Physical Therapy and Insurance: Everything You Need to Know — On Track Physical Therapy and Functional Training

Now that you have a good understanding of key insurance terminology, we can delve into whether or not your particular insurance will cover a physical therapy appointment. Benefits and eligibility for physical therapy from each insurance company may be different for each of their plans.

Determining physical therapy benefits under your specific insurance plan will take some work. Here are a few different options to determine your specific physical therapy benefits:

Reading: How many physical therapy sessions does insurance cover

  1. log in to your online insurance member portal and look up your physical therapy benefits.

  2. Call and speak to a customer service representative from your insurance company to inquire about your physical therapy benefits. There is usually a number to call on the back of your insurance card for these types of questions.

  3. If you want to work with a specific physical therapist or physical therapy office, call their office and ask if you can get help determining your physical therapy insurance benefits. our office is always happy to help people who wish to see one of our physical therapists to determine their physical therapy benefits and eligibility through their insurance.

    If you want to work with a specific physical therapist, be sure to find out if that particular physical therapist is in or out of your insurance carrier’s network, as your insurance benefits will likely differ accordingly. case.

    Do I need a referral for physical therapy?

    This is a question that is generally specific to your state. as of 2015, all 50 states have some form of direct access to physical therapy. in states that have relatively unrestricted direct access to physical therapy, it means you don’t need to get a referral from a primary care provider before seeing a physical therapist. The American Physical Therapy Association (APTA) maintains up-to-date information on direct access to physical therapy providers by state on its website.

    in vermont, we are fortunate to have relatively unlimited direct access rules for physical therapy, with the exception of medicare. In all states, if you have Medicare, you are federally required to receive a referral from a primary care provider before you can see a physical therapist, and you must renew this referral every 6 months if your physical therapy treatment extends beyond 6 months from your last primary care referral.

    If you are a Vermont resident with a Vermont insurance company or an out-of-state insurance company with a network in Vermont, such as BlueCross BlueShield, MVP, Cigna, or Medicaid, you likely have direct access to physical therapy; and therefore, you do not need to have a referral for physical therapy.

    There are potential health care cost savings when you self-refer to a physical therapy provider. For example, if you have a high-deductible plan, you’ll likely get a bill from a primary care provider for seeing them first for a musculoskeletal problem, where they’d simply refer you to a physical therapist. In addition, a primary care provider may send you for an MRI, see a surgeon, or receive a cortisone injection to temporarily relieve pain. You may be able to avoid all those often unnecessary and ineffective health care costs simply by seeing a physical therapist first, especially one that focuses on proper movement and treating the problem, not the symptom.

    The need for a physical therapy referral is a creature of insurance. If you go to a physical therapy office with cash or simply pay for physical therapy out of pocket, insurance company requirements to be reimbursed or to apply their costs to your deductible no longer apply.

    how much will physical therapy cost me?

    If you intend to use your insurance to see a physical therapist, answering this question will take some work to find out the physical therapy benefits of your specific insurance plan. You may already know this information if you followed the steps above to find out if physical therapy is covered by your insurance.

    But that information still may not give you an idea of ​​what your bill will actually be if you have a deductible or coinsurance that applies. If you have a simple copay for physical therapy services, you now know how much physical therapy will cost you, since copays are set amounts that you will be responsible for per appointment.

    If you have a high deductible plan that applies to physical therapy services, you can expect to be charged the full allowable amount for in-network physical therapy providers until you meet your calendar year deductible.

    To get a better idea of ​​how much you can expect to pay for a physical therapy appointment with an applicable deductible or coinsurance, it’s best if you call the physical therapist’s office or practice you’d like to see. Billers should generally have a good idea of ​​what the allowable amounts are for their specific insurance company based on the contract your insurance company has with your practice.

