Maximizing Private Insurance Coverage For Physical Therapy Visits

Physical therapy is covered by most insurance plans, but it's important to understand how to access it. While primary care providers often refer patients to physical therapy, you can also request a referral or go directly to a physical therapist. The cost of physical therapy varies depending on your insurance plan and whether you've met your deductible. Most insurance plans have a limit on the number of physical therapy visits they'll cover, but some insurers will approve more visits if your doctor makes a case for medical necessity. If your insurance doesn't cover physical therapy, you can still receive treatment by paying directly, which is known as self-pay or cash-based physical therapy.

Understanding what medically necessary means to insurance companies

Private insurance companies will only cover physical therapy if they deem it to be medically necessary. This means that the treatment is required to maintain or restore your health or to treat a diagnosed medical problem. Medicare defines "medically necessary" as:

> "Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice."

Medically necessary services must be appropriate, safe, and effective for your diagnosis or treatment, meet your medical and functional needs, and align with the general standards of healthcare.

Most insurance plans will not pay for healthcare services that they deem to be not medically necessary, such as cosmetic procedures or treatments that are considered experimental or unproven. However, "cosmetic" procedures done for restorative purposes, such as breast reconstruction after a mastectomy or plastic surgery after an injury, are generally covered by health insurance.

It's important to note that the definition of medical necessity can vary between insurance providers, so it's always best to check with your specific insurance company to understand their criteria. Additionally, even if a service is medically necessary, you may still have to pay for some or all of the cost due to copays, deductibles, and coinsurance.

To get insurance to pay for physical therapy, you'll need to follow your plan's rules regarding which doctors you use, how many sessions are allowed, and when you need approval from your insurance company. Physical therapy is typically prescribed by a doctor, chiropractor, or other medical professional and is covered by most insurance plans because it is considered an "essential benefit" under the Affordable Care Act (ACA).

Knowing the different payment options

The payment options available to you will depend on your insurance plan and your personal financial circumstances. Here are some of the most common payment options for physical therapy:

Copayment or Coinsurance: Many insurance plans require a copayment, or copay, which is a set fee for each physical therapy visit. This is usually a low amount, such as $20-$30 per session. Coinsurance is similar, but instead of a set fee, you pay a percentage of the total cost, such as 20%.

Deductible: Some plans require you to pay a deductible first, which is the amount you pay out of pocket before your insurance covers any portion of your physical therapy visits. After meeting your deductible, you may then pay a copay or coinsurance for each visit.

Out-of-Pocket Maximum: Once you have paid a certain amount out of pocket during your benefit period, your insurance will cover 100% of your medical care for the rest of that period.

Self-Pay: If you don't have insurance or your insurance doesn't cover physical therapy, you can pay for it yourself. This is called self-pay or cash-based payment. The average cost of physical therapy without insurance is $137 per one-hour session.

Payment Plans: Many clinics will work with you to create a payment plan so you can spread the cost of your treatment over time.

Sliding Scale Payments: Some clinics offer sliding scale payments, where you pay a set amount based on your income.

Telehealth Options: Depending on your insurance plan, you may be able to reduce your costs by opting for telehealth physical therapy sessions instead of in-person appointments.

Health Savings Account (HSA) or Flexible Savings Account (FSA): You may be able to use funds from an HSA or FSA to pay for physical therapy.

It's important to understand the terms of your insurance plan and the payment options offered by your physical therapist to make informed decisions about your treatment. Be sure to ask questions and get estimates of potential costs before starting treatment.

Knowing the limits of your insurance plan

• Understand the terminology: Familiarize yourself with key insurance terms such as "deductible," "co-insurance," "co-pay," and "out-of-pocket maximum." Knowing these terms will help you interpret your insurance plan's limits and coverage.
• Review your insurance policy documents: Carefully review your insurance policy to understand the specifics of your coverage for physical therapy. Look for information on in-network providers, coverage limits, deductibles, co-pays, and co-insurance. Knowing these details will help you determine if you need to pay anything out of pocket and if there are any restrictions on the number of therapy sessions covered.
• Contact your insurance provider: Reach out to your insurance company's customer service team to clarify any questions you have about your coverage. They can provide specific details on covered therapists, out-of-network benefits, and any pre-authorization or referral requirements.
• Understand the limits of your plan: Most insurance plans have limits on the number of physical therapy visits they will cover within a specific period, such as a benefit period or a year. These limits may vary depending on your condition or the type of treatment you require. Some plans may also have restrictions on the duration of each therapy session or the types of treatments covered.
• Inquire about in-network and out-of-network providers: Typically, insurance plans offer different coverage rates for in-network and out-of-network therapists. In-network providers have negotiated rates with your insurance company, resulting in lower out-of-pocket costs for you. Out-of-network providers may have different coverage rates or, in some cases, may not be covered at all. Understand the specifics of your plan regarding these two categories.
• Consider the financial implications: Determine if you will be responsible for any co-pays, deductibles, or co-insurance payments. These out-of-pocket expenses can vary significantly between different plans. Additionally, if you choose to see an out-of-network therapist, you may need to pay upfront and then seek reimbursement from your insurance company.
• Ask about pre-authorization and referrals: Some insurance plans may require pre-authorization or a referral from your primary care physician before covering physical therapy services. Make sure you understand these requirements to ensure that your therapy sessions are eligible for coverage.
• Verify the credentials and specialties of potential therapists: When selecting a physical therapist, ensure they are licensed and specialized in the type of treatment you need. This is crucial for ensuring that your insurance company recognizes them as a legitimate provider and covers their services.
• Discuss costs with your therapist: Before initiating treatment, have an open discussion with your physical therapist about the expected costs of each session and the anticipated number of sessions you may require. This will help you estimate your overall financial commitment.
• Explore alternative options: If you cannot afford physical therapy, there are alternative resources available. These include sliding scale fees, community health centers, nonprofit organizations, educational institutions, government programs, and payment plans. You can also consider at-home exercises, telehealth options, or support groups to supplement your treatment.

