Health plans vary, and we all know they can be confusing and complicated. What you can expect to pay out of pocket for physical therapy varies by health plan, and can even vary by clinic based on their contract with your health insurer.
If your plan’s deductible applies to physical therapy, you are responsible for paying the full “contracted rate” for the services provided. Your PT will send a claim for services to your insurer. Your health insurer adjusts the claim, sends it back to the PT, and your PT must then bill you for the adjusted amount. This process is a key part of the contract between your PT and health insurance companies: your PT agrees to accept the adjusted amount, to not bill you for the difference, and to make every effort to collect the amount due.
Copays or Coinsurance
Some health plans apply a copay or coinsurance to physical therapy visits, and we are seeing more networks within networks that vary the copay based on which physical therapy clinic you choose. For example, your plan might dictate that PTs in the Standard Network will collect an $80 copay per visit (yes—we’ve seen copays this high, or higher, which is outrageous), but PTs in the Enhanced Network will collect a $40 copay (still pretty terrible, in our opinion). Coinsurance is the same concept except that it’s a percentage amount instead of a flat rate per visit. The clinic will send a claim for services to your insurance company and receive the contracted amount minus the copay or coinsurance amount. Again, as part of your PT’s contract, it’s agreed that the clinic will make every effort to collect the amount due, and not more.
Contracted Rates Vary by both Health Insurer and Clinic
Wait—why does my visit cost more than your visit? This is where health insurance gets even weirder. Your PT agrees to charge the same amount for the same services, but the contract with Insurance Company A is different from Insurance Company B. We can send a bill to both insurance companies for $200. Insurance A will adjust it to a reimbursement of $50, while Insurance B will adjust it to a reimbursement of $100. A small clinic such as Restorations PT has zero bargaining power—if we want to be in-network with Insurance A and Insurance B, we have to agree to their rates. A larger company with physical therapy clinics all over the place will often be reimbursed at a different amount as they may have actually negotiated their own rate.
Are There “Hidden Costs?”
No. If your physical therapist provides a service that is not covered by your insurance, he or she is obligated to tell you before providing said service. You may decline it or agree to pay cash for that service.
As the healthcare climate continues to evolve, it seems that we can all expect higher out of pocket costs for many services. Our experience is that in general our clinic’s contracted reimbursement rates are declining, and the costs being passed on to the patient are increasing. This is just one more reason to do your part to make your physical therapy work for you. You can shorten the amount of physical therapy visits and reduce your costs but still reach your goals if you follow your therapist’s advice, do your home exercises, and stay compliant.