Your child may need speech or occupational therapy and you may have decided that you are ready to take him or her in to be formally tested/evaluated.  When parents call our office we get 2 questions almost always:

1. Are you accepting new patients?
2. Do you take my insurance plan?

We all know that the world of insurance is very complex.  In my opinion-I think it is set up to be unclear.  But if you have an insurance plan-it is YOUR responsibility to know what is covered and what is not covered.  For many of us-gone are the days that we hand over our insurance card to a doctor or therapist and the entire cost service is covered.  With factors like deductibles, in network vs out of network providers and co-insurance-I have seen families pay nothing and I have seen families pay for 100% of the service-even though they had insurance!  Today’s blog post is dedicated to clarifying some of the terms listed above.

What is a deductible?

The deductible is the amount paid out of pocket by the policy holder before an insurance provider will pay any expenses.  So if you have a $5000 deductible (like I have, yikes!)-you must pay the first $5000 of all medical, therapy expenses before your insurance will pay ANYTHING. 

The difference between in network and out of net work  

 The difference is that an in network provider has agreed to be paid at a negotiated rate with the insurance company. It is usually a reduced amount from the providers usual charge amount and the provider cannot then bill the member for the difference between what is paid and the charge amount (minus any copay/coinsurance the member is responsible for)  If the provider is out of network then the provider charges their usual fees for services and bills the member  all remaining amounts owed after the insurance pays what the insurance feels is appropriate for the services rendered. Usually the members insurance benefits will be higher for an in network provider, for instance a $10 copay for in network vs. $30 copay for seeing an out of network provider. 

How it may be better to pay for therapy out of pocket if you have a high deductible.  

It may be (financially) a better option to opt out of filing your insurance if you have a high deductible plan. Many offices offer a self-pay rate (either a flat rate for services or a percentage off the total charge amount) for patients that will not be filing your insurance. For instance, say a provider charges $50 for therapy that will applied to your deductible. You would have to pay $50 until your $5000 deductible is met. It is likely that you will never meet your $5000 since that would be 100 visits. (and you would owe $1300 for 26 visits)  A provider may charge a self pay patient their flat rate of $35 per visit. That same 26 visits will cost $910 out of pocket, saving the patient $390. The provider does not file a claim to the insurance (hence the cheaper rate since there is no administrative work of filing the claim, following up to make sure it is paid correctly, etc) A patient must consider if they want the charges applied to their deductible or not. If the charge is to insurance then the provider must collect the amount owed by the patient (deductible, copay).

Insurance plans are a wonderful thing-but always take the time to get to know the benefits that your insurance plans actually cover.  It’s worth a phone call just to get that information. 

Stay safe out there!