Photograph of a physiotherapist calling an insurance company to get billing information

The 4-1-1 of Third Party Insurance Plans

September 12, 2018 | Article | By: Sara Hodgins

When a patient has third-party insurance coverage, it can be overwhelming to know what questions to ask, so many owners opt to take a picture of the patient’s insurance card, submit the claim to the insurance company, and hope for the best. But not so fast! This approach can cause delays in your billing cycle, rejected claims, and awkward conversations with your patients weeks down the road when you need to ask them for more information or tell them their services were not covered by insurance and you now need payment.

Some patients will know the details of their third-party benefits, but unfortunately, most don’t! And asking them “are you covered for physiotherapy?” just doesn’t cut it. Luckily, you can call their insurance company and with the patient’s permission, ask all of the questions that you need to ensure you and your patient aren’t going to get any surprises down the road. Here are 9 simple questions to ask your patient or their insurance company!

  1. Does the plan cover the services offered at your clinic (for example PT, OT, DC, MT or orthotics)?
  2. Is the coverage combined for paramedical or separate? Combined coverage for paramedical services would mean that the patient has a set dollar amount (let’s say $500) that they can use for physiotherapy, massage therapy and chiropractic services together (so a total of $500 that they can use in any combination of those services). Whereas separate coverage means that they have a set dollar amount (again let’s say $500) that they can use for physiotherapy, massage therapy and chiropractic separately (for a total of $1,500 coverage, but only $500 can be used in each of the 3 services mentioned).
  3. Is there a deductible and if so how much? A deductible is something that the patient needs to pay before the insurance company will cover anything. So, if they have a $50 deductible and their initial assessment is $100, you should collect $50 from them at the time of their assessment and direct bill the insurance company to get the balance.
  4. Is there a visit coverage limit? Some plans will only cover up to a set dollar amount per visit (usually they cover more for the initial assessment). So if you charge $100 for a PT visit, but their plan deems that ‘the reasonable and customary amount’ is $80, they will need to pay the balance of $20 each visit
  5. Is there a co-pay amount? Co-pay is a balance that the insurance company will not cover and the patient needs to pay it instead. For example, the company may only cover 80% of the visit, so the patient will need to pay the remaining 20% each time they attend your clinic
  6. What is the coverage period? Most plans are cover a calendar year (Jan 1 to Dec 31), but sometimes you’ll get a plan that covers a different time period, like June 1 to April 30, so always ask! At the end of the coverage period, your patients' plan renews and they have full funding again
  7. Have they used any of their plan yet for their coverage period? It is great if someone comes in with a plan that covers $750, but if they’ve already used $740, you are going to need to discuss paying out of pocket until their coverage period renews
  8. Is there a doctor’s note required? Occasionally, a plan requires that a doctor refer them to a certain service (massage, orthotics, physiotherapy) before the insurance company will cover any of their treatment. It is important to communicate this with the patient before they start their treatment, or at the very least at their initial appointment, so they don’t get sticker shock down the road
  9. How many insurance plans do they have coverage under? If your patient is covered under their spouse's plan, or a child is covered by both parents plans, you will be able to bill both of the insurance companies, or at the very least inform the patient that whatever is not covered by the first plan should be submitted to the second

Having the information is the first step; properly storing it and using it to track your patients’ coverage and limits throughout their treatment plan is the next! By using the industry leading EMR and software system, you will be able to easily track your patients’ usage of their third party insurance, automatically calculate co-pay amounts and deductibles, and even direct bill 11 third-party insurance companies, reducing your number of rejected claims and awkward conversations about money owed!