Understanding Insurance Benefits for Outpatient Physical Therapy During Open Enrollment

Most insurance plans cover the costs of outpatient physical therapy when it’s provided by a licensed physical therapist. Insurers differ on how much they will pay and for how many visits. PT services are an essential part of optimizing your recovering from an injury or surgery, but insurance companies often cut PT benefits to “cut costs”. As you are evaluating your plan choices during the open enrollment season, then, you will want to check on the physical therapy benefits provided by each plan. Here are some important issues to consider:

Is a referral/prescription from my doctor required?

You should know that in the state of Nebraska, you never need a referral to be seen by a physical therapist. However, some insurance policies require an MD referral if you want your insurance plan to pay for physical therapy. Many of our patients with high deductibles choose to come to PT without spending the money for an MD visit beforehand. If you think you have a musculoskeletal problem (back/neck pain, muscle or joint pain), then a physical therapist is well equipped to evaluate and treat that, with or without an MD visit. (Rest assured, that if the therapist encounters any “red flags” that suggest a medical issue outside the scope of a PT’s practice, the PT will send you right off to see an MD!). SO – if your insurance doesn’t require an MD referral, and you have a problem that you believe to be related to muscles or joints (or sometimes pinched nerves) – then seeing the MD ahead of time may simply increase the cost of care. PT is often the most cost effective treatment for these sorts of problems. The bottom line is that the only reason you ever need a doctor’s referral for PT in Nebraska is if your insurance provider requires it for payment. You can always call the number on the back of your insurance card to find out whether your particular plan requires an MD referral – OR you can simply contact our staff at (402) 939-7939 and they will be happy to assist you with this – be sure to have your insurance card handy when you call.

How do I know if my provider is in-network?

Again, you can always call the number on the back of your insurance card to find out whether a particular provider is in-network for your insurance plan – OR you can simply contact our staff at (402) 939-7939 and they will be happy to assist you with this – be sure to have your insurance card handy when you call.

Is it important to choose an in-network provider?

Sometimes, choosing an in-network provider is the only way to keep your costs down – HOWEVER – it’s important to know that sometimes you can save money and get superior care by seeing an out of network provider. This is often the case when hospital system clinics are the only options that are considered “In-Network” for an insurance plan. So how could you save money with an out of network, or tier 2 provider? Hospital based PT charges are often significantly higher than the charges for the same care at a private outpatient clinic, so your out-of-pocket expense might be the close to the same. Moreover, with a private outpatient clinic, you are more likely to find convenient appointment hours and access to therapists with specialization (which is often lacking in hospital-based PT services).

What are my out of pocket costs?

All insurance plans are different. Some commercial plans will have a co-pay due at each visit, and the insurance company picks up the rest of the cost. Other plans have an annual deductible. If there’s a deductible, then you’re responsible for the full cost of the care until the amount of the deductible has been paid. After your deductible has been “met”, then you will sometimes have to pay “coinsurance”. Coinsurance is a percentage of the allowable charge, usually somewhere between 5% and 30%, depending on your plan; and the insurance company pays the rest. Medicare Part B will pay 80% after the annual deductible is met. If you have a Medicare supplement plan (Medigap), it often covers the remaining 20% that Medicare does not cover unless you have a high deductible plan. Medicare Replacement plans most often have a co-pay between $25-60 per visit. However, Medicare replacement plans often significantly limit the number of visits allowed for PT, which can have a negative impact on the results of your rehabilitation. If you have questions about the potential cost of PT please contact our office and we will do our best to help answer this question. The number of visits needed to alleviate your problem cannot be estimated though, until the PT has seen you to evaluate the problem and develop a plan of care.

Are my therapy visits limited?

Some plans will limit the number of visits allowed per year. The maximum number of visits may be combined with other services such as occupational therapy, speech therapy, and chiropractic services. Because of this, it is important to keep track of the number of visits you are using. It is also important to note whether visits allowed have a hard limit or a soft limit. If it is a soft limit, under certain circumstances, you may be able to request additional visits if the services are medically necessary. Know that at Specialized PT, we will work hard with you to make sure you receive the PT services you need, and to make those visits affordable. We have several different options to help you achieve your goals, even when insurance no longer pays for your PT visits.

Knowing what your physical therapy benefits are can go a long ways toward helping you plan for the out of pocket costs. Because all plans vary, you are encouraged to contact your insurance company to understand the extent of coverage that you have available. Most insurance cards have a phone number you can call or a website where you can find your specific outpatient physical therapy benefits, but we know that it can still be confusing! Please feel free to contact our staff at (402) 939-7939 and they will be happy to help you sort through it.




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