If you’re recovering from an injury and you’ve been prescribed physical therapy, or PT, by your doctor, you may be wondering: is physical therapy covered by insurance? Understanding the way that insurance works when it comes to PT is the key to avoiding a physical therapy claim denial, so read on to learn more!
How Much Does Physical Therapy Cost Out of Pocket?
Physical therapy, also known as physiotherapy, is an essential treatment if you have limited mobility, chronic pain, or are recovering from an acute injury or procedure. But if you don’t have insurance, or your insurance won’t cover PT, you’ll have to take on the full cost of your care.
Each session may run you somewhere between $75-$350 depending on whether or not you also get a consultation, what equipment you use, and what your physical therapist’s rates are. Since most issues that need physiotherapy take 6-12 sessions to improve, that can add up fast!
Does Health Insurance Cover Physical Therapy?
The short answer is… Well, yes and no. While most insurance providers cover physical therapy to some extent, this varies based on your state, insurance plan, and the reason you need PT. The most common scenario is that insurance providers will limit you to a certain number of sessions per year. For certain injuries, that may not be enough! That’s why you should always check the fine print of your insurance plan before making an appointment to understand whether or not your health insurance will cover physical therapy.
Does Medicare Cover Physical Therapy?
Yes, Medicare will cover outpatient physical therapy. The law has been changed so that Medicare will no longer limit you to a number of sessions the way many private insurance plans will. Even so, Medicare only covers medically necessary PT, so keep in mind that you and your physical therapist may have to prove why this treatment is essential to your health and wellbeing.
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What is Medically Necessary Physical Therapy?
You may see this term on your plan documents or a claim denial: “medically necessary.” While insurance companies may interpret medical necessity in different ways, medically necessary treatment is usually that which is standard practice for a condition and recommended by your doctor at the time. Usually physical therapy is considered medically necessary when there is no less costly alternative that could improve your condition.
Basically, this term is a way for your insurance company to figure out whether or not it’s worth it to pay for your PT. Will the payment now help avoid further health treatment later? Does your healthcare provider think that physiotherapy is the best or only way forward for your condition?
For example, you may have better luck getting PT sessions labeled as “medically necessary” if they are prescribed by a doctor after an injury or surgery as part of your recovery plan. Most insurance plans will cover physical therapy for chronic pain, but that’s where it gets a little fuzzy in the “medically necessary” department. Receiving PT treatment simply to strengthen your muscles as part of preventative care may involve you convincing your insurance company of its medical necessity.
Why Do Physical Therapy Claims Get Denied?
Unfortunately, physical therapy claims do get denied, and often because of circumstances outside your control. Here are a few reasons for physiotherapy claim denials:
Diagnosis Code Errors
Diagnosis codes are something that doctors and physical therapists handle on their end of the paperwork in order to specify what the patient is getting treated for. In the past, physiotherapy diagnosis codes were really simple, but recent additions to the system means that your physical therapist has to be much more specific with their diagnosis. Some physical therapists aren’t used to this yet and may use the wrong diagnosis code, leading to a claim denial.
Paperwork or Billing Errors
This type of denial reason may seem easy to avoid, but it is actually really common! If your provider makes an error when filling out paperwork (such as missing a number in your insurance member ID or misspelling your name), you may receive a denial letter. That’s why it’s important to know why a claim was denied before you pay an outstanding bill. The denial may be a simple fix.
Not Medically Necessary
As mentioned above, your health insurance will want to make sure that the physical therapy treatment you received was medically necessary. If your insurance company challenges the medical necessity of a PT session, or if you finish your allotted sessions but still need physical therapy, you may have to take on a health insurance denial.
Another issue that can get in the way of insurance covering physical therapy is eligibility. This can mean that your insurance plan doesn’t cover PT, that your insurance has expired, or there is some other issue with your coverage. If you believed that you were covered and learned of this denial reason, it can be extremely confusing and frustrating!
What Can You Do About Denied Physical Therapy Claims?
The most important thing to do about denied physical therapy claims is to understand the reason they were denied. This means reaching out to your insurance provider to get more information that will help you decide your next steps. Some denials due to errors are easily fixed by a quick call to your physical therapist’s office, but others may be much more complicated than that.
Denials because of medical necessity probably require you to get proof from your doctor that your physiotherapy is crucial to your health. If your insurance is still giving you a hard time, you may even need to file an appeal, which is a process characterized by lots of phone calls, paperwork, time, and energy. In some cases, you may even consider hiring a health insurance denial attorney if your insurance provider refuses to cover a PT session.
Turn to aJust
The medical claim denial process can escalate quickly. One minute you’re receiving a denial letter from your health insurance, the next minute you’re drowning in paperwork, stuck in the health insurance phone tree, and stressed out by a bill you weren’t expecting that you just can’t make go away. That’s when aJust comes in.
Physical therapy is an important part of taking care of your body and avoiding future health issues. The experts at aJust know that, which is why they will take over your physical therapy claim denial and head into battle with your insurance company. Why should you agonize over the appeals process when the experienced team at aJust knows exactly how to handle it? Give your denied physical therapy claim the best shot it has at being overturned by asking for help from aJust.