Insurance Verification and Coverage

Before starting therapy, verify your own insurance benefits to understand what services are covered.

• In-Network Provider: An in-network provider has a contract with your insurance company to provide services at a negotiated rate.

• Out-of-Network Provider: An out-of-network provider does not have a contract with your insurance company, which often means higher costs for services.

• In-Network vs. Out-of-Network: We are in-network with most major insurance providers. If your insurance is out-of-network, you may have higher out-of-pocket costs.

• Example: If we are out-of-network, you might pay 40% of the session cost instead of 20%.

• Covered Services: These are the medical or therapy services that your insurance plan agrees to pay for. Coverage varies by plan and might include services like physical therapy, occupational therapy, speech therapy, or ABA therapy. 

• Not all therapies are covered. Check which services (e.g., occupational, physical, speech, mental, ABA therapy) your plan covers.

• Example: Your insurance may cover speech therapy but not ABA therapy. You would need to pay out-of-pocket for ABA therapy.

• Limitations and Exclusions: 

• Visit Limits: There may be a limit on how many sessions are covered each year.

• Example: Your plan might cover 20 physical therapy sessions per year. After that, you’d need to pay out-of-pocket.

• Exclusion: A condition or instance that is not covered by your insurance plan.

• Example: Some out-of-state commercial plans only cover ABA therapy for patients with an Autism Diagnosis and therefore all other diagnoses are excluded. 

• Service Caps: Certain services may have caps on the amount of coverage.

• Example: Insurance might only cover up to $2,000 of ABA therapy annually. Anything beyond that would be your responsibility.

• Requirements: Some plans need authorization from your insurance or a physician’s order from your doctor before we can start therapy.

• Authorization: Authorization is a pre-approval process where your insurance company agrees that a specific service or treatment is medically necessary.

• Physician’s Order: A physician’s order is a written order from your primary care doctor or specialist for you to see a therapist or receive a specific service.

• Example: Without prior authorization for occupational therapy, your insurance may deny the claim, making you responsible for the full cost.

Financial Responsibilities

• Coordination of Benefits: If your child has coverage from more than one insurance plan, benefits will need to be coordinated between the two plans.

• Primary Payor: The insurer that pays a healthcare claim first up to the limits of its coverage. This is usually a commercial insurance plan from an employer or self-sponsored. If no commercial coverage, this may be a government-sponsored plan (Military or Medicaid). 

• Secondary Payor: After the primary issues their payments, the claim goes to the secondary to pay the remaining balance up to the limits of its coverage. Depending on coverage, there may still be a balance. Government-sponsored plans (Military or Medicaid) will always be secondary payers to commercial plans. 

• Example: If one plan covers 80% and the other covers 20%, you might not have any out-of-pocket costs.

• Deductible: The amount you pay before your insurance starts covering services.

• Example: If your deductible is $1,000, you must pay this amount out-of-pocket before insurance covers any therapy sessions.

• Co-payment: A fixed amount you pay for a covered service, usually at the time of the visit. Co-pays vary depending on your insurance plan and the type of service.

• Example: You might have a $30 co-pay per session.

• Co-insurance: The percentage of the cost of a service that you are responsible for after meeting your deductible. 

• Example: If your co-insurance is 20%, you pay 20% of the service cost, and insurance pays 80%.

• Out-of-Pocket Maximums: After reaching this maximum, your insurance covers 100% of costs.

• Example: If your out-of-pocket maximum is $5,000, once you’ve paid this amount, insurance covers the rest of the therapy costs for the year.

• Some insurance plans have a combination of these.

• Example: You may need to meet a deductible first, then have a co-pay for visits after your deductible is met. 

Billing and Payment Policies

• Billing Process: We complete a payment estimate based on your insurance plan to be paid at the time of services. We then submit the claim to your insurance. Once processed, if there is any remaining balance, you'll receive a bill. 

• Example: If insurance covers 80% of a $100 session, you’ll receive a bill for the remaining $20.

• Explanation of Benefits (EOB): An EOB is a statement from your insurance company that details how a claim was processed, what they paid, and what you might owe. It’s not a bill, but a summary of how your benefits were applied.

• Denial: A denial occurs when your insurance company refuses to pay for a service or treatment. This can happen for several reasons, such as lack of authorization or services being deemed not medically necessary.

• Appeal Process: We can help you appeal the decision. This may involve providing more information to your insurance company.

• Example: If insurance denies coverage for a specific therapy, we’ll work with you to appeal the decision by providing additional documentation.

• Payment Plans: If needed, we can set up a payment plan to help you manage costs over time.

• Late Payment Fees: If a payment is late, there may be additional fees. See your intake paperwork for a comprehensive list of fees. 

