INSURANCE INFORMATION
IN-NETWORK INSURANCE
PDR is in network with:
- Blue Cross Blue Shield PPO — all plans
- Workers’ Compensation insurance
- Medicare Part B
- All Medicare Supplement plans
Medicare Supplement plans may help cover deductibles, coinsurance, and other eligible costs remaining after Medicare Part B processes
the claim. The amount covered depends on the patient’s individual supplement plan.
out of network PLANS
PDR may accept Medicare Advantage plans that include out-of-network benefits, including plans offered by:
- Blue Cross Blue Shield
- Aetna
- UnitedHealthcare
- Cigna
- Humana
- Other Medicare Advantage carriers
Coverage varies by plan. Our office may verify whether the policy includes out-of-network physical therapy benefits before treatment begins.
SELF-PAY OPTIONS
For patients without insurance, or those who choose not to use their insurance when permitted, PDR offers convenient out-of-pocket payment options.
Patients may:
- Pay separately for each visit
- Purchase the 7+1 Package — pay for seven visits and receive one additional visit at no charge
Please get in touch with our office for current self-pay rates and package details.
WORKERS’ COMPENSATION PATIENTS
Before scheduling a physical therapy evaluation for a work-related injury, the patient must:
- See a physician and obtain a referral or prescription for physical therapy
- Report the injury and open a Workers’ Compensation claim
- Obtain the Workers’ Compensation claim number
- Obtain the name and contact information of the insurance adjuster handling the claim
PDR must receive the claim number and the adjuster’s contact information before the first visit. This allows our office to contact the Workers’ Compensation carrier and confirm that the claim has been accepted and physical therapy services are authorized for coverage.
Please do not schedule your initial evaluation until this information is available. A physician’s referral alone does not confirm that Workers’ Compensation insurance will cover treatment.
KNOW YOUR INSURANCE COVERAGE
We are committed to helping patients understand their physical therapy benefits. As a courtesy, our office may verify insurance coverage before treatment begins and provide an estimate based on information reported by the insurance company.
However, each patient is responsible for understanding the terms of their health insurance policy and how they apply to physical therapy services. Before beginning treatment, we recommend contacting your insurance company to confirm:
- Your physical therapy benefits
- Your deductible, copayment, and coinsurance
- Any visit limits
- Referral or prior authorization requirements
- Any other restrictions that may affect coverage
Any benefit information provided by our office is based on information received from the insurance company. It is not a guarantee of coverage or payment. Final coverage and payment decisions are made solely by the insurance carrier after a claim is processed.
Patients are responsible for all deductibles, copayments, coinsurance, and charges not covered by their insurance plan. Not knowing the terms of an insurance policy does not remove the patient’s financial responsibility for services already provided.
HOW YOUR FINAL BALANCE IS DETERMINED
Your final cost depends on how your insurance company processes each claim. Here is what happens after you receive treatment.
You Receive Treatment
Our therapist documents the services provided during your visit, and based on that, we submit the claim. Because treatment depends on your needs and how your body responds that day, we cannot know in advance exactly which services the therapist will provide.
Your Insurance Processes the Claim
Your insurance company reviews the services listed on the claim. It then applies your plan’s deductible, copayment, coinsurance, and other coverage rules to calculate how much the plan will cover. Ultimately, they determine how much you will owe for that visit.
Your Initial Estimate May Change
Before your insurance processes the claim, any amount provided is only an estimate. Deductible and coinsurance amounts depend on the insurance company’s calculation. Therefore, your final cost may be higher or lower than the original estimate.
Your Final Balance Is Determined
After processing the claim, your insurance company determines the amount assigned to you under your policy and sends the claim details to our billing department. Your final balance reflects the insurance company’s determination.
UNDERSTANDING INSURANCE TERMINOLOGY
Health insurance terms can be confusing. Understanding the following terms can help you anticipate what you may be responsible for paying for physical therapy.
A deductible is the amount you must pay for covered healthcare services before your insurance plan begins sharing the cost. For example, if you have a $1,000 deductible and have not met it, you may be responsible for the insurance-approved cost of your physical therapy visits until the deductible is satisfied.
