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March 7th, 2017

Navigating the Insurance World

Let’s face it: insurance is confusing. Our goal at Finish Line Physical Therapy is to make the process of understanding your insurance benefits as simple and hassle-free as possible. After all, your job of recovering from injury and achieving your goals is hard enough. Why make it even harder by worrying about what your insurance policy may or may not cover? We’ve got your back.

Our insurance team is here to proactively check your insurance details so you know your coverage before you walk in the door. Having a conversation with you in advance is important to us because we understand that each individual’s situation is different.

If you want to get a head start on understanding some of the more confusing aspects of the insurance world, here are some of the most common questions people ask. Still have questions? Give our office a call at (212) 486-8573, and we’ll connect you with our Insurance Coordinator.

What is the difference between an “In Network” Provider and an “Out of Network” Provider?
An In Network Provider has a contract with an insurance company in which that clinic is funded BY the insurance company. This means the insurance company has complete control over how it’s run and what treatment is provided. There is no wiggle room for negotiations, and whatever they want you to pay (deductible, copay, etc.), you pay fully to them. The insurance company places restrictions on the clinic based on what it believes is best without having the knowledge of each patient’s needs – but as you can imagine, money is the motivating factor in the end. This, of course, restricts a patient’s recovery at times, especially when it’s not an individualized treatment plan that a patient may need.

An Out of Network clinic such as Finish Line funds itself. This means we provide individual treatment based on each patient’s needs/wants and not based on what an insurance company believes will bring in the most money. When you choose to go to an Out of Network Provider, your insurance company is responsible for funding you to go there, and they have no say in the kind of treatment being provided. You’re responsible for paying what the Out of Network Provider rates are – not what the insurance company tells you.

I’ve also heard the terms “Participating” and “Non Participating.” What does that mean?
Another example of confusing insurance company language. They mean the exact same thing as in and out of network. Participating = in network; non participating = out of network.

Can I go in network through Finish Line PT?
No, we are out of network with all insurances, which is much better for our patients. Read on for the reason WHY this is ultimately the best option for your care (even if it doesn’t always seem like it).

Why does Finish Line PT choose to be an Out of Network Provider?
We choose to remain out of network to maintain the highest quality of care for our patients. We provide 45-minute, one-on-one treatments with the physical therapist in which an individualized program is developed WITH you based on what you need for your specific injury, prehab or recovery.

In Network Providers are restricted by what an insurance company wants them to do. They need to see a certain number of patients per hour, which leads to less one-on-one time per session. They’re also guided on what type of treatment to do for an injury, as opposed to developing a program based on each individual patient’s needs.

I’ve heard terms like “deductible” and “co-insurance” before. What do those refer to?
Deductibles are placed at the beginning of any plan (similar to auto insurance plans) so the insurance company can see a certain amount of medical expenses being submitted before committing to covering anything else for the year. They want to make sure you’re committing before they commit.

Co-insurance tells you what percentage they will cover after that deductible is met and what percentage you will be responsible for. An example would be a co-insurance of 80-20%, meaning that your insurance covers up to 80% of the claim while you may be responsible for up to 20%.

(If this is still confusing, don’t worry – we can clear up any questions you have in a conversation with our insurance coordinator.)

How is my deductible met, and how much will I be responsible for?
Your deductible is met once your claims for each visit are processed by your insurance company, and when the amount of medical expenses matches the deductible amount in full. Once this happens, your insurance will begin paying for your visits. Your responsibility depends on the information our insurance coordinator discusses with you in detail before your first appointment. We don’t want any surprises!

Will my insurance company reimburse me if I don’t have an out of network policy?
No. Because we are an Out of Network Provider, your claims will be denied if you only have in network coverage.

I’m in the process of picking a new insurance plan. What should I look for?
The specific detail to look for when choosing a policy is a plan that has “Out of Network Physical Therapy” coverage. The next step is comparing plans according to what you can afford and how often you think you will be using it throughout the year. What is the deductible amount, co-insurance and visit limit for physical therapy?

As a courtesy to anyone who’d like to come to Finish Line, we will help you through this process either by walking you through the information you may have received, or by calling your insurance company for the specific details after you have chosen a policy. We are always here to help – just give us a call!

Our ultimate goal is to help our patients to achieve their goals, which also includes understanding all aspects of their patient care and insurance policies. Once you become a patient with us you are considered part of the team, part of a larger family that works tirelessly to help you cross whatever finish line you are training for.

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