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The health insurance representative told my patient that she has a $30 dollars copay per physical therapy visit. That seemed simple enough, and she started coming for treatment and feeling better.

A Few visits later, after the insurance processed some claims, she learned that the insurance is not covering any of the cost! They informed her that she has a $1000.00 deductible, and that she would have to meet that first before receiving any insurance coverage for services.

So what happened there? How did we go from $30.00 copay to a $1000 deductible?

Well, let me explain.

The structure of insurance benefits varies from plan to plan. To make things more confusing, even within the same plan, there can be many choices depending on the type of care or provider you seek.

Here are the basics:

–Premiums, they are universal. No matter what your plan is, you will have them. They are the monthly dues that you have to pay to get the insurance policy

— Deductibles, are often a cause for confusion. They refer to the monetary amount that patients have to pay out of pocket before the insurance begin paying for rendered services. The catch is the following—the amount of a yearly deductible often depends on whether you are seeing an in-network versus out-of-network providers. Generally speaking seeing an in-network provider is associated with lower deductibles. However, you have to adhere to the insurance list of participating providers. That being said, patients like to go to the provider of their choice even if they are out-of-network. Don’t be discouraged by the higher deductible. Often seeing an excellent provider will yield better results and have you returning less often, saving money and your health that way. So consider the deductible, but know your options and work with the provider you choose to arrange for payment or pace the visits so you are not basing your choice on cost over quality.

–Copays, is a fixed fee you pay when you visit your doctor or other specialists

— co-insurance, is a fee that you pay per office visit, however, unlike a copay, it is a percentage of the charges incurred during the visit. For example, the insurance may cover 80% and the patient covers the remaining 20%

Hope this will help you navigate the maze of benefits and fees of health insurance. Please share your thoughts and questions.

Perhaps if there is interest we can go over what questions a patient should ask when speaking to the health insurance representative.

Till next time.


@Vital Physical Therapy

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