Insurance FAQs | Carroll Physical Therapy

UNDERSTANDING YOUR INSURANCE

Frequently Asked Questions

Health insurance terminology can be difficult and confusing to understand. At Carroll Physical Therapy, we want to make sure our patients fully understand their insurance benefits and responsibilities prior to receiving treatment. That is why our office staff will always verify your health benefits prior to your arrival to determine if there will be a copay, deductible, or coinsurance for therapy services.

Here are a few questions that we often get asked by our patients. Please call our office at 973-366-1600 if you have any question. Our office staff would be happy to assist you.

What is an in-network vs. an out-of-network provider?

In-network providers are typically the most affordable option to receive care. To be in-network, the provider must have agreed to discounted contracted rate with your insurance company, while out-of-network providers do not have these discounted contracted rates.

If a provider says they “accept” my insurance, does it mean that they are in-network?

No, a provider “accepting” your insurance does not mean they are in-network. It is possible that a provider accepts your insurance, but bills at an out-of-network rate. It is always a good idea to confirm that the provider is in-network before beginning your treatment.
At Carroll Physical Therapy, we accept AND are in-network with most insurance plans, making us among the most affordable options for care. Also, as a courtesy to our patients, our office staff will always verify your benefits and communicate your coverage to you prior to beginning treatment.
Click here to view a list of insurance plans accepted by Carroll Physical Therapy.

What is a deductible?

A deductible is the total amount you must pay out-of-pocket before your insurance starts to pay for services. For example, if your deductible is $1,000, then your insurance won’t pay anything until you have paid $1,000 for services subject to the deductible (keep in mind that the deductible may not apply to every service you pay for).
After you’ve met your deductible, you may still need to pay a copay or coinsurance for each visit, depending on your individual plan.

What is a co-pay? Do I have to pay it?

A co-pay is a fixed amount you must pay for a covered service, as defined by your health plan. Co-pays are due at the time of service.
If your insurance requires a co-pay, it means you share the cost of the treatment with your insurance company. For example, if your insurance company has a contracted rate of $50 per physical therapy session and your copay is $20, your insurance company is responsible for $30. Contrary to popular belief, a copay is not a charge over-and-above the treatment cost.
Waiving co-pays is in violation with the contracts providers have in place with insurance companies and is illegal. In order to comply with our insurance contracts and provide quality care to our patients, we are not able to waive co-pays.
However, our primary goal at Carroll Physical Therapy is to provide exceptional care and promote improved health among members of our community. If you are experiencing a financial hardship,we are happy to work with you to create a payment plan that works for your budget. Please contact our office manager for more details.

What is coinsurance?

Coinsurance is an out-of-pocket payment for a particular service that is a percentage of the total cost of the service, as defined by your health plan. Co-insurance typically applies after your deductible has been met.
For example:
- The contracted rate for a service is $100
- Your insurance plan states you are responsible for 20% of the service once your deductible is met.
In this case, you would owe the health care provider $20. Your insurance would then pay the remaining balance. Please keep in mind the cost of the service may vary by visit depending on what services are provided.

What is the coinsurance for Medicare Part B?

Medicare Part B patients are responsible for a 20% coinsurance, which typically amounts to $11-25 per visit. If you have original Medicare as your primary insurance, but you also have a secondary insurance, the secondary payer becomes responsible for the 20%. In some cases, the secondary insurance also charges a copay, coinsurance, or deductible. We recommend contacting your secondary insurance carrier to find out.

Why do some providers get paid more than others for the same treatment?

Each provider has its own contract with insurance companies, which dictates their contracted reimbursement rate. Therefore, there can be a range that insurance companies pay in-network providers for the same treatment.
Typically, small, privately-owned practices like Carroll Physical Therapy have lower contracted in-network rates when compared to large corporate-owned health companies because they have less negotiating power. This means that practices like Carroll Physical Therapy are often the most cost-efficient option for you. You can always contact your insurance company directly to find out how contracted rates vary across providers in the area.

Do I need a prescription from my doctor to go to physical therapy?

No. Most states, including New Jersey, no longer require a prescription for physical therapy. This law, known as direct access, allows patients to seek physical therapy treatment immediately rather than waiting to see a doctor. However, it is always a good idea to consult with your doctor if you are not sure what type of treatment is right for you.