Legislation passed in 2011 mandates that PT co-pays/co-insurance may not exceed the co-pay/co-insurance for a physician office visit. This legislation applies to ALL practice settings. Many insurers are not complying with this legislation. If you are treating patients with high co-pays/co-insurance, please follow the steps outlined below and share this information with your billing staff.
Ensure your client’s insurance is not a Medicare or self-funded plan (co-pay/co-insurance legislation does not apply to these plans). If the insurance not a Medicare or self-funded plan, then proceed with the following steps:
- Charge the patient the co-pay\co-insurance that is in compliance with the law and make them aware their carrier is not abiding by KRS 304. 17A-177.
- When you bill the health insurance carrier include a copy of the law, which can be found here and request compliance.
- If the carrier does not comply within 1-2 weeks, you may report the noncompliance to the Ky. Department of Insurance. Print, fill out and have the patient sign the Kentucky Department of Insurance Consumer Complaint form here.
- Notify KPTA of your actions and results.
The investigation should take no more than 30 days. Make a note on your calendar to follow up with the patient after 30 days. Typically the Kentucky Department of Insurance has been contacting the patient and NOT the therapist with the results of the investigation.
For your information, following is the wording of KRS 304.17A-177:
304.17A-177 Limitation on amount of copayment or coinsurance charged for services rendered by occupational or physical therapist — Insurer to clearly state coverage.
- An insurer shall not impose a copayment or coinsurance amount charged to the insured for services rendered for each date of service by an occupational therapist licensed under KRS Chapter 319A or a physical therapist licensed under KRS Chapter 327 that is greater than the copayment or coinsurance amount charged to the insured for the services of a physician or an osteopath licensed under KRS Chapter 311 for an office visit.
- An insurer shall state clearly the availability of occupational and physical therapy coverage under its plan and all related limitations, conditions, and exclusions.
Effective: June 8, 2011
History: Created 2011 Ky. Acts ch. 92, sec. 1, effective June 8, 2011