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How Does My Insurance ACTUALLY Work?

Do You Understand Your Insurance?


Insurance can be confusing, and most of the time, this is just what the insurance companies want. Most people do not fully understand their insurance and the coverage they have. Thankfully, we are going to dive head first into understanding how your insurance works so you can maximize your benefits!


What is health insurance?


Simply put, insurance is a contract between you and a third party company to help cover your healthcare. Most insurance policies consist of in-network providers and out-of-network providers giving you in-network and out-of-network coverage. The difference is between in-network and out-of-network providers is whether or not the provider has a contract with your insurance company. These contracts reimburse the provider at a lower rate in exchange for promoting that the provider accepts their insurance which is thought to drive revenue.


However, due to reduced reimbursement rates, patients often see longer wait times and very short face to face times with their actual provider. For this reason, many of these providers get paid incentives for seeing patients for more than a certain number of sessions or more frequently.


This is the reason why many patient focused providers are now switching to an out-of-network model.


Not sure if you have out-of-network coverage?


The easiest way to identify if you do have out-of-network coverage is to take a look at your insurance card. If you see the letters PPO or POS on your card, then you will have some sort of out-of-network coverage! Unfortunately, if you see the letters HMO or EPO then your insurance plan does not have out-of-network coverage.


If you do find you have out-of-network coverage, or still aren’t sure whether or not you do, then we can look into your benefits for you. Here at Streamline Performance Physical Therapy, we want you to receive reimbursement for everything that your plan covers, but we cannot control what your insurance company will ultimately pay.


Let’s look at what it takes for your insurance to start covering your visits with in-network and out-of-network coverage.


With almost every insurance, you will have a deductible. A deductible is the amount the patient is financially responsible before the insurance will cover any part of a patient’s bill. That being said, with most insurances, a patient will have an in-network deductible AND an out-of-network deductible; just as they have in-network and out-of-network coverage.


Once the deductible has been met, the insurance will cover up to a certain percentage per visit and you, the patient, will have either a copayment or co-insurance. The difference between the two? A copayment is a flat fee that you pay your provider while co-insurance is a percentage of the visit that you pay your provider.


The biggest difference with meeting your deductible with in-network vs. out-of-network is the percentage of your payment that goes towards the deductible. With your in-network deductible, 100% of your payment goes towards the deductible so it can be met and coverage can begin. With your out-of-network deductible, that same percentage of coverage you receive once your deductible is met is the amount that goes towards the deductible.


Health insurance companies try their very best to not pay for out-of-network services since the provider has no contract with them. But here at Streamline, we can look into your benefits and if it looks promising, we can courtesy-bill for you.


How Can an Out of Network Provider Help Save Money?


Without being limited by poor insurance reimbursement rates, your provider can spend a full hour with you. This allows us to see you much less frequently than typical PT clinics. That means less co-pays, less time off work for appointments and more time for you! On average Streamline sees patients for nearly 50% less visits than national averages.


That means that if you have yet to meet your deductible and you’re paying out of pocket for your therapy regardless, you stand to save nearly 50% because of the increased efficiency in this model of patient care.




If you have met your deductible and PT would be provided for simple co-pays at other in-network clinics, you can still save money utilizing Streamline. Typical co-pays are $30-$80. If a traditional PT clinic asks you to come in 2-3x/week that can add up quickly. Coming just 1x/week or even once every other week in our model will save you money and a TON of your time. You will feel actually cared for rather than like a number in the system to be passed off to other support staff.


What is Courtesy Billing?


This is when we, the provider, send off claims for your visits on your behalf, instead of you having to try to send it all to the insurance company yourself. You will typically see a quicker turnaround time for reimbursement as well with our courtesy billing service!




Overall, insurance can be a bit tricky but the information above will point you in the right direction when it comes to understanding your policy and your coverage. It is always important to pay careful attention to your policy details such as your deductibles, policy information, and coverage. We will always do our best to get you the reimbursement that you deserve when you book an appointment with Streamline Performance Physical Therapy.


If you have questions regarding your benefits, don’t hesitate to call us directly! We’re happy to check these benefits for you and explain how to best use them.




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