Physical Therapy and Your Insurance

Authorization

Though your insurance company may allow many physical therapy visits per year, they usually also reserve the right to do a pre-check to ensure that the treatment you’ll be receiving will be medically necessary or able to make a positive change.

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or pre-certification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.

- Healthcare.gov

In and Out of Network

Some insurance companies have in-network providers, which means that they have pre-negotiated rates with those doctors or physical therapists, but insurance companies may also restrict the patient to the in-network providers. Some insurance providers that have in-network providers will also have out-of-network providers, although they may cover less of the expense of the treatment and have the patient pay the remainder of the bill.

Knowing your rights when it comes to your insurance

• First, you should know that your insurance company is there to help you, you are not subject to their demands

• You have a right to go out of network if your provider doesn’t have any in-network providers

• If you are denied for authorization, you have your right to have your voice heard and to request more visits. If you are entitled to more visits than you were authorized for, you can speak to your insurance along with you physical therapists and doctor to be granted more visits

• You are never locked into a healthcare provider, whether it is a doctor or a physical therapist. If you are unhappy with the care you are receiving, you are entitled to finding a care provider that you feel is good for you

• For some more detailed info concerning healthcare laws in New York, please visit: http://www.dfs.ny.gov/consumer/hrights.htm

If you have any questions, give us a call at 718-258-3300 or contact us today!

What Is Direct Access and How Can It Help You?

What is direct access?

Direct access is the legal term that states that patients can go straight to a physical therapist to receive treatment, and do not have to get referrals from physicians, which can cause delays and be costly. The term has different conditions in every state, but direct access is available in all 50 states in the US, which means that patients are put at the focus of the treatment plan, and are allowed to receive faster and cheaper services than when required to go through a physician.

Are physical therapists qualified to deliver services independent of referral?

Absolutely. Physical therapists are educated at the post-baccalaureate level and receive extensive education and clinical training in the examination, evaluation, diagnosis, prognosis, and intervention of patient/clients with functional limitations, impairments and disabilities. All accredited entry-level physical therapist education programs currently culminate in a Doctor of Physical Therapy (DPT) degree. Physical therapists are qualified to recognize when a patient presents with signs and symptoms inconsistent or outside the scope and expertise of the physical therapist and when the patient should be referred to a physician. APTA's Guide of Professional Conduct advocates that physical therapists should assist patients in receiving appropriate medical care when the physical therapist's examination and evaluation reveals signs and symptoms inconsistent with a condition that can be appropriately treated with physical therapy or needs a physician's care and expertise.

Direct Access Laws in New York

The direct access laws in New York have three conditions:

• Treatment can be rendered by a Licensed PT without a referral for 10 visits or 30 days, whichever comes first.  

• Licensed PT must have practiced PT on a full-time basis for no less than three years; be of at least twenty-one years of age.

• PT must provide written notification that services without a referral might not be covered by the patient’s health plan or insurer; notification must state that said services might be covered by health plan or insurer with a referral. Must keep a copy of the written notification in the patient’s file.

The Bottom Line

Allowing individuals to make decisions regarding their health care is inherently good. Eliminating the referral requirement is one step to making health care more accessible to more people across the United States.

Physical therapist education supports practice without referral. Physical therapist practice in the states that allow treatment without referral has proven that it is safe. Yet consumers in many states continue to face arbitrary barriers to physical therapist services.

Direct access is about individual choice in health care decisions through the elimination of unnecessary and burdensome regulation. Direct access also puts control in the patients’ hands, and allows them to be a part of their own plan of care.

What this means for you

This means that you can come to Evolve Physical Therapy without a referral and get treated by one of our amazing physical therapists right away! Should you need more than ten visits, we’d need to get in contact with your doctor, which we’ll try to make as smooth a process as possible.

If you have any questions, give us a call at 718-258-3300 or contact us today!