You may be able to contribute to your deductible while paying to see your favorite provider!
Cash pay gives us the flexibility to move fast and provide the care you need. The way insurance is set up can bring challenges for both of us!
To begin, most health insurance policies don't cover the entire cost of a physical therapy visit. Many plans require patients to pay their full deductibles and even then, require copays of $50 or more per physical therapy visit.
This results in you paying out of pocket for physical therapy whether you use your insurance benefits or not! Frustrating I know.
The biggest difference in choosing cash pay over an in-network provide is the overall quality of the services and the value you experience at each visit.
Why Do Providers Prefer Cash?
For in network providers, the clinic and insurance company will agree to a certain amount for PT services in exchange for access to all patients in the insurance providers' network. For the agreement, let us say the insurance company and the clinic agree to charge $100 for an evaluation and $40 dollars for each visit. At this particular clinic, the normal cost for an initial evaluation is $200 and $125 for a follow up visit.
Now every time you go to an 'in network' provider, you'll be saving $100 for an initial evaluation and $85 for each follow up visit. (This price reflects if you have not yet met your deductible).
Although the cost savings sound nice at face value, the price difference puts clinics in a difficult situation where often these rates make it challenging to keep a clinic afloat if they only see one patient an hour.
To compensate for this lower rate, (and you may have experienced this yourself) in network physical therapy clinics will attempt to make up for the reduced insurance rates by increasing the volume of patients they see. This means patients might be double or triple book on one therapist's schedule.
Exchanges like this can (not always!) lead to an impersonal physical therapy experience and poor continuity of care. You’ll often get minimal face time with the licensed physical therapist, different physical therapists for each visit, and inconsistent messaging about your care plan.
For those highly invested in their health, having a consistent message, with an exact plan toward your desired goals, and with the licensed professional you value can be a game changer for your recovery.
Avoiding The Medical Run Around
After being referred by your primary care doctor to an orthopedic specialist, who suggested physical therapy, you received the number to schedule an appointment.
Despite eagerly seeking answers for your persistent pain, you learned that you may need to wait 1-2 months before seeing a physical therapist. Frustrated, you seek to find answers and realize if you choose to pay for services upfront, you may be able to get an appointment with a licensed professional sooner.
This is where cash pay for healthcare makes the most sense for both the patient and the provider. You get access with less waiting and quality care with your favorite provider.
Additionally, in California, you can see a physical therapist for up to 45 days or 12 visits without needing your physician's approval, thanks to Direct Access. While waiting for your doctor's appointment, you can start on your path to recovery with personalized rehab plans. If you are paying cash, you may be eligible for reimbursement through Superbilling, which I explain below.
What Is A Superbill
At the end of each our billing month, you will be sent a 'Superbill' that you can then send to your insurance company to review.
This form reflects the date(s) of service, the service code or CPT code, the diagnosis code(s) and the billed amount from the the physical therapist, along with their credentials.
I will provide you with all of this information but here is the general format of what goes on your Superbill Form:
Provider’s first and last name
Provider’s NPI number and/ or tax identification number
Office location where services took place
Provider’s phone number
Provider’s email address
Referring provider first and last name
Referring provider’s NPI number
How Do You Submit A SuperBill?
Each insurance company has unique policies. Therefore, it’s best to call your individual insurance company to obtain your plan benefits. This call will take approx. 15 minutes to verify benefits and submit a Superbill. This will be helpful in the future to realize the benefits and expectations of submitting a Superbill to your insurance.
On the back of your healthcare insurance card, call the phone number for “Members” or “Members Services” with your insurance card in hand and the ability to take notes.
To make sure your submission will be accepted:
Verify out-of-network benefits
Verify how to submit a Superbill
Confirm your home address with your healthcare insurance (especially if a check will be issued)
Below are two examples of the back of the insurance card:
In the call to “Member Services,” make sure they have your correct address on file. The healthcare company obtains the address directly from the sponsoring employer. To change the address with healthcare insurance, the policyholder will need to update the address through the Human Resources Benefits Specialist from the employer who sponsored the plan. The individual in the household that works with the employer will need to follow the employer policies to update the address at work and for the healthcare insurance.
