Am I Covered? Physical Therapy and Health Insurance
Will my Insurance Cover Physical Therapy?
How Well Do You Know Your Physical Therapy Benefits?
If I asked you to describe the physical therapy benefits included in your insurance plan without referencing your policy could you do it? For most of us the answer is probably a hard no. Unless you live with a chronic condition or are frequently injured this is probably not at the forefront of your mind when you are selecting an insurance plan. Deductibles, out of pocket max, in-network coverage, and monthly premiums are often the factors we weigh most heavily when selecting a plan. It often isn’t until we are standing at the front desk of the physical therapy clinic before our first visit that we find out what our coverage actually looks like. For some of you it may be a pleasant surprise, for others it could be a bit of a disappointment. If you are hoping to start physical therapy and aren’t sure how your insurance plan will cover the treatment, this article will provide you with a six step plan to evaluate your insurance coverage for PT services.
STEP 1: DOES MY THERAPIST ACCEPT MY INSURANCE PLAN?
Just like physicians, dentists, or chiropractors, physical therapists and physical therapy clinics can select the insurance plans with which they want to be in contract. If you are hoping to use your insurance coverage for physical therapy you should contact your insurance provider to verify whether your therapist is in-network or out-of-network with your insurance plan and ask how this will affect the amount you will be responsible for paying for each visit.
STEP 2: DO I NEED A REFERRAL?
In the past a referral from a surgeon, physician, or other qualifying provider was required to initiate a physical therapy evaluation without exception. This rule has changed, however, in some cases in states that allow direct access. Direct access gives physical therapy providers the ability to evaluate a patient without a physician’s referral. Direct access is not allowed in all states and its scope varies quite a bit by state as well. In some states PT’s can evaluate you but not start treatment without a referral. In other states they can treat you for thirty days but not beyond that, and still in other states there is unrestricted direct access in which the PT can carry out an entire plan of care without getting a referral.
If you live in a state without direct access then you can be certain you need a referral to start care and to ensure insurance coverage. In states with direct access, however, even if the law allows a physical therapist to treat you without a referral your insurance may not pay for the services if they require that you have a referral. That’s right, some insurances require a referral as a necessity of utilizing your physical therapy benefits so be sure to read through your policy or call your insurance plan if you aren’t sure.
STEP 3: HOW MANY VISITS AM I ALLOWED?
While most insurance plans will cover physical therapy care that is appropriate and safe for your medical condition, meets the standard of good healthcare practices, and is medically and functionally necessary, they are not required to offer you unlimited coverage. Being aware of how many visits you are allowed under your current coverage will help ensure you use them wisely.
Insurance plans typically follow one of these rules when it comes to determining how many visits you are allowed each year:
The plan places a hard limit on the amount of visits covered each insurance-year (i.e. 15, 30, 60 visits). Whether you are seen for one, two, or three separate episodes of care during the year you will be slowly chipping away at this allowed total during each visit.
The plan specifies coverage for physical therapy is “based on medical necessity” Technically this type of plan does not place a hard limit on yearly physical therapy but this does not give carte blanche for physical therapists to continue treating patients without good reason. If your insurance plan requires intermittent authorization for continued visits or if they audit your chart at any point they will be looking for evidence that there is a medical or functional necessity for continued care, that you are responding to care, and/or that there is good evidence that your condition would decline without physical therapy intervention. Without this justification your plan will likely not pay for these services.
The plan specifies a certain dollar amount that they will pay for services
Medicare is the most well-known plan that uses this construct. Up until 2018 Medicare placed a hard “cap” on how much physical therapy, speech therapy, and occupational therapy could be reimbursed by Medicare. After you met that cap further services were no longer eligible for reimbursement. Since then the rules have been relaxed to allow beneficiaries to continue to receive care beyond the first cap as long as it is medically necessary. Effective January 1, 2022 the current Medicare cap for physical therapy and speech therapy combined is $2,150. Physical therapists are allowed to exceed this threshold if it is medically necessary with the addition of a “kx modifier” on their charges and after $3,000 a targeted medical review may be initiated.
STEP 4: DO I NEED PRE-AUTHORIZATION?
The need for pre-authorization is very plan-specific. Some insurance plans require that the therapist or clinic submit for pre-authorization prior to completing the initial evaluation. Other plans will allow the therapist to complete the initial evaluation but must submit a pre-authorization outlining their intended plan of care and wait for insurance approval before continuing care. Typically in these cases the insurance plan will supply the therapist with an authorization specifying what treatment codes and how many visits will be covered up until a certain date. Request for coverage of further visits usually requires that the therapist provide proof of response to therapy services and medical necessity for ongoing care.
STEP 5: HOW MUCH WILL THESE VISITS COST ME?
Many insurance plans limit out-of-pocket costs for physical therapy to a copayment. Other plans may require you to pay for part of all of your visits until you have met your deductible or your out-of-pocket max for the year.
STEP 6: ARE THERE CERTAIN TREATMENTS OR CONDITIONS NOT COVERED BY MY INSURANCE?
Treatments that are not considered medically necessary or targeted towards improving function may not be reimbursed by the insurance plan. In states where physical therapists perform dry needling, for example, you may be required to pay a cash rate for this service if it is not covered by insurance. Other treatments like electrical stimulation or ice/heat also may not be covered.
Similarly, wellness, sports performance, and fitness services are typically not covered by physical therapy benefits.
The key to documenting medical necessity for physical therapy is describing how PT services eliminate or improve impairments (pain, range of motion restrictions, weakness, etc.), activity limitations (difficulty going down stairs, pain with running, etc.) and participation restrictions (unable to return to work, can’t care for your children). If your medical condition impacts any of these areas then there is likely medical necessity for at least some physical therapy.
UNDERSTANDING YOUR COVERAGE IS IMPORTANT
After reading this article you should have a better understanding of how insurance plans reimburse for physical therapy. With this information you can make more informed decisions about how to use your current physical therapy benefits so there won’t be any surprises. Reviewing your policy and calling your insurance plan is the best way to get this information but the administrative staff at the physical therapy clinic can usually help answer some of these questions after verifying your benefits. Physical therapy is an excellent way to address any injuries or conditions impacting your ability to participate in your life fully. Now that you understand how your insurance coverage works it is time to call Evolve PT and schedule your physical therapy evaluation today.
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About EvolveNY-
Brooklyn's Premier Holistic Physical Therapy Clinics- There’s physical therapy, there’s training, and then there’s EVOLVE. We use the science of biomechanics merged with fitness to help our patients get better and stay better!
First we evaluate, then we heal, then we strengthen our clients so they can reach their goals, feel better, and live happier lives. We do so by utilizing a range of core techniques and specialized treatments to reduce pain, improve mobility, enhance physical strength and deal with the underlying issues, not just the pain itself.
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