​Understanding Your Healthcare Benefits

Networks

Insurance Network- A group of providers who have a contract with an insurance company to accept a reduced rate for rendered services in order to see patient's with with a particular plan.
- In-network provider- A provider within an insurance network, who is bound by a legal contract to accept a reduced rate for a fixed list of procedures that the insurance will cover. Providers are legally required to collect all fees required/outlined by the insurance plan.
- Out-of-network provider- A provider who does not have a legal contract with a insurer. Some insurance plans, as seen below, have coverage for out-of-network providers. Typically, these plans pay a percentage of the billed amount. Those that do not have out-of-network benefits, will be responsible for 100% of the billed amount or a selected self-pay rate.

Types of Plans

PPO- Preferred Provider Organizations- These policies cover practitioner inside and outside of the plan's network, however it is typically less expensive to see a practitioner that is in network.
HMO- Health Maintenance Organization- These policies cover providers only within the plan's network, and often require a referral from the patient's primary care doctor to be seen by a specialist.
EPO- Exclusive Provider Organizations- These policies are a typically similar to HMOs in that most do not cover provider's out-of-network, however they often do not require a referral from your primary care physician
POS- Point of Service- These policies highly vary, but are somewhat of a hybrid between PPOs and HMOs. They may require a referral, but may have some out of network benefits. Typically these plans require the policy holder to pay a larger portion of the out of network expense compared to other plans.
Medicare Part B- this plan covers outpatient services for the disabled and those of retirement age at a rate of 80% with the subscriber responsible for the remaining 20% after their $183.00 deductible has been paid. Most often, those with Medicare have a secondary insurance which pays the remaining 20% and no additional cost is passed along to the patient. Many times secondary insurers with cover the full amount if Medicare benefits have been exhausted. Medicare requires a referral or a signed plan of care by a physician for physical therapy benefits to be used.
Worker's Compensation- this is a coverage plan is paid for by your employer, or possibly yourself if you own a business. These plans cover 100% of all costs of care, and there is no copay or coinsurance for the patient. Treatment is limited to particular in-network providers like an HMO. Often these plans will have different contracted rates with healthcare providers, and patient's will be pushed towards providers that except lower rates, however they are entitled to see any provider within the network. Patients with with poor compliance to their treatment prescribed by the supervising physician may lose benefits to receive further services or may have their pay held by the worker's compensation insurance.
Motor Vehicle Insurance- Motor vehicle insurance covers those injured in car accidents, and typically requires a prescription from a physician, physician notes, and precertification before physical therapy services can be rendered beyond an evaluation. These plans require a deductible to be paid, and very specific guidelines to be followed to receive care.

Consumer Costs

Insurance premium- the money you pay for policy coverage before any healthcare benefits are utilized. This money is typically automatically taken from your pay check, social security check, or paid by your employer as a benefit.
Deductible- A fixed out of pocket amount the patient must pay beyond their premium prior to their insurance policy covering any costs of care. Most plans have individual deductibles and family deductibles. Individual deductibles are less than a family deductibles, and the patient is responsible for paying each family member's individual deductible prior to insurance coverage. The patient is no longer responsible when the individual's deductible has been met, or when the sum of all family members deductibles to date have met the family deductible. When the family deductible is met patient's will only be responsible for a copay or coinsurance based on their plan. Deductibles reset to a $0 balance every year with most plans resetting on Janauary 1st.
Copay- this is a fixed rate you pay for a service on each occasion the service is rendered after any deductible has been met. Co-pays vary dramatically between plans, and their are typically different rates for offices vs facilities as well as for specialists.
Coinsurance- this is a fixed percentage of the total cost of service that the patient is responsible for each time they use benefits. It works like a copay, but the greater the expense of the visit, the more the patient is responsible for.
Out-of-pocket-max- this is the maximum expense the patient or patient's family is responsible for in a year's time. Once this amount has been met, the insurance will cover 100% of all costs with no further deductibles or copay/coinsurance.

Direct Access to Physical Therapy

Direct access means that you can seek out a physical therapy provider without having to first see a physician. Physical therapy has been accessible via direct access per New Jersey state law since 2003 despite limited consumer knowledge.

Direct access has been shown to dramatically cut the cost of healthcare utilization for both consumers and insurance companies. One study conducted over the course of a year for those with back and neck pain, demonstrated that those who saw PT first saved $1,543.00 on average and both groups saw clinically important improvements. Another study showed those who get imaging studies done first, typically spend $4,793.00 more on their course of care.

Not only is there a cost savings for a course of care, physical therapists have been shown to be comparable to orthopedic surgeons for diagnostic accuracy when assessing compared to MRI findings.