FAQ: Understanding Your Insurance Benefits

In Counseling, physical therapy, Uncategorized by compleoPTLeave a Comment

Why are you not in-network with my insurance?

At Compleo, our mission is to provide the best possible care to help you reach your goals as quickly as possible. When we are not in-network with insurance, we can make decisions based on what YOU need instead of a third party’s non-medical opinion.

Examples include: Insurance often dictates the number of visits, in-network clinics shorten visits or double book due to declining reimbursement rates, and insurance often dictates which interventions may be performed (clinics will perform the interventions with higher reimbursement instead of interventions best fit for the patient)

When working directly with the patient, we cut out the middleman and ensure you get the highest quality evidence-based care. And this does not always mean it will be a higher cost (see below).

Compleo is not in-network with my insurance; can I still get reimbursed?

This varies based on the insurance plan, but often the answer is yes! You can call your insurance and ask:

  1. Do I have Out-of-Network Benefits?
  2. What is the best way to submit out-of-network claims?
  3. What is my out-of-network coverage (deductible, coinsurance, copay, etc.)?

If you have out-of-network benefits, let us know, and we will happily email you a superbill at the end of each session! This superbill will include the diagnosis code, CPT (intervention codes), tax ID number, provider NPI number, and any other information insurance requests.

What to ask in-network providers before committing?

Just because a provider is in-network does not always mean they will be less expensive. Here are questions to ask when deciding where to go for your care:

Is this a covered service?
If this is a covered service, are there visit limits?

What will the cost per visit be after my visit limits are reached?
What is my responsibility?

If you have a deductible, you need to ask for an estimate of what each visit will cost (this will be the contracted rate, at a hospital-owned clinic, this will be much higher than at a privately-owned clinic)
Copay: This means regardless of the length of visit or units billed, your visit will always cost the same.

Coinsurance: You owe a percentage of the billed cost. Same as deductible, this may vary depending on the size of the organization and their insurance contracts.

How often will I need to come?
Will I be seen consistently by the same provider?
Will my care be one on one? Will I receive an individualized home program? If going for physical therapy, will my provider be a physical therapist or a physical therapist assistant?

What if I can’t find the service you offer at another in-network clinic in Central Texas?

This is often the case for our dietitian or Schroth scoliosis therapy. If you can not find an in-network provider within 60 miles who offers the service you need (or is on a waitlist for said service), you can request GAP COVERAGE.

Gap coverage is different from out-of-network benefits. It means your insurance plan will reimburse you based on your IN-NETWORK benefits due to not being able to provide the service. You must use the wording gap coverage when asking about this benefit. It may often require you to schedule a peer-to-peer review (one of our providers speaking on the phone with your insurance company) to explain how our service is unique.

Compleo Physical Therapy & Wellness | 6704 Woodway Dr. | Woodway, TX 76712

Ph: (254) 892-4957 | Fax: (254) 265-6766 | compleowaco.com | @compleowaco | @compleokids

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