WHAT IS OUT OF NETWORK PHYSICAL THERAPY?
In a cash-based treatment model, the patient pays at the time of service, allowing the therapist to focus attention on providing the best possible service while keeping administrative costs low. Typically, coding for physical therapy services provided (CPT codes) is determined using a complex matrix of "timed codes" and "untimed codes". This often results in confusing patient bills, as the amount billed to insurance will vary visit to visit based on the exact services provided that day. Cash-based billing eliminates this confusion and allows for clarity in decision making on the part of the patient and their provider. Documentation for evaluations, treatment visits, and progress notes are performed just like any physical therapy practice and comply with all legal requirements.
CAN MY INSURANCE BE BILLED FOR CASH-BASED PHYSICAL THERAPY SERVICES?
Most insurance companies, with the exception of Medicare, Medicaid and some HMOs, will provide payment for services received "out of network". Many insurance companies will reimburse the patient at 80%, 60%, 40%, or not at all, minus plan deductibles and copays. The end goal of documentation and billing is the same - getting paid - it's just that, in the case of cash-based services, it is the patient who is waiting for reimbursement rather than the provider.
FULL REPS PHYSICAL THERAPY IS AN OUT OF NETWORK PROVIDER - WHAT DOES THIS MEAN?
This simply means that the therapist has not entered into a contract with individual insurance companies to receive reimbursement based on their contracted rates. There are MANY insurance companies, each with their own contracted rates and regulations, and Full Reps Physical Therapy's energy is best spent working with patients. It is important to note that in network provider status is not currently based on education, experience, skills, or treatment outcomes, but is often determined by the number of providers in a demographic area.
WILL I END UP PAYING MORE FOR CASH-BASED PHYSICAL THERAPY?
In many cases, the out of pocket expenses for a course of physical therapy will actually be LESS. In large part, this is due to the ability to charge less per visit, with these charges being well below the national average charge submitted to insurance in a typical fee for service outpatient practice. Restore Physical Therapy can charge less because the simplified cash-based fee structure streamlines billing and does not require various adjustments, hiring billing personnel, or paying fees to a third party billing service. This allows Full Reps Physical Therapy to focus all energy on patient care, and allows patients to make informed decisions regarding the costs of their health care choices.
WHAT STEPS ARE INVOLVED IN SUBMITTING A CLAIM TO MY INSURANCE COMPANY?
The process is actually quite simple: Full Reps Physical Therapy will provide you with an invoice at the time of service, and you may submit that invoice and receipt to your insurance company for reimbursement. The invoice has all of the necessary information (business name and address, tax ID, national provider identification, license numbers, etc.) as well as the patient’s ICD-10 (diagnosis) and CPT (billing) codes. You may choose to submit bills following each visit, one time per month, or at any other interval, typically up to one year following your treatment visit.
MY INSURANCE CARRIER IS MEDICARE - ARE THERE ANY SPECIAL RULES THAT APPLY TO PHYSICAL THERAPY SERVICES?
Outpatient physical therapy services are generally covered under Medicare Part B, provided the service is considered medically necessary to treat a disease or condition. Under current Medicare regulations, it is illegal for a physical therapist to accept cash pay from Medicare patients for services that may be covered under Medicare, even if the services provided meet all treatment, documentation, and HIPAA requirements and have been prescribed by their physician. In some cases, a Medicare beneficiary may pay cash for services that are no longer considered medically necessary, for example a "maintenance" or "wellness" program. In these cases, the limits on what a provider may charge must comply with Medicare fee schedules. Failure to comply with Medicare rules in every case, even with best intent, could result in a federal investigation, fines, or other legal action. The Medicare Benefit Policy Manual is available in full as a series of downloads at CMS.gov; outpatient physical therapy benefits are discussed in Chapter 15, which is currently 289 pages.