What to Ask Your Insurance Company Before Submitting Your Superbill
As a paying member to a healthcare insurance plan, you can call for an explanation of benefits (EOB). Especially when submitting a Superbill for an out-of-network provider, the benefits can be dramatically different from your in-network benefits.
Call the healthcare “Members Services” line and ask the questions below:
“What are my out-of-network healthcare benefits for physical therapy in an out-patient setting?”
Pen to paper may be helpful for the following questions :)
Is pre-authorization required? (if applicable)
Co-payment? (if applicable)
Deductible? (if applicable)
Today’s accumulation for deductible? (if applicable)
Co-insurance? (if applicable)
If pre-authorization is required, ask the representative to get this started. Often they will need to transfer the patient to the person who can grant the authorization.
They will ask the patient’s name, date of birth, and member number, along with the name and address of the physical therapist (me) who will provide rehab.
Once completed, the representative will give you the authorization number that is stored in the insurance database. The authorization will provide a time frame (i.e. 02/01 to 05/01) and a total number of visits allowed during the time frame (12 visits).
Next ask, “I have a Superbill, how do I submit?”
Each healthcare company has various ways to submit a Superbill. Most will have one of the below options or all three:
1. Fax Superbill to Insurance
Insurance will provide a fax number to transmit the Superbill. Please do not send from public fax or work fax, as the receipt of fax will include your original fax with Personal Healthcare Information (PHI).
Items to fax include:
A cover letter is needed to include the patient name and member identification number
2. Mail Superbill to Insurance
Insurance will provide an address to mail the Superbill. Along with the superbill, a cover letter is needed to include the patient name and member identification number.
3. Upload Superbill Through Your Insurance Company’s Portal
Your insurance company may have a portal that you can use to upload the Superbill. The portal is the insurance company’s website that requires a username and password. This is the most secure way to transmit your Superbill, and the most timely.
When speaking to the representative, ask if the web portal requires an invitation from them to get started. If not, ask for the web address for the insurance portal. Typically, to create an account an email address will be required, along with a password.
Items to upload via the insurance portal include:
A cover letter—include the patient name and member identification number
Determining How Your Superbill Is Processed & Paid
Your individual healthcare benefits will determine how the Superbill will be processed and any subsequent reimbursement. The primary factors for your plan include copayment or a deductible, along with timely filing.
The reimbursement will be the allowed amount for each service, minus the copayment. As the member is responsible to pay out-of-pocket (the copayment), this amount will be deducted from the payment.
When a policyholder has a deductible, reimbursement needs to be determined by insurance. This is calculated from the amount of the deductible and the accumulations for each therapy session applied. After the deductible is reached, insurance will issue payment, minus the coinsurance. The member is responsible to pay the coinsurance out-of-pocket, which will be deducted from the payment.
Timely filing is the time limit that an insurance company allows for a claim to be submitted. For example, a payer has a 90 day timely filing. This means that all Superbills must be submitted within 90 days of the date of service. Claims that are older than 90 days submitted to insurance, will be “Denied” for being outside timely filing.
What Can I Expect After Submitting My Superbill?
When received, most insurance companies will make a determination in two weeks. If reimbursement is due after the claim is processed, most insurances have a specific day of the week when checks are mailed.
When the claim is processed accurately and applied to the deductible, no payment is forthcoming.
I Submitted My Superbill & Received No Payment?
Generally, the Superbill will be processed within two weeks. After this time, with a copy of the Superbill, call the “Member Services” number on the back of your healthcare card.
Ask, “What is the status of the claim submitted?”
The representative will ask for dates of service and the total amount of the charges. Total amount is simply the accumulation of all the dates of service to include the date range on each page of a Superbill.
Insurance will inform you of the status of the claim at the time of the call: Denied, in process, or completed:
This is the time to ask the representative for the Denial reason, while on the phone. (see reasons foer denial below)
The claims are currently in the process of being completed. Insurance is still completing the process of reviewing the claim(s) against the policy. Insurance has yet to make a final determinization on the claim(s). More time is needed for the insurance claims adjuster to “Finalize” the claim.
