How does insurance work with physical therapy?

The short answer to this is no, In Massachusetts you do not need to see your doctor first. Massachusetts is a direct access state, which means you can go directly to a physical therapist. Physical therapists are the providers of choice to restore function and movement for those with conditions affecting muscles, joints, bones and nerves. Your physical therapist will perform a thorough evaluation and if your injury falls outside of the PT’s scope of practice, they will refer you to the right provider.

Whether your insurance requires you to see a doctor before seeing a physical therapist is a different story. Some policies require a doctor’s referral (see question 2) and some do not. Generally speaking, HMO plans require referrals for PT, and PPO plans do not, but this can vary. It’s best to contact your insurance company directly to find out what your plan requires.

These terms can be confusing, especially because they are often mistakenly used interchangeably. They are, however, very different.

Prescription: A prescription is a brief note from the doctor to the physical therapist. This note typically includes information on what the doctor thinks is wrong, may include general guidelines for treatment, and, in some post-surgical cases, may include more specific protocols. Again, in Massachusetts, a prescription is not required to see a physical therapist.

Referral: A referral is a signed order from the doctor (usually a primary care provider or pediatrician) sent to the insurance company ordering physical therapy. If a referral is required by your insurance company, they will not pay for PT until one is received, so be sure to know your policy or work with a PT office that will help you determine if you need a referral.

If you do need to call your doctor’s office for a referral, they will likely need some information about the physical therapy office, typically: name of clinic or provider, fax number, and NPI (National Provider Identification) number. Be sure to have this information handy before you call to streamline the process.

Authorization: An authorization comes from the insurance company and is the number of PT visits that the insurance company has approved. Some policies require an authorization and some do not. The PT office should be able to tell you how many PT visits your insurance has authorized. Often, if only a few visits are authorized initially, more can be requested as necessary.

Please note that the number of visits a doctor or physical therapist requests is not always the same number authorized by insurance. Just because your doctor writes a prescription for PT 2 times per week for 6 weeks does not mean the insurance company will approve all 12 visits. Be sure to check with your PT office to see how many sessions were authorized.

It’s important to understand these terms, as they will determine how much you are required under your insurance to pay out of pocket.

Deductible: Your deductible is the amount you pay for health services before your insurance kicks in. For example, if you have a $1500 deductible, you must pay that amount before insurance will pay. Some healthcare services don’t work against your deductible, but typically physical therapy does.

Coinsurance: Coinsurance would kick in after you have met your deductible and is a percentage of the health care cost that you share with insurance. For example, after reaching your deductible, your insurance may cover 90% of healthcare service cost and you are required to pay the remaining 10%.

Copay: Your copay is a fixed cost you pay for health care service. For example, you could have a $30 copay for physical therapy due at time of service. This varies by insurance plan and type of service, but you could have a copay before your deductible has been reached or along with your coinsurance.

These items all vary depending on your insurance plan, and it’s really important that you either contact your insurance company and/or make sure you are working with a PT office that can help you determine your out-of-pocket cost for PT.

The number of PT sessions will depend on your specific insurance plan. When a PT clinic does an initial insurance verification process, they should be able to tell you how many sessions are covered under your policy. Keep in mind that just because the visits are covered, this does not necessarily mean they are approved.For example, your policy may cover 30 PT visits per calendar year, but your insurance may have approved (through their authorization) only 12 visits for this episode of care. When this happens, if more PT is needed after the first 12 sessions, your therapist can usually submit a request for more sessions. Occasionally, if there is a denial, it is helpful for the patient to call the insurance company directly to request more visits (sometimes they are nicer to you than they are to us!).

With rising costs of deductibles, copay, and coinsurance, we are sometimes asked if it is possible to forgo insurance and just pay out of pocket for physical therapy. The answer is generally yes, but there are some cases where we are contractually required to bill insurance. Medicare, for example, requires us to bill them for any physical therapy provided to their subscribers unless they have used up their benefit or it is for a service they do not cover. Again, the clinic you work with should be able to give you the answer to this question along with their self pay fees. For reference, our self pay fee is $140 for the initial evaluation and $95 for follow up visits.