While we make every attempt to expedite processing of claims, Medicare processing may take several weeks. If a secondary carrier exists, the claim may be a) forwarded directly by Medicare or b) sent back to Southtowns for re-submission to the secondary carrier. Regardless of the method, several more weeks may elapse before a final patient balance is determined. Please note that we make every effort to process you claim and notify you of any balance in a timely manner. Unlike many “managed care” plans, Medicare stipulates that coverage is provided as long as the patient meets the criteria of “medical necessity,” measurable progress is being made, and services are rendered by a Medicare-approved provider.

Blue Cross & Blue Shield:

Considered by many as a "traditional" insurance, Blue Cross coverage will apply to Physical Therapy if there is a "major medical" rider. This is commonly the case for most, but not all, plans. In the event of coverage, there is typically an annual deductible which must be paid by the patient before coverage begins. This applies to most services, and may range from as little as $50.00 to several hundred dollars. Once the deductible has been met, the carrier usually pays at the rate of 80% of an allowed amount. Blue Cross coverage may also act as a secondary to other insurance plans, such as Medicare.

Health Maintenance Organizations (HMO's) and Preferred Provider Organizations (PPO’s):

If we are "in network" for your Health Maintenance Organization (HMO) or Preferred Provider Organization, they usually have strict pre-certification requirements and limits on the amount of Physical Therapy they will cover. They usually have a co-pay. Co-payments are fees established by the carrier that are required to be collected by the provider at the time of service. Due to the frequency of therapy, lump payment one time per week may be considered if pre-arranged with the office. Please note that routine waiver of co-payments is considered insurance fraud and therefore the policy of Southtowns is to not waive any co-payment.

If we are not "in network" for your HMO, and you have "out of network privileges" you may still elect to receive services. In this case, you may have a deductible in addition to a slightly higher co-insurance. Check with Members Services at your carrier for specific guidelines.

Workers' Compensation:

New York State provides for coverage to individuals who are injured as a result of performing work-related tasks. As per state law, a prescription from an appropriate source is required. In order to facilitate reimbursement, requests for authorization are initiated at the time of the first visit and as needed thereafter.

Most carriers elect to authorize in 30-day increments. As per New York State law, the part responsible for payment, either the carrier or employer (if self-insured) is entitled to monthly reports and copies of any requested records necessary for determining coverage.

No-Fault:(Auto Liability):

New York State recognizes No-Fault liability coverage in the case of injuries resulting from motor vehicle accidents. The general guidelines for reimbursement and delivery of care closely follow those of the Workers’ Compensation system. A prescription is required for treatment and authorization from the carrier is typically requested in order to ensure coverage. The carrier may determine that they are not going to authorize further services beyond a certain point of time. In this case, it is important that the patient provide appropriate information regarding personal coverage if they wish to have their claims submitted. If no personal coverage exists, the patient retains the right to continue on a “private pay” basis. The billing department will notify you immediately in the event of an insurance authorization denial.

Liability:

In the event that you have suffered an injury as a result of slip, fall, or other incident related to a third party (person or location), you may be offered compensation for medical services by the insurance carrier for the involved party. Please note that we are not in a contractual agreement with the involved party or their insurance carrier. While we will make every attempt to assist you in submitting for payment of rehabilitation services rendered at Southtowns, you are ultimately responsible for all charges incurred at our facility. Therefore, it is strongly suggested that you provide any required information relating to your personal insurance so that proper authorizations may be obtained while receiving services. Failure to obtain this authorization in a timely manner will allow your carrier the option to disallow all submitted claims, thereby leaving you responsible for any and all outstanding charges.

Medicaid:

We currently do not accept Medicaid coverage at any of our locations. Patient’s with Medicaid coverage are referred to the nearest hospital-based outpatient department.