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What Your Patients Don’t Know About Their Insurance Coverage for Physical Therapy

by Domanique Davison


Did you ever wonder how health insurance became an entity? Well, it’s quite interesting, the first health insurance offered was actually called accident insurance. Hospital and medical insurance were non-existent until about the 20th century. Services were only offered on a prepaid basis. Along with other unprecedented events, the former hospital and medical insurance became the gateway to other insurances such as: medicare, medicaid, and managed care through HMO insurance policies. Today, we see an abundance of health insurance plans that are more extensive and quite complicated.

What is health insurance?

Based on definition, health insurance is a contract that requires your health insurer to pay some or all of your healthcare costs in exchange for a premium. Health insurance within the marketplace has many different types of plans. The following are very common types of insurance plans:

  • EPO(Exclusive Provider Organization)- This type of insurance plan is a managed care plan, services are only covered if you use specialists within the plans network.
  • HMO(Health Maintenance Organization)- This type of insurance plan limits coverage to where you can only seek treatment from specialists who work for or contract with your plan. This insurance plan will not cover out of network benefits unless it’s an emergency.
  • POS(Point of Service)- This insurance plan will allow you to pay less when you use specialists that belong to the plans network. It will typically require the patient to get a referral from their primary care physician in order to see a specialist.
  • PPO(Preferred Provider Organization)- This insurance plan will allow you to pay less as well if you use providers that are within your plan’s network. But, you are also able to use providers out of your network without a referral for an additional cost.

That all may seem like a lot of information to take in, but there’s still more to come. Below I will introduce to you non-traditional health insurance plans:

  • Indemnity Insurance Plans- These are what we call “fee for service” plans. Patients may be responsible for deductibles and coinsurances. They will pay out of pocket first and then file a claim to be reimbursed for their covered amount.
  • Health Savings Account Insurance Plans(HSA)- For this insurance plan patients have a savings account where there are funds that can be used for medical expenses.
  • Health Reimbursement Arrangements(HRA’s)- For this health insurance plan employers will reimburse employees for their out of pocket expenses.

And lastly, here are our government insurance plans:

  • Medicare- This is a federal insurance program that provides insurance coverage for those that are 65 and older. Patients under the age of 65 can also have medicare if they have a disability. As long as you meet the requirements for medicare you can qualify for it. Medicare is not income based.
  • Medicare Advantage Plans- These are medicare health plans offered by a private insurance company that contracts with medicare to provide you with both part A and part B benefits. A commonly used advantage plan is Aetna Medicare.
  • Medicaid- This is considered a state and federal insurance plan that provides health insurance to individuals with a very low income.

Physical Therapists see a lot of different insurances on a daily basis. The insurances are not limited to what was mentioned above. Patients may have a workers compensation claim or motor vehicle claim which will ultimately result in those insurances paying for physical therapy services too. Now that we are familiar with types of insurance plans, there are key terms that are commonly used to describe your insurance benefits.

Some Key Insurance Terms

For physical therapy insurance coverage there are about 4 key terms that are very important. These terms describe whether or not there is a responsibility from the patient when seeking physical therapy services. Some patients are subject to copay amounts. These are fixed amounts that are paid at the time of service. Patients can also have deductibles. Deductibles can get very tricky because they are amounts that have to be paid by the patient before the insurance plan starts to pay for any services. If a patient doesn’t have a copay, they may have a coinsurance. A coinsurance is the percentage of costs that the patient will have to pay once they have met their deductible. Lastly, most if not all health insurance plans have an out of pocket maximum. This is the most you have to pay for services within your insurance plan.

List of Insurance Plans Seen Throughout Physical Therapy

  • Aetna
  • Medicare
  • Medicaid
  • Horizon Blue Cross Blue Shield
  • Humana
  • United Healthcare
  • Amerihealth
  • Amerihealth Administrators
  • Independence Blue Cross
  • Independence Blue Cross Administrators
  • Aetna Medicare
  • Medicare Supplemental Plans(AARP,etc)
  • Meritain
  • Oxford United Healthcare
  • And more...

When and How Should We Educate Patients About Insurances?


There are many instances when it’s important to educate patients on their health insurance coverage. You should always make a patient aware if their insurance is capped for them to seek physical therapy treatment at a specific physical therapy company. This will affect their in and out of network insurance benefits. Patients should always be made aware if their insurance plan only allows a certain number of physical therapy visits. Some insurances require authorization for physical therapy and this can impose stipulations on how many visits patients are approved for physical therapy. High copays and high deductibles should be mentioned to the patient as well.


Patients are typically given their insurance benefit details at the time of their appointment when they are signing their billing and payment forms/intake paperwork or prior to their appointment. However, Physical Therapists should reiterate the patient's insurance information during the Initial Evaluation. First, the Physical Therapist should go through all the patient’s concerns and their intake questions. After that the Physical Therapist should notify the patient of anything that is alarming within their insurance coverage. For example, high copay, high deductible, etc. All of this should be as simple as having a regular conversation with the patient.

“Hello Mr.Smith it is a pleasure to be able to treat you and get you through your current condition. I did just want to mention that your insurance only allows 20 visits per condition. But, I will guarantee that we will make progress with what is given and if by the end of the 20 visits you are still not where needed I will extend my services to you by making myself available through email, video chats, or any other way that can help you to continue to progress daily.”

What To Do If You Don’t Accept Their Insurance Plan?

  1. Never turn the patient away without giving them options!!
  2. Most office based practices will have self pay rates. Try to offer the patient a self pay rate. If the patient states the self pay rate may be too expensive for them, possibly offer them a payment plan as long as it is an available option within your company.
  3. The last resort would be to direct the patient to call their insurance company to see what physical therapy companies are accepted within their insurance plan.

Although insurance companies may place stipulations on physical therapy treatment, always give the patient your best work. Physical Therapists don’t work for insurance companies and patients deserve to receive ultimate treatment no matter what guidelines insurance may have set in place. Always remember why you joined the physical therapy profession and use that as fuel to overcome the challenges faced when dealing with insurance companies. And patients please take the time to educate yourself on your insurance policy. If there is something you don’t understand, ask for written statements or even take it an extra step by calling your insurance company and speaking to a representative in regards to your coverage.





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