By diligently researching the limits of your insurance plan, you can make informed decisions about your physical therapy treatment and effectively navigate the process of applying for more visits with private insurance.

Knowing when you need approval from your insurance company

• Review your insurance plan: Different insurance plans have varying coverage levels for physical therapy. Some plans offer full coverage after you meet your deductible and co-pay, while others only provide partial coverage, leaving you responsible for the remaining balance. Understanding the specifics of your plan will help you know if approval is required.
• Understand medical necessity: Most insurance plans cover physical therapy deemed medically necessary. This means that the treatment should be appropriate, safe, and effective for your diagnosis or treatment and meet your medical and functional needs. If your physical therapy is medically necessary, your insurance company may be more likely to approve the costs.
• Check for pre-authorization requirements: Some insurance plans require pre-authorization or prior approval before covering physical therapy costs. This means that you or your healthcare provider must obtain approval from the insurance company before starting treatment. Make sure to check with your insurance provider to see if pre-authorization is needed.
• Consider the number of visits: Many insurance plans limit the number of physical therapy visits they will cover in a specific period, such as a benefit period or a year. For example, a plan may cover 20 to 60 sessions per year, depending on your specific plan and medical necessity. If you require more visits than your plan covers, you will likely need approval from your insurance company.
• Referrals and signed plans of care: Most insurance plans require a referral or a signed plan of care from your doctor or qualified medical professional to cover physical therapy. This referral is typically sent to the physical therapy clinic, which will then reach out to you to schedule an appointment. Keeping track of these referrals and ensuring they are up to date is important for insurance approval.
• Understand your out-of-pocket costs: Knowing your out-of-pocket expenses, including deductibles, co-pays, and co-insurance, is crucial. Your insurance company may require you to meet certain out-of-pocket thresholds before they approve coverage for physical therapy. Understanding these thresholds will help you know when to seek approval.
• Contact your insurance provider: If you are unsure about whether you need approval, the best course of action is to contact your insurance provider directly. They can provide specific details about your plan's coverage, limitations, and requirements for covering physical therapy services.

Remember, the specifics of insurance plans can vary, so it is always a good idea to review your plan carefully and stay informed about your coverage limits, co-pays, deductibles, and any pre-authorization requirements. Don't hesitate to contact your insurance provider for clarification if you have any questions.

Knowing if you can go out of network

When considering going out of network for physical therapy, it is important to understand the difference between in-network and out-of-network care. In-network care means that the physical therapist has a contract with your insurance company, which ensures that the company will cover the services offered to patients with that specific insurance type. The physical therapist is a member of that insurance company's healthcare network. Fees for patients are usually lower when they choose to receive care from providers that are in-network with their insurance company.

"Out-of-network" physical therapy providers do not belong to the insurance company's network, and no contract exists between the provider and the insurance company. Providers do not necessarily have to abide by the in-network guidelines for billing set by the insurance company for a patient they treat when they are out of network. However, fees tend to be higher for out-of-network care, and certain plans like HMOs do not always cover any out-of-network services unless a medical emergency occurs.

Some advantages of going out of network include receiving more one-on-one time and quality care from your provider. You will likely see your provider for fewer visits when going out of network. This is because you are getting more individual attention and better care from your provider. They will work with you to get to the root cause of your symptoms, get you out of pain, and get you back to your regular activities as soon as possible.

Another benefit of going out of network is that there is more transparency about the cost of care. With in-network clinics, you may not know the cost of the care you are receiving until afterward since the insurance company determines the rates. You may receive a surprise bill because you thought your insurance covered the therapy. Out-of-network providers can tell you exactly how much you will be paying and what value you will get for that cost.

However, it is important to note that some insurance companies will not cover out-of-network physical therapists, so it is crucial to communicate with your insurance provider and understand your plan's specifics.

Frequently asked questions