Therapy Coverage: Insurance Considerations

Physical therapy can be costly, and insurance coverage varies depending on the type of health plan and provider. Most insurance plans, including Medicare, private insurers, and workers' compensation, cover medically necessary physical therapy services. However, the specific definition of medical necessity may differ among insurance providers. In general, physical therapy is considered medically necessary when it is appropriate, safe, and effective for the patient's diagnosis, treatment, and medical and functional needs, aligning with general healthcare standards.

Before initiating physical therapy, it is crucial to understand your insurance coverage to estimate your out-of-pocket expenses. Contact your insurance provider to confirm coverage, as some plans may require a referral from a healthcare professional or have specific guidelines and limits on the number of covered sessions. Additionally, consider reaching out to the physical therapy clinic to inquire about their billing practices and accepted insurance plans.

'>What is considered ''medically necessary' physical therapy?

The definition of "medical necessity" varies across different insurance companies. However, physical therapy is generally considered medically necessary when it:

• Is prescribed by a qualified healthcare professional, such as a chiropractor, DO, MD, nurse practitioner, podiatrist, or other licensed health professional.
• Is deemed appropriate, safe, and effective for the diagnosis or treatment of the patient's condition.
• Meets the patient's medical and functional needs.
• Conforms to general standards of healthcare.

Medicare Part B, for example, covers medically necessary outpatient physical therapy services with no limit on the amount it pays in a calendar year. However, the patient's costs will depend on factors such as other insurance coverage, the type of facility, and the frequency of services.

How much will insurance pay for physical therapy?

The amount that insurance will pay for physical therapy depends on several factors, including the type of insurance plan, the specific insurance provider, and whether the physical therapy is deemed "medically necessary". Most insurance plans, including Medicare, private insurers, and workers' compensation, will cover at least a portion of the cost of physical therapy if it is deemed medically necessary. However, the specific amount covered can vary significantly.

Medicare Part B, for example, will cover an unlimited amount of medically necessary outpatient physical therapy services in a calendar year, but the patient is still responsible for paying 20% of the Medicare-approved amount after meeting the Part B deductible. For those with Medicare as their primary insurance, the plan will typically cover about 80% of the claim for physical therapy, leaving the patient to pay the remaining 20%. If you have secondary insurance, it may cover some or all of the remaining amount.

For other insurance providers, the amount covered can vary depending on whether the physical therapist is in-network or out-of-network. If the therapist is in-network, the insurance company will typically pay a larger portion of the cost. If the therapist is out-of-network, the patient may be responsible for a higher out-of-pocket cost.

The specific amount covered by insurance can also depend on the type of treatment, the number of sessions, and the frequency of the sessions. Most insurance providers will cover at least 50% of the cost of physical therapy, but this may only apply after the patient has met their yearly deductible, which can range from $250 to $1250 or higher. Additionally, co-payments and insurance premium payments typically do not count toward the deductible, so patients may need to pay the full cost of physical therapy until they meet their deductible.

The cost of physical therapy without insurance can range from $75 to $350 per session, with an average cost of $150 per session. The cost can depend on the type and severity of the injury, as well as the specific treatments and equipment used. In-home physical therapy is typically more expensive, ranging from $100 to $150 per session, including travel expenses.

To determine the exact amount that insurance will pay for physical therapy, it is important to review your insurance policy and contact your insurance provider. Additionally, discussing coverage and costs with your physical therapist can help you understand the potential out-of-pocket expenses.

What if my physical therapist is out of network?

If your physical therapist is out of network, it means they are not a participating provider with your insurance company. In other words, they do not have a contract with your insurance company and will not bill them directly. This means that you will have to pay for your PT session upfront and then file a claim for reimbursement with your insurance company.

Most insurance companies do have out-of-network coverage for physical therapy, but it is important to check with your insurer beforehand. If you choose to go out of network, you will be responsible for paying the difference between what your PT charges and what the insurance company pays. This can result in higher expenses, which is why insurance companies often deter people from going outside their preferred network of providers.

However, there are benefits to going out of network. Out-of-network physical therapists are not under the same constraints as in-network providers, who are restricted by the insurance company in terms of the types of services permitted and the number of visits allowed. This means that out-of-network therapists can offer more individualized care, spending more one-on-one time with each patient.

If you are considering going out of network, it is important to be knowledgeable about the type of healthcare plan you have. Communicate with your insurance company and your physical therapist to understand the potential costs and how billing will work.

What if my insurance doesn't cover physical therapy?

If your insurance doesn't cover physical therapy, you will have to pay for it yourself. The cost of physical therapy can vary depending on the type of treatment, the length of each session, and the overall length of treatment. Without insurance, you can expect to pay at least $50 and up to $350 or more per session.

There are several options for reducing the cost of physical therapy if your insurance doesn't cover it:

• Payment plans: Some physical therapists or clinics may offer flexible payment plans or financing options to make treatment more affordable.
• Sliding scale payments: Some physical therapists or clinics offer sliding scale fees based on your income, making their services more affordable.
• Community health centres: Many communities have health centres that offer low-cost or free healthcare services, including physical therapy.
• Non-profit organisations: Some non-profit organisations provide low-cost or free physical therapy services to individuals in need.
• Educational institutions: Universities or colleges with physical therapy programs may offer low-cost treatment provided by students under the supervision of licensed professionals.
• Government programs: Check if you are eligible for government-sponsored healthcare programs like Medicaid, which may cover physical therapy services for low-income individuals.
• Employee Assistance Programs (EAP): Check if your employer offers an EAP, which may provide short-term assistance for various health-related services, including physical therapy.
• At-home exercises and self-care: While not a direct substitute for professional physical therapy, you may find relief by following at-home exercises, stretching, or self-care techniques for your condition. Consult with a healthcare professional or search for reputable resources online to guide your at-home practice.
• Support groups: Connect with support groups for individuals with similar conditions or challenges, as they may offer helpful advice and resources for accessing affordable physical therapy services.
• Telehealth or online physical therapy: Some online platforms offer more affordable rates for physical therapy services compared to in-person treatment.

It is important to explore multiple options and resources to find the support that best suits your needs and financial situation. You should also discuss your financial concerns with your healthcare provider, as they may be able to offer additional suggestions or assistance.

What if I don't have insurance?

If you don't have insurance, you can still receive physical therapy treatment by paying directly. This is called "self-pay" or "cash-based". The cost of physical therapy without insurance can be several hundred dollars, depending on the type of therapy and the number of sessions you need. For example, the typical self-pay cost per session is $125 at Luna, but this can vary depending on where you live and the type of therapy you require.

If you are concerned about the cost, it is important to discuss this with your physical therapist. They can advise you on how to get the most value and quickest recovery, and may be able to offer a payment plan. You can also ask about doing exercises at home to reduce the number of in-person sessions you need.

Frequently asked questions