• Out-of-Pocket Costs for Uninsured Services: Some services may not be covered, in this care you are responsible for paying. 

• Private Pay Rates: We offer rates for services not covered by insurance.

• Example: If your insurance doesn’t cover feeding therapy, you could pay our private pay rate directly.

Additional Tips to Avoid Unexpected Bills:

• Ask for Cost Estimates: Before starting a new therapy or adding sessions, ask us for an estimate of your out-of-pocket costs.

• Example: If your child needs an additional therapy session each week, we’ll estimate the cost based on your insurance coverage.

• Review Your Explanation of Benefits (EOB): Your EOB is a summary from your insurance company showing what they covered and what you owe.

• Example: After a session, your EOB might show that insurance covered $80 of a $100 session, meaning you owe $20.

• Regular Financial Check-Ins: We’re here to help. Schedule a time to review your billing and coverage with us if you have any concerns.

• Example: If your insurance benefits are running low, we’ll discuss options with you to continue care.

• Updating Insurance Information: If your insurance changes, let us know immediately to avoid coverage issues.

• Example: If you switch jobs and get a new insurance plan, coverage might be different, and we’ll need to re-verify your benefits.

• Cancellation & Fees: We charge for late cancellations or no-shows.

• Impact on Insurance Coverage: Frequent cancellations could affect your insurance coverage for future sessions. Insurance might deny continued therapy if sessions are frequently missed or canceled.

• Stay Informed: Watch out for any changes to your insurance and review our financial policies before starting services. We want you to feel fully informed and confident in your child’s care.

Informed Care: Be informed of your treatment plan and participate in the development and implementation of your plan of care. Receive a clear explanation of evaluation results; to be informed of potential or lack of potential for improvement. Be fully informed of the care and treatment that will be provided by us, the cost of care, and how payment will be handled. Be provided with services in a timely and competent manner, which includes referral to other appropriate professionals when necessary. Be told the name of your health care provider and the professional qualifications of the person providing services. Be told in a timely manner of your discharge and be involved in your discharge plan. Request or refuse treatment, and receive information regarding the consequences of refusing treatment.

Restrictions: You have the right to request restrictions on certain uses and disclosures of your health information. We will make every effort to honor reasonable restriction preferences from our clients.

Confidential Communications: Expect full consideration of your privacy and confidentiality in care discussions, evaluations, and treatments. Expect that all communications and records about your care are confidential, unless disclosure is allowed by law. You have the right to request that we communicate with you in a certain way. You may request that we only communicate your health information privately with your other family members present or through mailed communications that are sealed. We will make every effort to honor reasonable requests for confidential communications.

Inspect and Copy Your Health Information: You have the right to read, review, and copy your health information, including your complete file, and billing records. If you would like a copy of your health information, please let us know. You will be charged, according to the State regulations for duplication costs.

Amend your Health Information: You have the right to ask us to update or modify your records if you believe your health insurance records are incorrect or incomplete. We will be happy to accommodate you as long as our office maintains this information. In order to standardize the process, requests must be made in writing along with a description of the reason for the change. Your request may be denied if the health information record in question was not created by our office, is not part of our records, or if the records containing your health information are determined to be complete and accurate.

Documentation of Health Information: You have the right to ask for a description of how and where your health information was used by us for any reason other than for treatment, payment or health care operations. Please let us know in writing the time period for which you are interested. Thank you for limiting your request to no more than six years at a time. We will charge you a reasonable fee for your request.

Request a Paper Copy of this Notice: You have the right to obtain a copy of this Notice of Privacy Practices directly from us at any time. We are required by law to maintain the privacy of your health information and to provide you and your representative this Notice of Privacy Practice. We are required to practice the policies and procedure described in this notice but do reserve the right to change the terms of this Notice. If we change our privacy practices, all patients will receive a copy of the revised Notice.

Complaints: You have the right to express concerns to us, or the Secretary of Health and Human Services if you believe your privacy rights have been compromised. We encourage you to express any concerns you may have regarding the privacy of you information. Please let us know of your concerns or complaints in writing and address them to our Patient Advocate so that we may undertake the proper procedures to remedy the situation as quickly as possible.

As a patient, you have the responsibility to:

• Provide complete and accurate medical, health, and insurance carrier information.
• Remain under the care of your physician while receiving our services.
• Keep your appointments or call to reschedule with 24 hr notice: (270) 688-4889
• Accept the responsibility for any refusal of treatment.
• Ask questions when you do not understand information or instructions.
• Treat staff with courtesy and respect.
• Contact our office in the event of change of address, phone, or insurance information: (270) 688-4889