Insurance benefits do not always follow the same renewal schedule. A calendar-year plan runs from January 1 through December 31. Deductibles, visit limits, and other benefits may reset on January 1.
A plan-year or contract-year policy follows renewal dates established by the insurance plan or employer. It may renew at another time during the year. When a new plan year begins, deductibles and visit limits may reset—even if this happens in the middle of your treatment.
A copayment, or copay, is a fixed amount you are responsible for paying for each covered visit. For example, your insurance plan may require a $30 copayment for every physical therapy appointment.
Coinsurance is the percentage of the insurance-approved cost that you are responsible for paying after your deductible has been met. For example, if your plan pays 80% and your coinsurance is 20%, you are responsible for 20% of the allowed amount for each covered service.
The allowed amount is the maximum amount your insurance plan recognizes for a covered service. Your deductible, copayment, or coinsurance is generally calculated using this amount rather than the clinic’s original charge.
An Explanation of Benefits is a statement from your insurance company showing how a claim was processed. It may list the services billed, the amount charged, the insurance-approved amount, the amount paid by insurance, and the amount you may owe.
An EOB is not a bill. If a balance remains after the claim is processed, you may receive a separate statement from PDR.
Prior authorization means that your insurance company must approve certain services or visits before they will be considered for coverage. Receiving authorization does not guarantee that the insurance company will pay the claim.
Some insurance plans limit the number of physical therapy visits covered during a calendar year or plan year. The limit may apply only to physical therapy or may be shared with occupational therapy, speech therapy, chiropractic care, or other services.
A referral is an order or recommendation from a physician or another authorized healthcare provider. Although Illinois allows Direct Access to physical therapy, an insurance plan may still require a referral before it will cover treatment.
IF YOUR INSURANCE CHANGES
Please notify our office before your next appointment if your insurance plan, member ID, employer, or coverage changes during treatment. Bring your current insurance card and provide the updated information before services are rendered.
Delays in reporting an insurance change may prevent us from submitting claims correctly or within the insurance company’s filing deadline. Patients may be responsible for charges that cannot be covered because current insurance information was not provided on time.
FREQUENTLY ASKED QUESTIONS
What insurance plans does PDR accept?
PDR is in network with Blue Cross Blue Shield PPO plans, Workers’ Compensation insurance, Medicare Part B, and Medicare Supplement plans. We may also accept Medicare Advantage plans that include out-of-network benefits.
Will PDR verify my insurance benefits before treatment?
Our office may verify your physical therapy benefits as a courtesy. However, patients should also contact their insurance company to confirm their deductible, copayment, coinsurance, visit limits, and authorization requirements.
Does insurance verification guarantee that my visits will be covered?
No. Benefit information is based on details provided by the insurance company and is not a guarantee of coverage or payment. The insurance carrier makes the final decision after processing each claim.
Why did I receive a bill after my insurance paid?
You may still be responsible for a deductible, copayment, coinsurance, non-covered service, or another amount assigned to you by your insurance plan. Your EOB will explain how the claim was processed.
Is an Explanation of Benefits the same as a bill?
No. An Explanation of Benefits, or EOB, is a statement from your insurance company. It shows how a claim was processed. If you owe a balance, you may receive a separate bill from PDR.
Can my deductible reset during physical therapy treatment?
Yes. Calendar-year plans typically reset on January 1. Plan-year or contract-year policies may renew at another time, so your deductible and visit limits could reset in the middle of treatment.
Does my insurance require a referral or prior authorization?
It depends on your plan. Although Illinois permits Direct Access to physical therapy, an insurance company may still require a referral or prior authorization before it will consider treatment for coverage.
What do I need before scheduling Workers’ Compensation physical therapy?
You need a physician’s referral or prescription, an open Workers’ Compensation claim, a claim number, and the name and contact information of the insurance adjuster. PDR must receive this information before your first visit.
Does PDR offer self-pay options?
Yes. Patients may pay for each visit individually or purchase the 7+1 Package, which includes one additional visit at no charge after paying for seven visits. Please contact our office for current rates and package details.
QUESTIONS ABOUT YOUR COVERAGE?
If you have questions about the insurance plans accepted at PDR or the information needed before your first visit, please contact our office. We can explain our billing process and help you understand what information to confirm with your insurance company.