Insurance

Here are eight questions with additional notes to ask your insurance company to help determine if your plan includes out-of-network benefits and what may or may not be reimbursed:

1. Do I have coverage for out-of-network physical therapy services (sometimes called "a non-preferred provider")?  

• If so, what does this coverage include?  Please note that having out-of-network benefits does not guarantee full reimbursement. 
• If you do not have such benefits, the physical therapy services provided by Shift will, therefore, not be reimbursable.

2. Do I have a deductible?

• If so, what is the amount and how much has already been met?
• A deductible must be satisfied before the insurance company begins to pay for therapy.  
• Ask if the submission of the super bills given to you will then be applied to your deductible. 

3. What percentage of reimbursement do you offer?

• Common reimbursement rates are 60%, 80%, or 90%, but your plan may differ.

A few notes:

• Find out if the reimbursement rate changes when seeing a non-preferred provider / out-of- network provider. 
• If you have an office visit co-pay, the insurance company may subtract it from the reimbursement percentage, which may affect your reimbursement amount.
• Reimbursement is based on your insurer’s "reasonable and customary/fair price” for the service codes, which may be more or less than your billed charges.

4. Is pre-authorization necessary for physical therapy?

•  If yes, ask the representative what the process is to obtain the pre- authorization. 
•  This will be needed before you start services at Shift Physical Therapy to comply with the reimbursement procedures. 

Extra notes:

• If your policy requires pre-authorization or a referral, and your insurance doesn’t yet have it, you may need to call your primary care provider's referral coordinator to file a referral dated to cover your first physical therapy visit.
• Some referrals and pre-authorizations have expiration dates and sometimes visit limits. Please know that it is your responsibility to keep track of the expiration dates and/or visits numbers .
• If there are expirations on the pre-authorizations, ask the representative what steps you need to take to either extend the date or obtain additional authorization. 

5. Are additional forms required besides the super bill invoice for reimbursement?

• If yes, where can they be obtained and where should they be sent (mail, email, fax)?
• If physical therapy progress notes are needed, please give Heather a two-week notice. The notes will be given directly to you for your submission to your insurance company—these will not be sent automatically.

6. Is a prescription from my physician required?

If yes,

• Do you already have one on file?
• What wording and information is needed to be acceptable for possible reimbursement or pre-authorization?
•  Will I need to send a copy of the prescription with each super bill submission? 

A few notes:

• Contact your doctor to obtain a prescription that states: “Physical Therapy Evaluation and Treat” or whatever specific wording the insurance representative instructed.
• Treatments might not be covered without the correct prescription.
• Keep a copy and bring this to your initial session.
• If your policy requires a prescription from your PCP, obtain one and submit it with your claim.
• Make sure to include any updated prescriptions with future claims.

7. How long does claim processing typically take?

8. Are there coverage limitations?

• For example, is there a monetary or visit limit per year?