If you have ever been injured or have been to any medical professional one of the first questions that you may have asked was, “How much am I going to have to pay for this?”. I am sure that more times than not the answer was, “Well, it depends.”
It’s frustrating, trust me we get it. Unfortunately dealing with some insurance companies can become a nightmare for both the patient and the doctor’s office as well. As a private physical therapy practice our office staff spends a good portion of our day speaking with insurance companies and finding out what is covered and what is not. I cannot speak for all other medical practices, but I can give you some unknown and firsthand information of how it applies to physical therapy.
Before a patient is seen at our office we do an insurance verification to determine what the out of pocket expense for a patient is. Sometimes it is a very straightforward answer and we can give an exact amount based off of the patient’s insurance plan. If the patient has a copayment, it’s very simple and we know exactly what that cost is. However, some insurance plans have deductibles or co-insurance responsibilities which can make things more complicated. I’ll give you an example below, but in essence if you to have a deductible or co-insurance you will be responsible for paying a portion of your bill.
Here is an example: You go to a physical therapy office and have a private insurance with a deductible plan of $5,000 per year. You have not met any of it, meaning that your insurance company will not reimburse anything until you have paid $5,000 out of your own pocket. As a physical therapy office, everything is billed in 15 minute codes. So if you receive therapy for 60 minutes (or 4 codes) and each code is $20 then you will be responsible for paying $80 for that visit.
So it can become complex as you can see and it does depend on what treatment is performed at each session. I know, you’re probably wondering how it can be cheaper at one physical therapy office compared to another. So here is the simple truth that most people do not know or understand. Insurance contracts for every facility do vary, and sometimes by a quite a bit.
A private practice physical therapy facility, like Advanced Physical Therapy of Clinton, has contracts that can be considerably less than other PT practices. Some of our contracts are like the one mentioned above. However, other insurances have a maximum amount reimbursed per session. This can result in tremendous savings for you. If you had an insurance (let’s call it Health Co.) that will only reimburse $50/visit, you can be assured that you can never be billed for more than that amount.
Another facility that accepts Health Co., but has a contract like the example given earlier, could cost you more than $100 for the same visit. In June, 2014 the National Institute for Healthcare Reform reported that hospital based physical therapy for private insurance is reimbursed approximately 52 percent more per code compared to a private physical therapy practice. That means that you may be responsible for a bill that is 50% greater just because of where you chose to go to therapy.
So does it matter where you go to therapy? It definitely does, and the level of service provided can vary from one facility to another. I always put my word behind my practice, and those that have worked with our practice knows that.
However, your financial obligation can vary greatly as well. You should always know what you will have to pay before you go to your first physical therapy visit. The option of choosing where you go for physical therapy regardless of anyone’s recommendation is yours. If a patient was referred to us by their doctor, but wanted to go another facility because it was either their preference or cheaper, I always tell that it’s their decision. Remember, in North Carolina you do not need a referral for physical therapy and where you go is your choice. However, comparing your options before you start physical therapy can save you a lot of money in the end.
Dr. Daniel Skulavik, PT, DPT, OCS, is with Advanced Physical Therapy located in the Food Lion Shopping Center, Clinton.