What is a “Superbill” and how does it work?
Before we dive into this topic, lets define a few terms.
Superbill: is not really a bill at all. It is a receipt that shows that you paid out of pocket for a medical expense to a provider who is out-of-network with your insurance provider. It typically will have your diagnosis and codes that relate to services used to treat you.
Out-of-network provider: This is a healthcare practitioner or company who does not have a contract with your insurance company, therefore does not abide by their rules for providing or paying for services.
In-Network-Provider: This is a healthcare practitioner or company who DOES have a contract with your insurance company. They must follow your insurance company’s rules for treatment, including approving or denying certain services, as well as accept the agreed upon rate for treating you.
Deductible: Amount of money that you must pay before insurance starts to pay for anything.
Co-Pay: A set dollar amount that you will have to pay for a service, usually AFTER your deductible has been met. Many people have a flat rate of $30-50 dollars for a physical therapy co-pay, per visit.
Co-Insurance: A set % that you must pay for treatment, usually AFTER deductible has been met. An example would be if you have a 20% co insurance and a treatment costs $100, you would owe $20.
So, you want to know how Superbills work? Strap in, because insurance questions/regulations are riveting. There are basically two types of healthcare providers you can see. In-Network and Out-of-Network, which you can refer to the above definitions if you are unfamiliar with.
Buffalo Performance Physio is considered and Out-of-Network(OON) practice, meaning we do not have any contracts with any insurance companies at this time. This does not mean that your health insurance plan will not help you pay for treatment, it just means that we will not directly bill or receive money from your insurance company.
When you go to an In-Network physical therapist or other provider, they take your insurance information, verify benefits, and determine from there what you will owe for treatment. Often times people have deductibles, co-pays, or co-insurances that they must pay. This can be frustrating because often you don’t know how much you actually owe at the time of service. You may think you have a $25 dollar co-pay, then get a surprise bill in the mail for $400 because you hadn’t hit your deductible yet.
In Out-of-Network, the patient and practitioner have a direct relationship. The price is set, and the patient/client pays it in full. There is no guess-work or surprise bill down the road. You can then your receipt, or Superbill, and submit this to your insurance company. Most insurance companies will have a document uploader that you can submit digitally with little effort. Depending on your insurance, you may get reimbursed for a percentage or portion of your treatment costs.
To summarize: patient pays physical therapist. Physical therapist gives Superbill to patient. Patient submits Superbill to insurance. Insurance sends check to patient to cover cost of service, depending on the insurance plan.
Every insurance plan is different. I have seen some plans locally that have really great OON benefits and will cover almost 80% of treatment costs, meaning you may actually pay less for a much better service. Other insurances are going to have very high deductibles before they would kick in any money for OON treatment, but it is worth finding out.
Either way, this is really just an added benefit. Most patients of our practice don’t even submit their bills to insurance. Often the problem they are having can get solved much quicker with more direct and individualized care, so the cost of going to an OON vs going to an in-network clinic is really not that much different. Especially when you consider the cost of time spent in the office, waiting for appointments, driving between places, the cost of going to an In-Network provider 2-3x per week versus an OON 1x every week to two weeks can often be less.
In-Network:
Average Plan of Care 2-3x/week 4-8 weeks
Total visits range from 8 to 24. Let’s take an average of 16.
16 x $40 co-pay = $640 + 16x you drove to PT and 16 hours you spent in a PT clinic. Plus whatever time you had to wait to get in, wasted time sitting on heat or ice that you could do at home, or doing exercises in the corner by yourself.
Buffalo Performance Physio
Average Plan of Care 1x/week x4-10weeks
Total visits range from 4-10. Let’s take 7 visits as an average.
7x $125 = $875 + 7x you drove to PT and 7 hours spent in clinic. Your appointments start on time, you didn’t waste any time lying face down on a table by yourself, or being off in the corner doing the same exercise you did last time unsupervised.
Just on the drive time alone, you saved 9 hours, plus whatever wait time you have because there are 12 other people there at the same time as you.
I hope this has given you a good overview about how superbills work, and also about the differences in paying for healthcare between different providers. I encourage you to think in terms of the value you are getting from your healthcare experience. Sometimes you can pay just a little bit more up front, but end up with a far superior product in the long run.
I also don’t want this to be misconstrued that OON is superior to in-network in all cases/examples. There are plenty of talented, good providers out there who take insurance, and there are plenty who do not. At the end of the day, the most important thing is that you have picked a provider who understands your situation, takes the time to listen to you, and works with you to lay out a treatment plan that is suitable for you.