Monday, July 1, 2019

insurance questions

At Deep Ground Massage + Bodywork, we call your insurance provider to verify benefits. As so much of this practice focuses on education, we want to share with you the questions we ask when we call to verify benefits and illuminate what these components of your insurance benefit mean (find a glossary after the break).

Before billing can take place client eligibility must clarified. It is your responsibility to be informed of your coverage, copay/coinsurance, and deductible.

Date Benefits Verified:

Name of Representative with whom you spoke:

Is Massage Therapy covered with this plan?

Is Physical Therapy covered with this plan?

Is the Provider (Stephanie Lavon Trotter) 

Are there 
Out-of-Network benefits?

Does this benefit required first meeting the 

Deductible Amount for the Year:

      Remaining Amount of Deductible:

Is a 
referral required?

        If so, by what type of practitioner?

Is a 
preauthorization required?

        If so, by what company? Please provide their contact information.

What is the 

Is there a 
yearly maximum for this benefit?

How many 
visits are authorized per year?

How many visits are records as of today?

97140 covered?

Is 97140 applied to the deductible?

97124 covered?

Is 97124 applied to the deductible?

Often times 
Massage Therapy is not covered, but Physical Therapy (including manual therapies) are. In some insurance plans massage therapy benefits can be acquired through Physical Therapy benefits.

When a provider is "in-network" they are specifically credentialed with your insurance company or a clearinghouse that services alternative care for your insurance company.

Some plans allow you to see providers who are "out-of-network", however a higher copayment or coinsurance may be due.

Almost every plan has an amount that must be paid into the plan before the benefits will begin. For example, if you have a $2,000 deductible you will pay $2,000 out-of-pocket before your insurance will start paying for provider visits, lab work, etc. Once the deductible has been met, or in the rare case where Massage or Physical Therapy is covered without the deductible, you will only be responsible for paying copayment or coinsurance.

Some plans require a doctor's referral to received Massage or Physical Therapy. Plans that require this may differ, however if required a Rx must be on file from your MD, ND, DO or DC for Massage Therapy, including diagnosis codes, frequency of visits, and an expiration date.

Some plans require a pre-authorization before receiving Massage Therapy. Often your insurance company will use a third-party company to implement a pre-authorization. This is required to establish that the massage is "medically necessary" and you will need to provide an area of complaint (neck, back, left arm) that brings you into the office for massage. Most pre-authorizations are for a specific duration (4-6 weeks) and allow for a certain amount of visits (4-6) within that time period. Once the authorization has expired it will need to be renewed, or re-established before care can continue.

A copayment is a special dollar amount due to your provider at time-of-service.

Coinsurance is a specific percentage amount of the total billed that is due to your provider either at time-of-service, or after the insurance claim has been processed.

Yearly maximum:
Plans often outline a dollar maximum for a particular benefit, or even several benefits. For example, $1,500 maximum for Massage, Acupuncture, and Chiropractic care. This means that you may not be able to continue receiving care if billed amounts from all of these providers total $1,500.

Out-of-pocket Maximum:
You plan will have an out-of-pocket maximum, a dollar amount that once you've paid out your insurance company will pay 100% of the provider's billed amount, and you will not be responsible for payment.

Visit maximum:
Some plans outline a visit maximum. For example, 12 visits in a calendar year. Or, 30 visits in a calendar year combined with Massage, Acupuncture, and Chiropractic care.

97140 and 97124 are the codes we billed for manual therapy and massage therapy, respectively.

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