured person or his/her legal spouse or guardian.

Here are some common terms that are helpful when communicating with your insurance carrier and other medical providers:

Advance Beneficiary Notice (ABN): A form signed by the patient before certain services are rendered, notifying him/her that Medicare or Medicaid may not cover this service and that the patient will be responsible for payment.

Billing Statement: A summary of current activity on an account.

Claim: The information billed to the insurance company for services provided.

Coinsurance: The percentage of medical expenses an insured must pay the provider or facility for covered services. The coinsurance amount is based on eligible charges.

Coordination of Benefits: occurs when a patient is eligible for coverage by more than one insurance plan. The benefits of the plans are coordinated so that the patient may receive up to 100% coverage for his or her medical costs.

CPT Code: a code number used to identify medical services. Developed by the American Medical Association, "CPT" stands for Current Procedural Terminology. CPT codes are used by physicians in billing for services performed.

Eligible Charges (Allowed Amount): The maximum dollar amount allowed for covered services rendered by participating providers and facilities or by nonparticipating providers and facilities. Deductibles and coinsurance amounts are calculated from eligible charges. Participating providers and facilities accept this allowed amount as payment in full for covered services. Nonparticipating providers and facilities may not accept this amount as payment in full for covered services.

Exclusion: a condition or circumstance for which a health plan does not provide benefits.

Explanation of Benefits (EOB): A statement provided to the insured by an insurance company explaining how the claim was processed.

Guarantor: The person or entity who is financially responsible for payment on a patient's account. Usually the patient is financially responsible for medical charges. A parent or legal guardian/trustee is the guarantor for patient's 18 years of age and younger. This is also the case for patients with a decreased mental capacity.

ICD-9 Code: a code that indicates the diagnosis-illness, disease or trauma-for which care was rendered. "ICD" stands for International Classification of Disease. Diagnosis codes must correlate correctly with CPT codes for an insurance carrier to consider payment.

Medicare: Medicare is a federal insurance program which primarily serves those over 65 years old and younger, disabled people and dialysis patients. Medicare is divided into two parts: "

Medicare Part A covers inpatient hospital services, nursing home care, home health care and hospice care. "

Medicare Part B helps pay the cost of doctors' services, outpatient hospital services, medical equipment and supplies and other health services and supplies.

Non-Covered Services: A cost incurred by the patient when his/her insurance policy does not cover.

Out-of-Network (OON): Services rendered by a provider which does not have a contract to offer you care. Typically, managed care plans are contracted with a panel of providers. If a patient seeks care out-of-network, they may be financially responsible for some or all of the care provided. An exception to this rule is emergency medical care.

Out-of-Pocket Maximum: The total amount of eligible charges each year payable by insured directly to providers or facilities; 100 percent of eligible charges will be paid during the remainder of the year once the applicable out of pocket maximum is satisfied.

Payor: A third-party entity (commercial or government insurance carriers) that pays medical claims.

Pre-authorization letter: a letter written by a physician to an insurance company prior to surgery. It explains in detail the procedure a patient plans to have and requests confirmation that the patient is covered, the planned services are covered, and the level of coverage for the planned services.

Pre-determination: a review process conducted by an insurance company to verify the medical necessity of a planned procedure or treatment. Pre-determination is often a condition of plan payment.

Primary Insurance: The insurance primarily responsible for the payment of the claim.

Prior Authorization/Precertification: A formal approval obtained from the insurance company prior to delivery of medical services.

Secondary Insurance: The insurance responsible for processing the claim after the primary insurance determination of benefits.

Subscriber: The person who holds and/or is responsible for the medical insurance policy

Supplemental Insurance: An additional insurance policy that processes claims after Medicare reimbursement.

Worker's Compensation: Insurance coverage that is provided by employers to cover employees injured on the job. This coverage is separate from regular medical coverage.