How to do a Comprehensive Physical Therapy Eligibility Verification

by | Published on Jun 10, 2022 | Medical Billing

Comprehensive Physical Therapy Eligibility Verification
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Physical therapists provide services for a wide range of conditions, from helping patients reduce chronic pain, restore physical mobility, and regain strength to managing hand, wrist, arm, elbow and shoulder injuries and conditions. Physical therapy focuses on getting people back to get back to daily life and activities, sports, office, and more.  While they provide specialized services to address each patient’s injury or condition, physical therapy practices need to have efficient processes in place for verification of patients’ insurance coverage eligibility. Reports say that eligibility issues are one of the key reasons for claim denials in this specialty. The solution is to perform comprehensive insurance eligibility verification before services are provided. Outsourcing the task to an experienced physical therapy medical billing company is the best way to prevent claim denials due errors made at patient registration and to also free up time for patients.

Why is physical therapy eligibility verification necessary?

Physical therapy eligibility is the process of confirming that the patient’s plan will cover the physical therapy services you provide and is in your network. Every patient’s insurance coverage and benefits has to be verified prior to the office visit – at the first appointment and periodically thereafter as information can change at any time. Prior authorization is also necessary to confirm whether a treatment, care or service will be approved.

Verifying insurance coverage will provide you with a clear idea about the patient’s financial responsibility, including co-payment, co-insurance and patient-specific remaining deductible.  This information can be used to estimate patient costs before treatment decisions are made, create claims, and collect deductibles and co-insurance before patients leave the office.

While Insurance verification confirms your patient’s coverage and benefits, insurance authorization enables you to provide specific services. Neglecting verification of patients’ insurance coverage eligibility will result in claims denials for physical therapy billing errors such as:

  • Missing information
  • Submission of duplicate forms, and
  • Provision of unauthorized treatment or services.

Not completing insurance verification before a patient receives medical services will also result in expensive surprise bills for the patient.

Accurate and timely insurance verification and authorization services minimize denied claims, maximize reimbursement, and boost patient satisfaction.

Physical Therapy Eligibility Verification Process

The insurance verification process involves collecting patient insurance information when scheduling appointments and verifying it with the insurer. Comprehensive physical therapy eligibility verification is done at many points in the revenue cycle, especially scheduling, and pre-registration.

  • Patient scheduling: The process of insurance verification begins with patient scheduling. Schedulers collect data needed to schedule a patient’s appointment. Patient scheduling can be done via phone text, fax or email or self-scheduling. Staff can also record insurance information and do a real-time eligibility verification on the phone. The required demographic and payment information is captured and entered in the registration software. Patients can be informed about co-pay collection policies and also reminded to obtain a referral if required by their plan requires this.
  • Pre-registration: Collecting patient information prior to the appointment wherever possible can streamline the onboarding process. Appointments may have been scheduled months in advance and insurance information may have changed. That’s why insurance verification is important3-7 days before the appointment date. A pre-visit eligibility check is crucial to ensure that data stored in the registration/billing system aligns with that obtained from the payer. If any data is found inaccurate, it should be corrected quickly for a clean claims process.

Leading providers of insurance verification and authorization services work with a standard preregistration script to ensure that nothing is left out.

Eligibility Verification for Physical Therapy – What is Covered

Most insurance plans pay for medically necessary health care services, but definition of medical necessity may vary among insurance companies. Some plans cover physical therapy in full while others cover physical therapy in part. Further, insurance companies that designate physical therapists as specialists will require a referral from the patient’s primary care provider before they will pay for any specialist’s services. Insurance verification specialists will determine these aspects and confirm all patients’ insurance coverage, including:

  • Patient name, date of birth, insurance ID and other demographic information
  • Claims mailing address
  • Copay
  • Coinsurance
  • Deductible
  • Benefits/therapy cap
  • Patient policy status
  • Effective date
  • Payable benefits
  • Plan exclusions
  • Health insurance caps
  • Type of plan and coverage details
  • Referrals and pre-authorizations
  • Out of network benefits
  • DME reimbursement
  • Limitations in terms of Visit
  • PCP/Specialist Co-pay
  • PCP Information where applicable
  • Other payer information
  • Requirements for additional documents, if any

Prior authorization:  Payers typically require pre-authorization for PT,OT, and ST – unless the payer will retroactively authorize services. If prior authorization is not obtained before performing a PT, OT or ST procedure, the claim for that service will be denied and the patient cannot be billed for it. Insurers authorize only a specific number of visits with referral from a primary care provider and further visits will require prior authorization.

Physical therapists require seamless and comprehensive verification of eligibility and benefits to prevent claim eligibility-related denials and boost cash flow. Partnering with a competent provider of insurance verification and authorization services is the best option.

With expert physical therapy medical billing support, providers and their staff can focus on delivering quality care and improving the patient experience.

Meghann Drella

Meghann Drella possesses a profound understanding of ICD-10-CM and CPT requirements and procedures, actively participating in continuing education to stay abreast of any industry changes.

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