Question

2. Afaf Darcy is insured by an HMO with a $10 copay and out-of-network coinsurance on charge balances of 90-10. She needed ysical therapy after her knee replacement. Her HMO pays for eighteen physical therapy sessions in such cases at a rate of $63.50 per visit. If additional physical therapy is needed, the provider must document the reasons and submit a formal request. The therapist requested additional visits, and Ms. Darcy attended five additional physical therapy sessions. The request was denied. What amount will the insurance company pay for her physical therapy? What amount must Ms. Darcy pay?

Answer 1

I am assuming that Darcy took service from a therapy center that is within the network. Hence Darcy should pay $180 for 18 sessions, and the HMO will pay ($63.5*18=) $1143 or lesser than this if the per-session service is less than $73.5 (=10+63.5).

For the additional 5 sessions, since it is not mentioned after the request has been put forth, who will bear the amount, for the time being, we can safely assume that Darcy has to pay the additional session cost, i.e., 5*73.5= $367.5

Hence in total, Darcy will have to pay $547.5, and HMO pays $ 1143.