    If you have an insurance plan with a deductible, you may receive different bills from different physical therapy offices for the same service, depending on the differences in how each office bills your insurance company for the service. that may sound crazy, but consider this:

    In a 2018 Facebook post, a Burlington, VT resident expressed dismay at a nearly $2,000 bill he received from UVM Medical Center for his 4-5 physical therapy appointments. the allowed amount agreed upon between his insurance company and the uvm medical center skyrocketed, in his case, to around $400 per appointment. For comparison, the highest amount our practice received in the same year for a PT appointment was $173. and that amount is well above our average for physical therapy visits and is only received in rare cases when a patient is seen for the first time and has a particularly long initial visit.

    what is the drastic difference in costs here?

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    good question. We couldn’t see your bill, so in your case, we can’t be sure. but we can speculate several things here.

    1. it is quite possible that the uvm medical center physical therapy department is incredibly smarter in its billing process than our smaller private practice. Unsurprisingly, the largest hospitals have professional billing staff whose sole job is to find ways to maximize each department’s profits while minimizing expenses. These clever billing techniques employed by larger hospitals are likely to create dramatic cost differences between a private practice and a larger hospital practice.

    2. It is possible that this particular person did not have any insurance, and their bills were out-of-pocket expenses for physical therapy at the uvm medical center for the treatment.

    3. the uvm medical center could have reached a better agreement with that person’s insurance company to receive more for physical therapy services, although I think this is the least likely scenario.

      All this to say, if you’re concerned about the potential costs of seeing a physical therapist, try to find out the average cost per office visit. It will give you a good idea of ​​how much you can expect to pay on average to see a physical therapist in your location.

      We like to be transparent about our averages, so we’ve broken down how much you could expect to pay in our practice if you have a deductible insurance plan through BlueCross BlueShield of Vermont, MVP, Cigna, Aetna, Medicaid, and Vermont Health Insurance. condition.

      cost in ontrack physical therapy with bluecross blueshield of vermont

      At our practice, Vermonters with high deductible plans through BlueCross BlueShield of Vermont can expect their initial physical therapy appointment to be in the range of $143-$173. any additional quotes beyond the initial quote will likely be in the range of $60-$119.

      If you have a BlueCross BlueShield of Vermont coinsurance plan that applies to physical therapy, you can use these amounts to estimate your expected patient responsibility. For example, if you have 20% coinsurance, you can expect your initial quote to be in the $28-$35 range, and any additional quotes to be in the $12-$24 range.

      cost in ontrack physiotherapy with mvp

      In our practice, people on a high deductible plan through mvp can expect very simple bills. mvp contracted with our practice to establish a maximum amount allowed per appointment. the initial appointment is capped at $130, and any additional visits are capped at $85.

      cost in ontrack physiotherapy with cigna

      At our practice, those on a high deductible plan through Cigna can expect their initial physical therapy appointment to cost around $139 and any additional appointments to cost approximately $77 per appointment.

      cost in physical therapy ontrack with aetna

      aetna does not have a network in vermont; therefore, all vermont health care providers you see will be out-of-network and your out-of-network benefits would apply. At our Vermont practice, people with a high-deductible out-of-network Aetna insurance plan can expect their initial appointment to cost around $150-$220 and any additional appointments to be in the $80-$120 range.

      cost in physical therapy ontrack with medicare or medicaid

      In our practice, medicare and medicaid patients can generally expect their insurance to cover the full cost of their approved physical therapy appointments. In rare cases, a Medicaid-insured patient may have a small copay for physical therapy, and a Medicare-insured patient may be left with a small patient liability.

      Do I need insurance to see a physical therapist?

      The short answer to this question is no.

      In fact, many private physical therapy practices have begun to transition to cash-based practices, which means they generally do not accept any type of insurance. rather, they have the patient pay them directly, and provide the patient with all the information they may need to submit their appointment charge to their insurance company for possible reimbursement.

      While our practice accepts insurance, we have also established out-of-pocket fees that patients may choose to pay at their own discretion instead of processing their physical therapy appointments through their insurance company. In some cases, it makes more sense in our practice for a patient to simply pay out of pocket when, for example, the end of the calendar year is nearing, a patient is out-of-network, and the patient has a high deductible that is nowhere near be fulfilled.

      insurance denials for physical therapy

      Insurance companies have incentives to maximize profits and minimize payouts, so insurance denials for physical therapy services are inevitable.

