Physical therapy is a $34 billion dollar industry and growing. Understanding physical therapy billing guidelines can help you save on out-of-pocket costs before, during and after your visits.
Follow these 7 guidelines to keep your physical therapy bills in check.
The time you spend with the therapist is considered billable time. Typically, required breaks aren’t included in this billable time.
When your physical therapist calculates this billable time, they will include evaluations and reevaluations of your progress. This includes the initial visit to therapy where a care plan is decided.
Reevaluations are usually needed when your progress, or lack of progress, means coming up with a new care plan.
Group and individual therapy visits are billed differently. Group therapy includes the treatment of two or more people in the same session.
You don’t have to be doing the same activities during group visits. If each person needs individual attention during a group visit, your therapist will likely bill you for a one-on-one visit.
One-on-one visits are billed in units according to the amount of time you spend with a therapist. For example, 30 minutes is considered 2 units during a physical therapy appointment.
Sometimes you’ll see more than one therapist during an appointment. This is called co-treatment.
If you have a Medicare Part B plan, these therapists can’t bill your insurance provider separately if they treat you during the same visit. But with Medicare Part A, it is possible for your insurance to be billed twice as long as they are full sessions.
Both therapists have to have separate disciplines and provide different treatments in order to submit two bills.
If you are seeing a physical therapist who is in-network, the cost of a visit is usually lower than seeing a therapist who is out of network. Physical therapists become in-network providers by going through a credentialing process.
Some insurance companies choose to pay either a lower percentage of your treatment costs without of network providers while others won’t pay at all. Check with your insurance provider to learn the limits of your specific coverage.
Medicare, for example, won’t cover any physical therapy work done by a physical therapist who isn’t credentialed. If you don’t want to switch providers and your physical therapist is out of network, talk to them about their plans to become credentialed.
Some physical therapists have a successful practice without the need to be in-network. Others might be waiting for a compelling reason to go through the lengthy paperwork process.
If you have Medicare, the 8-minute rule is an important part of how your physical therapist submits billing to your insurance. Medicare has a rule of eighths, or the 8-minute rule, which breaks down your billing into units.
This rule was put in place by the Medicare Administrative Contract National Government Services. A Local Coverage Determination (LCD) is used to establish what the time codes should be for each billing unit.
The 8-minute rule only applies to the time you work directly with a physical therapist. The time you spend scheduling appointments, waiting for machines or meeting with assistants doesn’t count toward this billable time.
Medicare keeps a pretty strict guideline for how to measure each unit. As the name implies, your visit has to be at least 8 minutes long before it can be billed at all.
The Balanced Budget Act of 1997 (BBA) was introduced to control Medicare spending. The result was the therapy cap.
The bill states that the maximum amount that Medicare will payout in physical therapy costs for the year. The therapy cap was removed in 2018, but this doesn’t mean your old medical bills are now automatically covered.
You can appeal decisions on past medical bills of up to $2,080. These bills must be for speech, physical or occupational therapy.
Appeals are handled by the targeted medical review board. Claims selected for review might include:
If your claim is reviewed and an exception is made, your claim will be paid even though it exceeds the previous therapy cap.
Any physical therapy fees not covered by your insurance policy become out-of-pocket costs. These costs might include co-pays, co-insurance or the time billed by your therapist.
With Medigap insurance, you might be able to reduce these expenses depending on your plan. Medigap is a type of supplemental medical insurance that helps reduce healthcare-related expenses.
With Medicare, you typically pay 20 percent for outpatient therapy for the amount Medicare approves for that year. With Part B, you have to meet your deductible before Medicare will pay anything toward the bill.
Part A requires that you are hospitalized before physical therapy costs can be covered by your plan. With Medicare, a physical therapist alone cannot recommend a plan for you.
All treatment plans must be recommended by a doctor in order to be covered. If you pursue therapy without your doctor’s recommendation, you are agreeing to pay in full.
Understanding physical therapy billing guidelines can save you from surprise bills in the mail. For Medicare patients, the process of understanding your billing responsibility is easy.
Medicare has strict guidelines in place to make sure you receive fair invoices. With private insurance providers, coverage amounts can vary wildly.
Connect with your insurance provider to learn more about what to expect from your next physical therapy bill. For more information on physical therapy in Richmond Hill, check our blog for updates.
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