Insurance Verification

An open door to communication about financial issues with patients.

By Connie Ziccarelli

In these changing times, insurance benefits are also changing with every renewal date. Because of these constant changes and your clinic’s need for cash flow, it is important to verify insurance coverage and benefits for every patient. Whether the patient is new to your office or a return patient, knowledge is the key to smooth payment issues.

With today’s technology, it has become easier to verify coverage and check for benefits on your computer. Most companies make this process easy and user friendly but that is not always the case. Some companies do not delineate outpatient physical therapy benefits from their standard medical benefits. Sometimes the benefits are the same, but I have also found that the limitations differ from policy to policy and even patient to patient within the same employer group. Employers offer different benefit levels based on the policy the patient wants to subscribe to. Do not assume they are the same. Know what those limitations are—whether it is the number of visits allowed, maximum payout, or specific exclusions.

Most patients are uneasy about what their insurance company will or will not pay and what their out-of-pocket expense will be. Notifying the patient of their financial responsibility is an important part of the treatment cycle and to the clinic’s cash flow. Having a conversation or presenting a written explanation of benefits often opens the door to understanding on both parts.

The important components of an insurance verification letter should be:

• The date of verification
• The person that quoted you the benefits (if you spoke to someone)
• The effective date of the policy and as well as the termination date, if quoted
• The deductible amount and the amount applied to it, especially if outpatient physical therapy gets applied to it
• Coinsurance amount after deductible is met
• Out-of-pocket amount that must be paid before insurance will consider payment at 100 percent and the amount that has been applied to it
• The copay amount per visit
• Physical therapy limitations on the policy
• Whether physical therapy needs to be preauthorized and who to contact if so
• Who you spoke to in order to authorize care and the number of visits that they authorized
• Always include a disclaimer stating that the authorization are not a guarantee of benefits and that payment will be considered based on the policy provisions in effect at the time the service is rendered.
• Include an estimated amount that is due from the patient at the time of service unless prior arrangements have been made with the patient and the method of payment has been agreed on (credit card, cash, or check).
• Always include a thank you for your business and a contact number if they should have questions regarding these benefits.

By opening the door of communication with your patients regarding their financial obligation you will create a smooth experience and a healthy cash flow. 

Connie Ziccarelli is the chairperson of the PPS Administrator’s Council and an APTA member. She is also the cofounder, principal and chief operations officer of Rehab Management Solutions in Sturtevant, Wisconsin, where she manages, grows, owns, and operates a nationwide network of private practice physical therapy clinics..