      In general, you can expect to receive an insurance denial for physical therapy when you have reached your benefit limit for physical therapy in the calendar year. the benefit limit is generally a hard limit and cannot be challenged.

      However, there are other reasons to deny physical therapy treatment.

      Some insurance companies hire people whose only job is to determine if a person should receive or continue to receive physical therapy services, even if they have not reached the benefit limit for the calendar year. this practice acts as a check to verify that the physical therapy treatment you are receiving is medically necessary.

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      For example, the insurance company, Cigna, exclusively practices this technique to limit physical therapy payments whenever possible. After the initial 5 visits with a physical therapist, the therapist must submit a pt reevaluation to request additional visits beyond the initial 5 visits. then a “clinical quality assessor” will review the patient’s reassessment and determine, at her own discretion, whether she believes physical therapy is right for you. If the designated evaluator does not believe you need physical therapy, she will deny further visits.

      You have been denied physical therapy treatment through your insurance. what resource do you have right now?

      If you did not reach your calendar year benefit limit but were denied physical therapy treatment, you can try one of several things to get approval for visits:

      1. have your physical therapist challenge the decision. in our practice, we do this automatically. our therapists would not submit a request for additional visits if they did not think you needed additional visits to resolve pain or injury. Occasionally, a therapist may speak with an evaluator to explain your situation in more detail, which may help them understand why more treatment is medically necessary.

      2. See your primary care provider for a referral for physical therapy. A referral from your primary care provider can usually be enough to tell a clinical quality rater that your treatment physical therapy is medically appropriate. necessary.

      3. Continue physical therapy and pay out of pocket. While not ideal, continuing physical therapy may prevent higher health care costs, such as surgery or temporary injections to relieve pain in the future. . this is a decision you should make at your own discretion, and you should step back and consider the bigger picture. If you’ve been seeing a physical therapist with little or no improvement because the therapist is simply treating the symptoms and not the problem, continuing physical therapy doesn’t make sense, regardless of insurance coverage.

        If you’ve reached your benefit limit for the year, it’s okay to ask your insurance company if there’s any way you can get additional physical therapy treatment in the calendar year. but, in all likelihood, the benefit limit will be a hard limit (only in rare cases do insurance companies allow additional visits beyond your benefit limit). At this point, your only option to continue receiving physical therapy treatment is to pay out of pocket until the next calendar year begins.

        How does physical therapy work with insurance?

        many people who walk into our office think they can just give us their insurance card and we will be able to tell them exactly how much they will have to pay for their appointment. While that may be true for those with copays who request physical therapy services, it certainly isn’t true for everyone.

        As you may have noticed by reading the previous sections, insurance complicates the billing process. while providers can give you their best estimate of your cost based on previous insurance answers, ultimately it is your insurance company that has the final say on how much money a provider will receive for a service (depending on your mutual contract ) and how much patient responsibility will apply to each appointment (depending on the details of your insurance plan with them).

        So how exactly does physical therapy work with insurance?

        This is what an oversimplified insurance billing process looks like for healthcare providers:

        1. provider verifies that you have an active insurance policy

        2. the provider treats you

        3. Provider completes applicable insurance paperwork

        4. provider submits insurance documentation to your insurance company

          * typical delay of 1 to 6 weeks *

        5. provider receives response from their insurance company

        6. the provider bills you for any patient liability based on the insurance company’s response

          These 6 steps are incredibly simplified and the reality is that the process may not be the same every time due to a multitude of reasons which, quite frankly, are boring and not worth it.

          but, I’ll leave you with this. Have you ever wondered why health care costs are so high in the US? uu. compared to other countries? for-profit insurance companies certainly share some of the blame. insurance companies hire staff to mitigate payments for services rendered. As a result, healthcare providers, out of necessity, hire staff like me to deal solely with insurance claims to ensure they get paid for the services they provide. Ultimately, these profit-maximizing practices by for-profit insurance companies increase the cost of providing health care services to people like you.

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