Billing FAQs & Common Insurance Terms

Knowing Your Benefits

Deductible: What your insurance dictates that you pay to a provider before they begin paying anything at all.

Coinsurance: After deductible has been met, insurance will begin to pay (example) 80% of the allowed amount, leaving the remaining 20% to patient responsibility.

OOP max: The maximum amount that you will be responsible per year. (example: $1,000 OOP maximum, $500 deductible and 20% coinsurance per visit will apply to OOP maximum until it is met) After the OOP is met, insurance covers at 100%, leaving no patient responsibility.

Copay: in lieu of deductible and coinsurance, some plans only have a copay (example, $40 per visit)


Authorizations and visit limits

Some plans may require authorization from a third party company prior to you being able to receive treatment. This can take multiple days to complete and may  interfere with treatment. These companies can decline authorization at any time at which point your insurance will stop paying for treatment.

Some plans have a visit limit with either a hard max, or soft max. A hard max means that they will not cover any more visits after the (example 30) visits that you have used and you will be responsible for any balance after those visits. Soft max means that we may be able to obtain further visits based on medical necessity.

In Network, Out of Network and HMO

HMO plans will only pay for treatment from a provider that is within their network. This is generally a very limited amount of providers and anyone with an HMO will need to contact their insurance to find out where they can go for treatment

PPOs – In network vs Out of network – Most PPO plans will have in network benefits and out of network benefits. It is important to understand the difference. Generally in network has a lower copay, coinsurance, deductible and OOP max, however, many plans have the same benefits both in and out of network, OR the in network applies to the out of network.