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Insurance Trends In Physical Therapy

As the healthcare system gets reformed politically, there are several trends that are occurring and will occur with receiving healthcare going forward. Many of these changes may alter how patients receive and ultimately pay for services in the future. The many stresses of our current economy also place more of the burden on patients, providers, and business owners across all disciplines. For the purposes of this article, I will be focusing on the growing trends that occur in outpatient physical therapy.

As of October 1, 2006, state legislature passed the direct access bill for physical therapy in Connecticut. This law permits patients to seek physical therapy without the need to obtain a prescription first. This allows patients to obtain physical therapy immediately without having to see a physician or orthopedist first. This law is not intended to defer patients from seeking medical attention for your orthopedic care, but rather allows one to receive immediate effective care first. Patients always have the option of seeing a physician before or during the physical therapy regime. Insurance carriers, including Medicare, fully support this change and direct access does not negatively affect reimbursement.

This change in state law applies for both exacerbations of older injuries as well as new orthopedic conditions. After the evaluation, if an immediate need is found, then a referral to a physician and/or specialist is often recommended.

Generally insurance plans, including Medicare, commercial carriers, and Workers’ Compensation, allow for physical therapy visits. In most cases all or the majority of the fees are covered. Each insurance plan varies and it is important for patients to know the differences of the nuances in order to receive and pay for their care.

For physical therapy in an office setting, most plans require a co-pay or deductible to be paid at the time services are rendered. Over the last few years, both co-pays and patient responsible deductibles have risen to higher amounts. Copays are in lieu of reimbursement, not in addition to it. This places more financial responsibility by insurance companies onto the patient, while concomitantly it is growingly common for insurance companies to reduce the fee schedule paid to providers. And, as most small business owners can attest, the operating expenses to render services to patients typically go up.

The majority of commercial plans allow a certain number of visits per calendar year, regardless of the condition being treated. Several companies also require pre-authorization after the evaluation and need to approve the visits prior to being treated for the next session. It is important for patents and providers to know this and start that process promptly so that the patient does not experience a long wait time prior to receiving the care they need. Typically upon contacting our office, the office staff will gladly call prior to a patient’s first appointment to verify benefits and alert patients of any amount they may be responsible for.

Medicare changes have also made things confusing for elders. At the time of this article, Medicare has a dollar cap per annual year for therapy services. The number of visits is dictated by the procedures billed by the provider. Also Medicare pays for 80% of the allowed amounts, and patients often have a secondary insurance to cover the additional 20% remaining. There are exceptions to go over the cap, on a case by case level based on medical necessity rules, so it is important for the therapist and your physician to keep track and have open dialogue in order to coordinate appropriately and provide the best interests for the patients’ needs.

All of these trends can present challenges and basically leads to the mantra: Providers and patients need to work together, to accomplish more in treatment, with less time/visits, and with more patient fiscal responsibility – all while staying organized to prevent unnecessary delays by insurance companies. In closing, this article only brushes upon the ever changing insurance reimbursement world, and I am sure there is more to come.

Michael Dow MSPT is founder and Clinic Director of Amity Physical Therapy with offices in Woodbridge, Hamden and Branford. He received his degree from Sacred Heart University, and has been recognized by the U.S. Dept. of Health and Human Services for his work with the National Multiple Sclerosis Society. He treats patients of all ages, pediatrics to geriatrics, as well as local high school and college athletes. He can be reached at 203-389-4593 or email: mike.amitypt@yahoo.com. Also visit www.amitypt.com.


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