Gateau Physical Therapy & Sports Medicine

We participate in most insurance. Please read the FAQs below and contact our office for further details.

Know Your Insurance!

Frequently Asked Questions about
Health Insurance Benefits and Billing

(Click questions to read the answers)

Do you bill my insurance claims for me?

We will file your insurance claims for you to your Primary Insurance Carrier. We accept assignment on most, but not all, insurance plans. This means we will bill the insurance company and once they pay us their portion of the allowed amount, we will then bill you, the patient, any remaining patient responsibility.

How often do you bill my insurance?

We submit insurance claims on a daily basis, usually the morning after a patient has been seen. For example, if you are seen on Monday, your claim will be billed the following day (Tuesday) for Monday's date of service.

Will you tell me what my insurance covers?

We will call to verify your benefits prior to your first visit. You must remember though, that verification of benefits is never a guarantee of payment. What does this mean? It means that any information an insurance company gives us over the phone or via the internet stating benefits for a patient could possibly be different than what that plan covers when the claim reaches them. Bottom line - if Sue from Blue Cross tells us you don't have a co-pay, then your claim processes and you do have one, it is out of our hands. We rely on getting accurate information from your insurance upon verification of benefits - but that information is never guaranteed.

What should I be doing?

Being informed about what your insurance covers is an important first step. The insurance policy is a legal contract between the policyholder (you) and the insurance company. It is important for patients to know and be familiar with your own benefits as well as any restrictions and limitations that may apply. Ultimately, you (the patient) are responsible for knowing what your insurance company covers and what requirements they have for treatment (e.g., referral requirements, deductibles and co-payments). Keep yourself informed about your insurance coverage so you won't be blindsided by a bill once they start to pay your claims.

How much do insurances generally cover?

Rarely do insurance policies pay 100% of all the fees associated with physical therapy. Most plans either require the patient to pay a per-visit co-payment or a percentage of the cost for services. Many plans also have yearly deductibles which renew every January that require patients to pay 100% of the charges until a fixed amount (which can be anywhere from $250 to $1000) has been paid by the patient. It is important for you, the patient, to know if your deductible for the current year has or has not been met.

Can you waive my co-payment and/or deductible for me?

It is illegal for us as contracted providers with your health insurance to waive co-payments or deductibles. These must be collected appropriately according to your health insurance contract and are due at the time of service. If there is a financial hardship situation, arrangements with the billing office must be made prior to treatment.

Understanding Health Insurance Terms

Navigating your way through health insurance benefits can be a challenge. It is very important to understand the terminology especially when deciding which benefits will work for you and finding a plan that will best meet your needs. This brief glossary will provide insight for some of the more common terms when dealing with health insurance.

(Click terms below for the definitions)

Co-insurance:

The monetary amount to be paid by the patient, usually expressed as a percentage of charges.

Co-payment:

The monetary amount to be paid by the patient, usually expressed in terms of dollars.

Consumer Driven Health Care (CDHC):

Refers to health plans in which employees have personal health accounts such as an health savings account, medical savings accounts or flexible spending arrangement from which they pay medical expenses directly.

Deductible:

The portion of medical costs to be paid by the patient before insurance benefits begin, usually expressed in dollars.

Denial:

Refusal by insurer to reimburse services that have been rendered; can be for various reasons.

Eligibility:

The process of determining whether a patient qualifies for benefits, based on factors such as enrollment date, pre-existing conditions, valid referrals, etc.

Exclusions:

Services that are not covered by a plan.

Flexible Spending Arrangements (FSAs):

An account that allows employees to use pre-tax dollars to pay for qualified medical expenses during the year. FSAs are usually funded through voluntary salary reduction agreements with an employer.

Gatekeeper:

In managed care, it refers to the provider designated as one who directs an individual patient's care. In practical terms, it is the one who refers patients to specialists and/or sub-specialists for care.

Health Maintenance Organization (HMO):

A form of managed care in which you receive your care from participating providers.

Health Savings Account (HSA):

A savings product that serves as an alternative to traditional health insurance. HSAs enable you to pay for current health expenses and save for future qualified medical and retiree health expenses on a tax-free basis.

Managed Care:

A method of providing health care, in which the insurer and/or employer (policyholder) maintain some level of control over costs and utilization by various means. Typically refers to HMOs and PPOs.

Member:

A term used to describe a person who is enrolled in an insurance plan; the term is used most frequently in managed care.

Open Enrollment:

A set time of year when you can enroll in health insurance or change from one plan to another without benefit of a qualifying event.

Out-of-pocket:

Money the patient's pays toward the cost of health care services.

Payer:

The party who actually makes payment for services under the insurance coverage policy. In the majority of cases, the payer is the same as the insurer. But, as in the case of very large self-insured employers, the payer is a separate entity under contract to handle the administration of the insurance policy.

Policyholder:

Purchaser of an insurance policy; in group health insurance, this is usually the employer who purchases policy coverage for its employees.

Preferred Provider Organization (PPO):

A form of managed care in which the member has more flexibility in choosing physicians and other providers. The member can see both participating and non-participating providers. There is a greater out-of-pocket expense if member sees non-participating providers.

Premium:

The cost of an insurance plan shared by employer and employee.

Provider:

One who delivers health care services within the scope of a professional license.

Reimbursement:

Refers to the payment by the patient (first-party) or insurer (third-party), to the health care provider, for services rendered.

Source - APTA