In-Network vs. Out-of-Network Therapy

At Healthy At Home Physical Therapy, we work with a variety of insurance plans. Depending on your specific insurance, Healthy At Home may be considered either an in-network or out-of-network provider.

Understanding the difference can help you know what to expect when it comes to your insurance coverage and your portion of the cost.

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What Does "In-Network" Mean?

An in-network provider has a contract with your insurance company that establishes reimbursement rates and patient cost-sharing requirements.

When Healthy At Home is in-network with your plan:

• We bill your insurance directly.

• Your insurance processes the claim according to your plan's in-network benefits.

• You are responsible for any applicable deductible, copayment, or coinsurance determined by your insurance plan.

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Healthy At Home Physical Therapy is In- Network with Medicare and Blue Cross Blue Shield Insurance.

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What Does "Out-of-Network" Mean?

An out-of-network provider does not have a contracted reimbursement agreement with your insurance company.

Many insurance plans—particularly PPO plans—still provide benefits for out-of-network services. However, your out-of-pocket responsibility may be higher than it would be with an in-network provider.

Depending on your plan, you may have:

• A separate or higher out-of-network deductible.

• A higher copayment or coinsurance.

• A different allowed amount for services.

• A greater portion of the cost applied to your responsibility.

• No out-of-network coverage at all.

Out-of-network does not necessarily mean "not covered." It means your insurance processes the claim according to your plan's out-of-network benefits, which may result in a higher patient responsibility.

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What Will I Have to Pay?

Every insurance plan is different—even plans offered by the same insurance company.

Before beginning care, we recommend confirming your benefits so you understand your expected financial responsibility.

At HAHPT, we do our best to verify your insurance benefits as a courtesy; however, verification of benefits is not a guarantee of payment. The final determination of coverage and patient responsibility is made by your insurance company when your claim is processed.

You are responsible for deductibles, copayments, coinsurance, and other amounts assigned to you by your insurance plan.

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Do I Need a Referral or Prior Authorization?

Possibly. Some insurance plans require additional approval before physical or occupational therapy services can be covered.

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Referral

A referral is typically an order or authorization from your primary care provider or another qualified healthcare provider allowing you to receive therapy services.  Click HERE to learn about Tufts referrals.

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Prior Authorization

A prior authorization is approval from your insurance company for therapy services. Your plan may authorize a specific number of visits or a specific period of treatment.

A referral and a prior authorization are not the same thing. Depending on your insurance plan, you may need one, both, or neither.

It is important that any required referral or authorization is obtained according to your insurance plan's rules. If your insurance requires a referral or prior authorization and it is not obtained, your insurance may deny payment and you may be responsible for the cost of the services provided.

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We're Happy to Help

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Insurance can be confusing, and we're happy to help you understand the information available to us about your coverage.

However, insurance benefits and payment are ultimately determined by your individual health plan. We encourage you to contact the Member Services number on the back of your insurance card if you would like to confirm your specific benefits.

Helpful questions to ask include:

• Do I have out-of-network benefits for outpatient physical or occupational therapy?

• What is my in-network versus out-of-network deductible?

• What is my copayment or coinsurance for therapy?

• Do I need a referral?

• Is prior authorization required?

• Is there a limit on the number of therapy visits covered by my plan?

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Questions? Please contact Healthy At Home Physical Therapy.
We're happy to help you understand your coverage and your options for care.

Insurance verification is provided as a courtesy and is not a guarantee of coverage or payment. Patients are ultimately responsible for understanding their insurance benefits and for amounts determined by their insurance plan to be their responsibility.