So What About Insurance?
To go ahead and answer the top question anyone has when they think of physical therapy -
“Do you accept my insurance?” - the answer is: No
Why Not? I have decided to be Non-Participating & Out-of-Network with insurance in order to provide you better and faster care, that ultimately saves you time and money.
However, I will provide you with an invoice / superbill that you submit to your insurance if you have out-of-network physical therapy coverage. All reimbursement from your insurance plan will go directly to you - and it could be up to 60-80% of the amount you paid.
How does this reimbursement process work?
The allowed amount for a Nonparticipating Provider could be calculated by various scenarios described in your plan, but would be less than for an Out-of-network Participating Provider.
You would submit a claims form (found on insurance website) electronically, with a pdf of your superbill (includes all necessary info).
You would be reimbursed the allowed amount determined by the Claims Administrator.
The difference between the allowed amount and amount paid to Stubbs Mobile PT does not count toward your out-of-pocket maximum.
Typically there may also be an out-of-network deductible. First you must reach your deductible.
When you submit the superbill from your appt to your insurance, they will apply their allowed amount for the CPT codes to your account as the amount you have paid toward your deductible.
Once you meet your deductible, they would begin to reimburse you for the percentage they cover.
This percentage would not apply to what you actually paid for the service, but to the allowed amount for the service.
If figuring out the insurance claims forms is difficult, there is an app that can help save you time. It’s called Reimbursify. Your first claim file is free and it can copy previous claims so that it only takes you 2 minutes to file. Check it out here.
So, back to more about why its better without insurance
The beauty of not participating is that:
there is no pre-authorization required (which would delay your care)
no post evaluation authorization needed that dictates the total number of visits you can have
no expiration date on the authorized number of visits; meaning if you have a vacation planned or get sick, you could pass your expiration date without using all of your visits and would have to wait on an additional authorization.
you get undivided one-on-one attention for 1 hour or more during your session
you can combine both proactive and reactive care into one visit
less time and energy spent on determining insurance coverage means more time spent giving you the best care and treatment plan
no limitations to services based on insurance coverage
more time with you each session, treating you, teaching you, guiding you without distractions means you get results faster
faster means fewer visits and a greater value to you - saving both time and money
Insurance follows the REACTIVE HEALTHCARE model
Insurance companies and their plans still largely support the reactive healthcare model, which is what we currently know as healthcare, only seeking help after there is a problem. Annual wellness visits to the doctor have become more standardly covered by insurance plans with your PCP, OBGYN, Pediatrician, Dentist, etc. This is part of proactive or preventative healthcare. As it currently stands, most companies and plans do not cover an Annual Wellness Visit by an outpatient physical therapist. But as the expert musculoskeletal providers, I think it would help keep individuals healthy and slow the incidence and prevalence of chronic pain and dysfunction conditions. But since preventative or proactive care isn't covered by insurances, most physical therapy clinics won't provide those services to you, because they can't bill them to your insurance, and then you the patient would have to pay. In the reactive healthcare model, we as physical therapists provide interventions as a result of a condition, like rehabilitation after a surgery or injury, which are considered covered services by insurance.
“Services that we provide prior to a condition or injury as prevention, are not covered by insurance.”
What are examples of services they wouldn't cover?
Have you met all of your functional Activities of Daily Living (ADL) goals, but still have larger movement and participation level goals? (Insurance doesn't want to cover it after ADL goals are met.)
You had an ACL tear, ACL reconstruction, and started physical therapy. You may have an insurance visit per year limit that you exhaust before you are able to return to play. Return to play takes 6-12 months, usually closer to 12 for high level competition. Your insurance may not cover sport specific progression and training once you are able to do your ADLs with no problem. Then you'd switch to workouts on your own and using a trainer. But there are very specific tests and measures that are evidence supported that you should meet before returning to play - and PTs are equipped to test and assess these. With my model - you wouldn't have to stop using my services, because we have taken insurance out of the equation, or you can transition to my services once your insurance is no longer covering PT.
You had a total knee replacement so that you could live your life more fully, which to you means you fish, ride horses, hike many miles over unlevel and steep terrain. These goals are excellent and perfect and should be met, however progress toward these goals once ADL goals were met would not be covered by insurance. Or, your insurance may only authorize 8-12 visits based on the surgery you had, not because they know you, your specific situation, or your goals. If you have any minor complications at all, like mild prolonged swelling post-op that limit ROM, you will likely use your authorized number of visits just in attaining your ADL goals.
You have chronic low back pain but don't want surgery, or surgeons have said that surgery wouldn't help you. At first you just want to be able to sit in the car to travel to see family, stand in the kitchen to cook and clean, and get down on the floor to play with your grandkids. These are excellent goals which your insurance will cover progress toward, as long as you demonstrate progress every 4 weeks at re-evaluation. Lets say you are dutiful in your home exercises, you have gone to PT 1-2x/wk for 2-3 months and you are now able to get up and down from the floor - its stiff and somewhat painful, but not near as bad as it used to be and you can sit in the car as long as you need without much problem. You start to dream about some other things you'd like to be able to do - like zumba or yoga or walk a 5k for charity. Insurance may cover a few visits to create a plan for you to get there, but they likely won't cover all visits required to see you achieve those goals.
These are just some of MANY examples. In summary: ADL goals = covered. Recreation/Sport goals = not covered.
Are you feeling a bit stiff and creaky, and you can still participate in everything, but you wonder if you could do something to make your body feel even better? PT could definitely assess you, help relieve the joint stiffness, and give you exercises to feel better. This would probably also help your physical longevity - but it wouldn't be covered by insurance.
Would you like an annual check-up to make sure you are doing everything that you can to ensure you are fit and healthy in retirement and beyond?
Are you thinking about starting a new activity or form of exercise but are concerned you might get hurt or do it wrong and want some professional guidance?
Have you had a few injuries in the past that you don't want to flare up when you:
Go on vacation and are hiking, skiing, climbing a lot of stairs, sitting on a plane/train/car for hours?
Start training for a 10K, half marathon, marathon, triathlon, cycle trip, etc?
Move and have to spend a lot of time packing, lifting, carrying boxes?
Essentially: pick any new task/activity with demands moderately greater than what you're currently used to. You don't currently have symptoms, but you want to be prepared and avoid them - insurance wouldn't cover services until after you started having symptoms.
None of the above would be covered by insurance.
But I think being educated, prepared, assessed and given a treatment plan beforehand would be better for you and your life. No one likes to be in pain, so take action, take matters into your own hands, and in 1-2 visits you'll have a plan and be feeling more confident about the task ahead of you.