What is insurance?

Insurance is a contract between you and your insurance company. In most cases, we are NOT a party of this contract. We will bill your primary insurance as a courtesy to you. In order to properly bill your insurance company we require that you disclose all insurance information including primary and secondary insurance, as well as any change of insurance information. Failure to provide complete insurance information may result in patient responsibility for the entire bill. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility and benefits.

What is a Copay?

A copayment or copay is a fixed amount for a covered service, paid by a patient to the provider of service before receiving the service. It may be defined in an insurance policy and paid by an insured person each time a medical service is accessed. Our office will verify benefits with your insurance company, at that time a copay amount will be quoted by your insurance company. We will collect the amount quoted by your insurance company at the time of service. Once your claim is processed by the insurance company, we will post payment and make the patient responsible according to the explanation of benefits provided by your insurance company. If the insurance company process the claim with a patient responsibility different than the original amount quoted, this may create a balance due or a credit to this account. A statement will be sent to collect the addition amount required by your insurance company, if a credit is created the office will refund after services are completed.

What is a Deductible?

The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services. The office will verify your benefits, if your deductible has not been met for the year the office will collect $70.00 - $75.00 at the time of service, depending on your deductible. If while you are being treated your deductible is met the office will then collect the coinsurance or copay depending on the quoted patient responsibility.

What is Coinsurance?

The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible. Let's say your health insurance plan's allowed amount for an office visit is $100 and your coinsurance is 20%. If you've paid your deductible: You pay 20% of $100, or $20. The office will collect an estimated amount for the coinsurance, once your insurance has processed the claim this amount will be adjusted to reflect what your insurance actually requires. 

What does Maximum Benefit refer to?

The maximum benefit dollar limit refers to the maximum amount of money that an insurance company (or self-insured company) will pay for claims within a specific time period. Once you have maxed your benefits the insurance company will make you responsible for treatment. In the event this occurs you will have to discuss payment arrangements with the office prior to continuation of care.

What does Out-Of-Pocket refer to?

The amount you pay for coinsurance, as well as deductible and copays, all count toward the out-of-pocket expense. Once you reach your out-of-pocket maximum, the insurance pays 100% of covered cost for the rest of the year.

What is an in-network claim?

An in-network claim is usually filed directly by your provider with your insurance company. An in-network provider has a contract already in place with your health insurance company.

What is an out-of-network claim?

An out-of-network claim is a request for your health insurance company to reimburse a bill from a provider that does not have a negotiated contract with your health insurance company.

Do all health insurance policies reimburse out-of-network claims?

No, not all policies reimburse out-of-network claims. Check with your insurance provider to see if your plan has out-of-network benefits. Typically, a PPO or a POS type plan will have some type of out-of-network coverage, while most HMO and EMO plans only reimburse for out-of-network care in the case of an emergency.

How do I know if a provider is in-network or out-of-network?

Check your health plan's online provider directory or call your health plan. Make sure that you know the type of health benefit plan that you have. If you are told that a provider is "participating" or "accepts" payment directly from your health plan, follow up by asking if the provider is "in-network" or "out-of-network".

Can I see an out-of-network provider?

It depends on the type of health benefit plan you have

• The majority of Preferred Provider Organizations or PPOs, allow you to see any provider even if the provider is out-of-network
• Some Health Maintenance Organization (HMO) plans, restrict you from seeing an out-of-network provider
• You should review the schedule and summary of benefits for your health plan and it may be beneficial to contact your employer's human resources department of your plan provider for this information

What will I have to pay if I see an out-of-network provider?

• If your health plan does not cover out-of-network providers, you will be responsible for the entire cost of services rendered

How do I pay an out-of-network provider?

You will be charged a fixed amount established by the provider for physical therapy services. As a courtesy the provider will submit an out-of-network claim to your insurance plan on your behalf. If your insurance company provides payment, you may receive a refund in part or whole for your services.

When will I get a bill?

After each visit a statement of charges is sent to your insurance company. Once that has been processed it will be reconciled with any payments made in the office at the time of your visit. Patient statements are then mailed out monthly. 

It is our office policy that we will make three attempts to collect on any remaining patient balances. If after the third statement no payment has been received, the account will be sent to a collection agency. 

For questions regarding your insurance or a bill you have received in the mail please contact our billing department:

Cheque Claims Management

(440) 992-6770