If you are considering seeing a physical therapist, it’s a good idea to understand how the billing process works before you even make an appointment. Read on to learn about physical therapy billing and what to do if you get stuck with the full bill.
Does Insurance Cover Physical Therapy?
Insurance coverage of physical therapy (PT) depends on a few factors, such as your location, insurance plan, physical therapy facility, and the reason you are undergoing PT. If you were injured and are seeking physical therapy to heal from your injury, there’s a good chance your insurance plan will pay for visits. If you are in PT to prevent injury, however, that may not be the case.
That’s because most insurance plans cover only medically necessary physical therapy, or PT that has been prescribed as a treatment for a medical issue. While at each medically necessary visit you’ll still be responsible for a copay, deductible, or coinsurance as outlined by your plan, your insurance should cover the bulk of the costs for at least a certain number of physical therapy sessions each year.
What Are Physical Therapy Billing Codes?
Physical therapists, like all doctors, use billing codes when submitting claims to your insurance. These codes form a kind of language that practitioners and insurance companies share, allowing the insurance provider to quickly sort out whether or not your visit will be covered. The physical therapist will need to choose a diagnosis code to explain why your condition necessitates therapy, as well as codes that represent all the procedures or services they offered.
What Happens Once a Physical Therapy Claim is Submitted?
If you have health insurance, your physical therapist will submit a claim to your insurance for the services provided using the physical therapy billing codes. Your insurance provider will then process the claim to determine how much of it is their responsibility to cover.
Once your insurance provider has made a decision about the claim, they will pay the physical therapist, and then mail you an Explanation of Benefits that outlines the physical therapy claim and their coverage decision for each service. Then, the physical therapy office will bill you for the difference between the total amount and what your insurance company paid.
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Dealing With Denied Physical Therapy Claims
In the event that your physical therapy claim was denied by your insurance, you’ll be receiving a bill for the full amount from your physical therapist. Your claim may be denied for a few reasons:
- Simple Errors. A simple error in physical therapy billing (such as missing a digit in your insurance member ID) can lead to a denied claim. In some instances, your insurance will reject rather than deny a claim with errors, sending it back to the PT provider for more information.
- Eligibility Issues. If your health plan wasn’t due to start for a few weeks (or you were otherwise ineligible for coverage on the date of service) but you submitted a physical therapy claim anyway, that’s cause for a health insurance denial.
- Billing Code Errors. Using outdated, incorrect, or not-covered diagnosis or physical therapy codes could result in a physical therapy claim denial.
- Lack of Medical Necessity. When the billing codes your physical therapist uses make your insurance doubt the medical necessity of PT in your situation, your claim will be denied.
- Out-of-Network Provider. Seeing a physical therapist who is not contracted with your insurance provider automatically leads to a PT claim denial with most plans. In some cases, your insurance may cover out-of-network providers, just at a lower rate than those in network. Check your plan documents or speak to your insurance company to figure out which is the case for you.
When this happens, you have a few options. If the claim was denied due to a simple error, you can reach out to your physical therapist’s office and ask them to correct the error and resubmit.
If you believe that your insurance should have covered the claim, you can start the appeal process. This is time-consuming and is a daunting process to take on alone, so be aware that you’re in for a long and arduous road ahead!
If neither of these options works, or if you don’t have the time and energy to appeal a denied claim on your own, it’s a good idea to call a medical billing advocate. A medical billing advocate, like aJust, is a professional who can take over your case and swiftly discover where it all went wrong. Using years of experience, the medical billing advocate will then either take care of the appeal process or work on negotiating your physical therapy bill. In most cases, a medical billing advocate can either get the physical therapy claim covered or lower the rate of your bill.
Why Reach Out to aJust For Help With Physical Therapy Claims
With aJust, you can count on communication, transparency, and professionalism throughout the entire physical therapy bill negotiation process. Whether you’ve just received a claim denial or you don’t have insurance and need help negotiating down your bill, aJust is there to put their experience and expertise to good use.