Recommendations from a Billing Specialist
You just hung up the phone with one of our awesome Patient Support Specialists to schedule your kiddo for an evaluation with one of our stellar therapists – yay! Our team here at WPT is so excited to meet you and your family!
Below are some recommendations from a billing specialist on what you should do next to verify your services will be covered and to provide you with an idea of what to expect regarding cost.
The first and most important thing you should do is call your insurance company to make sure the services you are seeking are covered by your plan. There should be a Member Services phone number on the back of your insurance card. Call them and verify that whatever service you are coming for, whether it’s physical therapy, occupational therapy, or speech therapy, is covered under your plan’s benefits. Although it is uncommon, we have seen plans every now and then that do not cover speech therapy at all.
Secondly, it would also be a good idea to verify with them if they cover habilitative services and developmental delays. This will not apply to all our patients, but most of our patients receive habilitative services at our clinic, which means they are receiving services to learn and develop skills for daily living, as opposed to rehabilitative services, which are services to develop or improve skills that have been lost due to an accident, injury, illness, etc. Some plans distinguish these visits. For example, they might allow twenty rehabilitative PT visits per year and also twenty habilitative PT visits per year.
Next, you should confirm with your plan how many visits they allow for the discipline your child is scheduled for. Is the visit limit only for that specific discipline or is it a combined limit? Many plans combine PT, OT, and ST in the benefit limit for what we call a “combined limit”. Find out if that limit is a hard maximum or a soft maximum. When an insurance company tells you that your visit limit is a hard max, that generally means they will not cover any additional visits past that limit. So if they tell you that you have twenty ST visits per calendar year and that is a hard max, that means they will only cover twenty visits each year and nothing more. If it is a soft max, they might potentially cover additional visits, depending on medical necessity. If they do allow more, they will generally require an authorization when the time comes to utilize those additional visits (and that is something that us billing specialists here at WPT can do for you!)
Additionally, you should also check what your benefit year is. Most plans are a calendar year plan, but there are a handful that we deal with that run July - June or even October - September. You may already know the answer to this, because it is most likely when your deductible and out-of-pocket maximum restart, as well. But this is an important piece of information for you to be aware of, because that will let you know when to expect your cost to increase (if you have already met your deductible in December, but your evaluation isn’t scheduled until January, after your plan restarts, you can expect to pay more than if you had had your evaluation in December, when your plan was covering your visits in full). This is also an indicator for when your visit count will restart.
Finally, I recommend verifying with your insurance company what the patient responsibility will be for each visit, so you can prepare your budget and know what to expect financially. They should be able to let you know whether you have a copay or if you will be paying towards your deductible. If you are paying towards your deductible, they should be able to tell you how close you are to that and what your responsibility will switch to after your deductible has been met. For most insurance plans, after you meet your deductible, you will owe a coinsurance (could be 10%, 15%, 30%, etc) until your out-of-pocket maximum is met. Once that is met, they should start paying for your visits in full! If you will owe a copay for each visit, most plans will start covering that as well after you have met your out-of-pocket maximum! Of course, this is just generally speaking – each plan is different which is why we strongly recommend you reach out to your plan to verify your benefits.
Once you have all of this information, you can be an informed insuree and know how to best maximize your child’s therapy benefits! And of course, if you have spoken with your insurance company and still have additional questions, or ever have any type of billing questions or questions regarding your account with us, we welcome you to reach out to us here in the billing department, and we would be more than happy to talk through your questions with you! You can reach us by calling the office at 859-475-4305, extension 5, texting us at 859-475-4305, or emailing us at billing@wilsonpediatric.com. We are here Monday through Friday, 7:30am - 12:30pm and 1:30pm - 6pm, and we look forward to speaking with you!
**Please note: The billing department at WPT tries to be as helpful as possible in working with you and your insurance; however, it is ultimately the patient’s responsibility to know the coverage and limitations of their plan. WPT is not responsible for therapy that is not covered by your insurance.
