$15. The patient was seen in the office löP a tiethu were $115. What amount must
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$15. The patient was seen in the office löP a tiethu were $115. What amount must the patient pay? When? What amo must the insurance plan pay? When? 2. Afaf Darcy is insured by an HMO with a $10 copay and out-of-netwok coinsurance on charge balances of 90-10. She needed physical therapy after her knee replacement. Her HMO sessions in such cases at a rate of $63.50 per visit. If additional p therapy is needed, the provider must document the reasons any formal request. The therapist requested additional visits, a pays for 18 physical therapy attended 5 additional physical therapy sessions. The request was and Ms. Darcy What amount will the insurance company pay for her physical ther What amount must Ms. Darcy pay? apy? nformationExplanation / Answer
I am assuming that Darcy took service from a therapy centre which 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 session, 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
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