For people who have suffered from injuries, endured surgeries, or have chronic health issues, one of the first forms of treatment prescribed will typically be physiotherapy. Its primary focus is to manage pain, restore movement, and strengthen the body.
At the same time, just like any other products and services in the healthcare industry, people have to deal with the question of whether or not their health insurance will cover the costs. Like many aspects of healthcare, it is not a straightforward answer, as it relies on the specific type of plan, the diagnosed medical case, and the specific stipulation of the policy.
Educating yourself on the interplay of insurance and physical therapy will certainly ensure that you avoid sticker shock on medical expenses.
What is physiotherapy?
The treatment aims to improve functioning and movement of the body parts as well as restore the movement lost because of an injury, some illness, or major surgery. Pain relief and restoring movement is done through the combination of a specially designed medical plan, exercises, and careful therapy done by physiotherapists. People suffering from injuries sustained from participating in sports, arthritis, extreme chronic back pain, recovering from strokes, or healing after major surgeries, any of the prescribed exercises and therapy plans will be beneficial. The aim is to restore as much independence as possible, prevent any other injury, and maintain or improve quality of life as much as possible.
Why insurance coverage matters for physical therapy?
Lacking insurance coverage, physical therapy can get quite costly. Each session can range from $50 to $300 and depends on the clinic and its location. For patients with long-term conditions needing multiple sessions each week, the costs can add up fairly quickly. With therapy being sensitive to some, insurance coverage optimally reduces expenses and provides therapy to patients. On the contrary, no insurance plan covers physical therapy the same. Certain plans only approve therapy if certain conditions are met, as well as impose limits on the number of referrals and sessions.
Types of insurance that may cover physical therapy
Different types of health insurance provide physical therapy coverage, although to different extents.
Employer sponsored health insurance
Health insurance through an employer is most common for the population of the United States. These plans usually offer physical therapy as an added coverage, but the extent of coverage depends on the insurance provider. There are some employer plans that offer physical therapy if medically necessary and pull physical therapy out of the plan.
Private health insurance
Individuals owning a private cover may have plans which include physical therapy. Details concerning benefits, deductibles, and health care providers will govern the extent of coverage. Some health care providers pay for a certain number of physical therapy visits during a calendar year.
Medicare
Medicare covers elderly citizens aged sixty five and above, and those with select disabilities. If necessary for treatment, Part B of Medicare covers physical therapy. A client pays twenty percent of the approved amount after the set deductible is paid. Some therapy forms have set boundaries which may be exceeded if care is additionally required.
Medicaid
Medicaid provides services for the low income segment of the society regardless of their employment status. Under Medicaid, physical therapy coverage varies from one state to another. Some states will allow unlimited sessions whereas other states will limit the sessions. Referrals from the doctor may be required for therapy services to be covered.
Workers Compensation Insurance
Under your treatment plan, workers compensation insurance may provide for physical therapy if your injury occurred while you were working. This kind of insurance covers the medical treatment and rehabilitation necessary for an employee who has suffered a work-related injury, in order for them to be able to work again.
Auto Insurance
Auto insurance may provide for the physical therapy of a patient who sustains physical injuries as a result of an accident, depending on the terms of the policy and the no-fault state legislation.
Physical Therapy that is Covered by your Insurance
In most cases, insurance companies only cover physical therapy that is prescribed by a physician for a specific injury, illness, or surgery. Coverage depends on:
- Therapist participation in the insurance plan
- A diagnosis
- Doctor order for the therapy
- The condition being treated
- The number of visits allowed each year
- Prior certification
Most insurance companies will provide coverage for the physical therapy that is needed after surgery to the knee. If, however, the reason for wanting the physical therapy is only for general fitness and good health, it is highly likely that most insurance plans would not cover the expense.
Common Exclusions and Limitations
Even when insurance covers physical therapy, there are often restrictions that you should be most aware.
- Not enough visits: Some plans only allow twenty sessions each year which is severely lacking.
- Coinsurance and copayments: Each appointment, patients may have to pay a portion.
- Deductibles: Therapy may not start unless a member has met the annual deductible.
- In network providers: Going to a therapist who is not on the list may be more expensive and have no coverage at all.
- Prior authorization: Some insurance companies need to give a thumbs up before a patient begins therapy.
Knowing these limitations will ensure that overage bills will not be received.
Steps to check if your insurance covers physical therapy
It is beneficial to check your insurance coverage as part of the pre-appointment process. Consider taking the following actions.
- Go through your policy documents and claim rest if physical therapy is available or covered in any of the services
- Speak to your insurance company. Ask if it covers in-network provider therapy. What are the visit caps and out of pocket amounts?
- For your convenience, does the therapist have to go through any pre-approval steps?
- Witness if the therapist works in the same insurance provider network.
- Check to see the maximum number of counseling sessions covered and your total spent, to help manage overage costs.
Tips for maximizing insurance benefits
In order to receive complete coverage from your insurance provider for physical therapy, consider the following actions.
- Always obtain a prior referral or prescription from your primary physician.
- Ask your physician if the therapist has a clinical medical justification to support the treatment in WGS therapy.
- Use the network to the greatest extent possible.
- Use your private therapy allowance strategically if you are given a capped number of private sessions.
- Always appeal a denial, particularly if it’s one your provider believes is necessary, as it ought to be covered.
Out of pocket costs without insurance
In the absence of any insurance coverage, physical therapy will need to be self-paid, with the cost varying according to geographical location and the specific clinic chosen.
In addition to self-pay discounts, many clinics offer sliding scale fees, or payment plans. Lower cost therapy may also be available at community health centers and university clinics.
Conclusion
While physical therapy is often medically necessary and therefore covered by insurance, the amount of coverage you receive depends on your specific plan. Benefits may come from Employer insurance, Medicare, Medicaid, workers compensation or even auto insurance. Most plans, however, have rules around referrals, session limits, and prior authorizations.
In order to avoid surprises, it’s important to check your policy and confirm details prior to beginning treatment. Focused and undistracted recovery is vital, so having the peace of mind that comes with understanding your insurance coverage is important, as physical therapy can be life changing.
If you are curious about how decisions are made in the insurance industry, you can also learn who elects the governing body of a mutual insurance company for a better understanding of member-driven insurance models.
For those exploring other healthcare coverage questions, it may help to check are dermatologists covered by insurance to see how skin care treatments are handled by different plans.
FAQs About Insurance Cover Physical Therapy
Does Medicare pay for physical therapy?
Yes, Medicare Part B does cover physical therapy, assuming it is medically necessary. Patients pay coinsurance and must also meet the deductible.
Can I go to physical therapy without a doctor referral?
Yes, some states allow for direct access, however insurance at some level will require a referral for payment.
How many physical therapy sessions will insurance cover?
That depends on your plan. Many insurance plans have a set number of sessions covered per year, such as twenty, but will allow exceptions based on medical necessity.
Will physical therapy expenses for sports injuries be covered by my insurance?
Yes, with most insurance plans, physical therapy for sports injuries is covered provided that it is prescribed by the doctor and deemed medically necessary.
What should I do if my insurance claim is denied for the physical therapy?
You can appeal the decision first by showing necessary medical documents and a signed letter from the doctor explaining why the therapy is crucial is required.
