Knowing the ins and outs of an insurance policy can be a source of confusion for many people, but we are here to help! The Clubhouse is proud to have an extremely experienced billing team. We will do what we can to help you understand your benefits!
We have taken some of the common insurance terms and given a summary and tips to help you navigate your policy information:
“Covered Benefit”
If therapy is a “covered benefit” on your plan, this simply means that it is eligible to be paid – but is not guaranteed to be paid. No insurance company will guarantee your family or the Clubhouse that any given claim will be covered. However, when we are told that the therapy is a “covered benefit” and that there are no “exclusions” in the policy, then the therapy will usually be covered without a problem.
*Tip: Call your insurance company and ask if the service is a “covered benefit”, but also ask if there are ANY exclusions. Examples of exclusions could be “We only cover therapy if it is to restore function after an accident, illness or injury.”
“Deductible”
Your “deductible” is the amount of money that you must pay before insurance will start paying for your medical costs. Every policy is different – and some services may not require that you pay your deductible first.
*Tip: You can call your insurance and ask “Do I have a deductible? How much of my deductible do I still have to meet? Are the therapy or evaluation services applied to my deductible? There is often a family and an individual deductible. Ask your insurance policy how much has been met toward each. Many times, if the family deductible is met, it will override the individual and co-insurance will then apply.
“Co-Insurance” vs. “Co-pay”
Co-insurance is a percentage of the total cost of the service that you must pay. For example, if your co-insurance is 20%, then the insurance company would pay 80%. So if you have a $2,000 deductible, and a 20% coinsurance – this means that you would have to absorb the first $2,000 in costs and then pay 20% of the costs after that.
Co-Pay is a fixed dollar amount that you pay for each date of service. For example, your policy may ask that you pay $25 per visit, and they will pick up the rest of the fee.
Out of Pocket Maximum:
Your policy will have an “out of pocket maximum”. This is the total amount of money that you would owe for covered services in the year of the policy. Generally, your co-payments, coinsurance and deductible amounts apply toward this maximum annual $ amount. Once an out of pocket maximum is met, covered services are paid 100%!
*Tip: As with the deductible, check if there is an individual and family out of pocket max. If your family has met the out of pocket maximum, all covered services may be covered 100%!
Maximum Number of Visits
Some policies have a maximum number of visits for each service. For example, speech therapy may be limited to 30 visits per year. We also frequently see services fall into a “combined maximum”. For example, your policy may have a combined maximum of 60 visits for speech, occupational therapy and physical therapy.
Hard max vs. Soft max: If your policy has a “max” number of visits, it is important to know if you can request additional visits once the max is met. If it is a “hard max” then no more visits will be granted. If there is a “soft max” then the policy may allow us to submit clinical documentation to support medical necessity and grant additional visits. Therefore, is it important for The Clubhouse to always have a copy of a script and most recent evaluation so we can be ready to send these to insurance if needed!
*Tip: Ask your insurance company if there is a maximum number of therapy visits allowed per year, what therapy is included in the maximum # and if this is a “hard” maximum? Please be sure to keep track of how many visits you have used.
Not Covered
If your insurance company does NOT cover the service that you desire, the Clubhouse can offer you a scholarship rate, which caps the amount that you will owe. You can call the Clinic Manager to discuss these rates.
Pre-Authorization
Some insurance companies require that you have pre-authorization for services. This means that they will NOT cover the services unless they review our recommendations and a Physician’s script first and determine that the service is authorized.
When the service is “authorized”, the Clubhouse will receive written confirmation from the insurance company. The authorization will specify HOW MANY visits will be allowed. It is VERY important that you keep track of how many of these visits you have used, and ask the Clubhouse to “re-authorize” therapy prior to the visits running out. The Clubhouse will also track the visits, but the family is ultimately responsible for making sure that an authorization is in place. If an authorization lapses, you will be responsible for the costs – and we want to help you to avoid this.
*Tip: If an authorization is needed, help us by quickly getting the physician Rx to us per the codes given to you by the billing department. Also, call the insurance company after several business days to check on the status. The Clubhouse will also be calling and handling the pre-authorization process, but your help is important.
REMINDER: At the end of the year, many families have met their deductible or even out of pocket maximum. If a new evaluation is needed, this might be a good time to give us a call! We will be happy to verify your benefits for you and look for possible openings for evaluations before the new year.