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Why is it So Important to Verify PT Insurance Benefits and Eligibility?

One question that pops up when dealing with insurance carriers is: Why is it so important to verify benefits and eligibility of a patient before you treat them. In this discussion we need to be frank. We need to understand that there are two opposing forces at play here. There’s you as the provider, you’re trying to treat a patient and get paid for the services your render. You’re trying to get paid by an insurance company who’s trying hard not to pay.

You Need to Understand There’s Friction Between You and Your Money

So, to answer this question we need to understand that friction exits between you and the insurance company. As we all know, ultimately the real responsibility lies with the patient themselves because it’s their plan and subscription. However, we all know that the patient is not going to accept that responsibility, so we end up taking that burden on. Knowing that the insurance company is going to try to find every way not to pay means we must verify everything in advance, so we know exactly what the rules of their particular game are.

Is There Actually a Valid Plan in Place?

Number one, we need to make sure that the patient is actually in a plan with that particular payer. We then need to make sure that the plan is valid and intact while we’re treating them. We also need to find out if any documentation requirement exists. We need to know the how and the when of submitting this documentation. Requirements vary from carrier to carrier. Some will want documentation after the sixth visit, some will after the twelfth visit, and others have their own parameters. The point is that it varies widely from company to company and you’ll need to ask those questions up front.

What About Pre-Authorization Concerns?

Additionally, some plans are going to need a pre-authorization before you can treat that patient. In that case, they’re going to give you an authorization number. This number will authorize a certain number of visits. They may limit you to six visits, twelve visits, or they may even put a window of time on the authorization. For example, they may authorize six visits, but stipulate that you complete those six visits within a one-month period. If you step out of these tight barriers, they will deny the claim and label it an unauthorized visit.

Do You Need a Referral from the Patient’s PCP?


Finally, some plans are going to require the involvement of a primary care physician. The patient may need to obtain a referral or prescription from their primary care doctor to be seen for physical therapy. There aren’t many of those types of plans out there, they’re typically found when you’re dealing with an HMO. It is a good question to ask when you call ahead of treatment. There’s an awful lot of information that must be obtained before we can treat a patient and confidently expect to be paid for our services.

One last tip. When you or your team is making those authorization and verification calls, make sure that you get a reference number and not the name of the person you speak with. If there is ever a disagreement down the road, it makes it a lot easier to get corrections and adjustments when all that information is on file. It is common for the person who verifies a patient’s information to tell you one thing on the phone but do something totally different when it comes time to pay the claim. This one extra step ensures that you’ll have the documentation to support your position.

Hopefully, this gives you a little bit of information on this broad subject. There is a lot of information you need from the insurance company prior to treatment and unfortunately, they keep changing the rules. If you have more questions or thoughts on this subject, we’d love to hear from you. Don’t hesitate to reach out.


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      Franklin Rehabilitation

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      Optimal Physical Therapy

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      Lonoke Physical Therapy, Inc


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