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Understanding your physical therapy health benefits and options

(and why direct pay and out-of-network options may be a better bargain)

Understanding your health insurance benefits can be confusing

Confused about health insurance

Common Terms and Explanation


Deductible – This is the amount that your insurance plan has set that you must pay toward your healthcare before they will begin covering services. While there are often some exceptions (e.g., annual preventative physicals, some health and screening services, etc.), seeking treatment for something and the costs associated usually will fall to you until this threshold has been met. Anecdotally speaking, we have seen a trend over the last several years where people’s deductibles continue to climb higher.


Coinsurance – Often expressed as a percent, this is the amount your insurance plan has set for you to pay after your deductible has been met. For instance, let’s say you’ve met your deductible and have a 40% coinsurance. This means that for every $100 billed and processed by your insurance company, you will have to pay $40.


Max out-of-pocket – This may go by different names depending on your insurance carrier’s terminology (e.g., catastrophic max, maximum out-of-pocket, etc.), but this reflects the high-end amount that you will expect to pay for things like copays or coinsurance amounts even after your deductible has been met.


Copay – This is a payment amount set by your insurance carrier and plan to be paid per office visit. If your plan has a met deductible and a higher max out-of-pocket amount, it often is the expectation by your insurance plan that you continue to make the visit copayment, but this may vary by insurance and plan.


How physical therapy billing typically works


Most insurance carriers, as outlined by the rules set forth by the American Medical Association and Centers for Medicare and Medicaid Services, process claims billing based on coded procedural techniques, or CPT codes. These are the codes that correspond to what was performed in a visit. For example, if your therapist spends time performing soft tissue mobilization and a thrust manipulation of the neck, this would lead to a manual therapy code being billed. Different insurances have different rules and guidelines that pertain to when you can bill certain codes or how many units of a code can be billed (often predicated on the amount of time spent on the interventions). We do our best to explain up front what you should expect for billing, but the hard reality is that different insurance carriers set different rates – even some insurance carriers will have a different rate set for different plans they offer.


Out-of-network benefits for physical therapy


Different insurance carriers have different policies with this, but many insurances will allow you to see a provider and may still pay some (or all, depending on your plan and your deductible) for your care. While we are in network with many commercial insurance carriers, there are some that unfortunately will not allow additional providers into their network, like Optima Health, or other carriers that have created significant administrative burdens that ultimately make the provision of care very difficult. This is an issue that many clinics outside of partnered health systems continue to face, and ultimately it can hinder you as a healthcare consumer. Nevertheless, most offices will offer an out-of-network billing option. With these options, we will work with you in determining the necessary steps as laid out by your insurance plan. Typically, a billing rate will be explained up front to you; after you have paid, we will assist with providing what is known as a “superbill”. This is an itemized billing statement that will demonstrate the care you received, as well as the charged amount, and it can be submitted to your insurance for reimbursement by your carrier to you.


The unfortunate reality is, especially with specialty care options like pelvic health physical therapy, there simply aren’t enough providers to go around. With some of the insurance-imposed barriers, this route for care may enable you to receive a high level of care while reducing issues like increased drive time or distance or long wait times to be seen.


When direct pay, non-insurance options may be a more affordable option for care


Saving money on healthcare

Again, the vast majority of insurances will process claims based on the quantity and variety of codes submitted. Certain codes carry a higher cost – for example, an initial evaluation carries a higher rate than an intervention code (although we would contend that good care requires continuous reassessment in order to make sure that you’re feeling and moving better and moving toward your goals). One of the more frustrating things, even for us as providers, is that different insurance plans even under the same insurance carrier may put a different price tag on their codes. Often times hospital-based clinics or Medicare-certified rehab agencies may bill at a higher rate (statuses that are more reflective of business operations and ultimately don’t have any bearing on the quality of care being delivered).


Most independent clinics will offer reasonable per-visit rates – but why might someone with insurance want to pursue this route? Why not simply use your insurance? Here’s an example of someone we recently have seen.


A 33-year-old male woke up with acute neck and shoulder pain. His employer-based insurance carries a $12,000 deductible with a 30% coinsurance to be paid after deductible is met. He has no significant medical history and does not routinely utilize his health insurance. His pain is keeping him from going to the gym and playing with his toddler. Based on estimates received from his insurance, the expected rate to be billable by his insurance was roughly $120 per visit, and since he has not met his deductible, this means that the costs will be 100% paid by him. Instead, with offering a $90-per-visit direct pay rate, we were able to help him save some money. If we expect within 4-5 visits we can help him get back to feeling like his usual self, you're talking over $100 saved. It's one thing if he might meet his deductible, but in this case, 4-5 visits with us isn't going to get him close to meeting that deductible. However, more and more frequently we're seeing people have insurance plans with astronomically high deductibles. Ultimately, our hope is to help you get better as efficiently as possible, both in terms of time and cost.


For things like post-surgical care, this route isn’t always the most cost effective, but when you otherwise don’t usually utilize your insurance and have a very high deductible, treatment options like these may offer some relative savings. With acute-onset issues like these, we often only need to see people a few times to get symptoms managed and under control. Additionally, more and more insurance companies are requiring things like preauthorization, so in addition to insurances utilizing an often-confusing billing and reimbursement methodology, administrative barriers like these can create uncertainty, delay care, and ultimately be a hindrance to you.

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