The claim is “Finalized.” Finalized claims have two determinations:
1) Money will be issued
2) The amount for each claim was applied to the patient’s deductible, meaning no reimbursement will be issued to the insurance member.
Payment for your Finalized Claims will then be issued to the you.
Ask the representative:
"What is the dollar amount for each date of service (DOS) and the total check amount?"
"How will the money be issued, by check or EFT?"
"When will the money be issued?"
"If mailing, confirm the mailing address?"
Finalized Claim(s) to the patient deductible with no payment issued
Ask the representative information on how the claim was determined. Insurance will list the amount for each date of service and the amount that was applied to the deductible.
To understand the healthcare policy, ask for the total amount of the deductible and its accumulations.
Deductible Accumulations: the collection amount assigned to each therapy session. These accruals allow the total deductible to be obtained. After the deductible is met, then insurance will pay (minus the coinsurance, if applicable.)
My Superbill Was Denied – Now What?
In the case your claim is denied, call your insurance and ask for them to explain the reason for the denial. Possible claim denial reasons include:
Reason #1: Prior Authorization Was Required But Not Obtained
The Superbill was received and no prior authorization is on record. The insurance policy requires authorization to be obtained by the client, prior to the counseling session. If no prior authorization was received, this will cause the claim to be “Denied” on submission.
Potential Solution: Call “Member Services” with access to your Superbill. Simply ask about the status of the claim. If the claim was denied for “no prior authorization,” ask if they can “back-date” the authorization, if possible. Either way, it would be beneficial to obtain a new authorization for future care.
Reason #2: Date(s) of Service Was Outside the Timely Filing of Claims
The Superbill was received by insurance after the ninety-day period of the Date of Service. Any claims that are beyond the time frame of 91 days will be “Denied for timely filing.”
Potential Solution: Call “Member Services” with your Superbill and ask about the status of the claim. Ask the representative if they can reconsider your Superbill, especially, if you are within 30 days of the timely filing date.
Reason #3: Information on the Superbill Was Incomplete or Illegible
Your insurance is stating the Superbill received was not legible or did not include the required components on the form.
Potential Solution: Call “Member Services” with your Superbill and ask about the status of the claim. If they state that the form was incomplete or illegible, the representative will state the reason with what is missing or illegible.
For example, the Provider’s NPI or name are not present on the form, or the service code is not present on the form.
With the information the representative relays on the phone, examine the copy to see if the elements are present on the Superbill—maybe the insurance company received a bad copy. If they received a bad copy of the Superbill, it can be re-submitted by different means: Fax, mail, or insurance portal.
In the case that the information was not present on the Superbill, take notes of what's missing data and ask your physical therapist for a Superbill with all the elements needed for successful submission.
Reason #4: No Out-of-Network Coverage
The Superbill is submitted to insurance and denied because the policy has no coverage for physical therapists outside of your insurances network.
Potential Solution: Call “Member Services” with access to your Superbill and ask about the status of the claim. If the claim is denied for no out-of-network coverage, ask for a “Single Case Agreement,” which is a contract allowing the specific provider to treat the insurance company’s member or insured for a qualified number of sessions and/or date range. Many “Single Case Agreements” may be renewed at the discretion of the insurance company.
When an Insurance Company Will Not Accept a Superbill
Any insurance coverage inquiries require a call to “Member Services.” This inquiry will be in regard to the claims for an individual provider.
If the claims are present in the insurance company system, the questions are different:
How did the claim(s) finalize?
How much was assigned for each Date of Service?
To whom was the money sent—the patient or the provider?
In the case that no claims are present with insurance, ask how to submit the claims to insurance, either by the patient or the provider. Within this inquiry, ask how you can submit a Superbill to insurance. If the representative is being difficult, it may be best to hang up and call again with the hope of getting a better-informed representative with your insurance.
If all your calls are fruitless, contact your Human Resources Benefits Specialists from your employer. Your HR specialist represents your
employer group with the insurance company, and they do their best to keep your employer happy in a highly competitive insurance industry.
Hopefully this post is your ticket to getting cash pay covered by your insurance. If you have further questions, feel free to reach out to me via email listed at the bottom of the page.