It may not always be in your best interest to use it
Look, let’s just be honest - you’re probably hesitant to go to a physical therapist that is not in-network with your insurance company...and we don’t blame you. After all, you pay good money (or have good money taken out of your paycheck) for health insurance! It would make sense to want to use a service you already pay for.
But does it really make sense? Do we need to use insurance for everything? Should we?
What is Cash-Based Physical Therapy?
In a cash-based treatment model, the physical therapist enters into a contract with the patient to provide physical therapy services in a manner that both parties have determined will help them reach treatment goals most efficiently. The patient pays at the time of service, allowing the therapist to focus attention on providing the best possible service while keeping administrative costs low. You may pay for services using actual cash, a check, or a credit/debit card. You may also use FSA/HSA cards. Think of it as the same way services are rendered for a massage therapist or personal training.
Typically, coding for physical therapy services provided (CPT codes), is determined using a complex matrix of "timed codes" and "untimed codes". This often results in confusing patient bills, as the amount billed to insurance will vary visit to visit based on the exact services provided that day. Cash-based billing eliminates this confusion and allows for clarity in decision making on the part of the patient and their provider. Documentation for evaluations, treatment visits, and progress notes are performed just like any other physical therapy practice and comply with all legal requirements.
Tidal Sports Rehab and Recovery is an out-of-network provider- what does this mean?
This simply means that the therapist has not entered into a contract with individual insurance companies to receive reimbursement based on their contracted rates. There are MANY insurance companies, each with their own contracted rates and regulations, and Tidal Sports Rehab & Recovery’s energy is best spent working with patients. It is important to note that in-network provider status is not currently based on education, experience, skills, or treatment outcomes, but is often determined by the number of providers in a demographic area.
Is it possible for my insurance company to reimburse me?
Possibly! It is possible for insurance companies to reimburse patients depending on the individual provider and plan. There is no guarantee that your insurance company will reimburse you for the services, however, Tidal Sports Rehab & Recovery can provide you with the paperwork necessary to submit your claim. It is the patient's responsibility to do so and also to provide payment in full, up front, at the time services are rendered.
Most insurance companies, with the exception of Medicare, Medicaid and some HMOs, will provide payment for services received "out-of-network". Going out-of-network means that you can choose to see a physical therapist who is not a participating provider with your insurance company. Many patients choose to receive services out-of-network in order to see the physical therapist of their choice. In the case of cash-based services, it is the patient who is waiting for reimbursement rather than the provider.
Disclaimer: Tidal Sports Recovery & Rehab provides the required documentation, but is not responsible for reimbursement processing. Insurance companies reimburse patients according to their out-of-network benefits. Reimbursement benefits vary from company to company. Please make sure you understand the terms and conditions of the reimbursement eligibility and process through your insurance provider.
What steps are involved in submitting a claim to my insurance company?
The process is actually quite simple: Tidal Sports Rehab & Recovery will provide you with an invoice at the time of service, and you may submit that invoice to your insurance company for reimbursement. The invoice has all of the necessary information (business name and address, tax ID, national provider identification, license numbers, etc.) as well as the patient’s ICD-10 (diagnosis) and CPT (billing) codes. You may choose to submit bills following each visit, one time per month, or at any other interval, typically up to one year following your treatment visit.
Will I end up paying more for cash-based physical therapy?
In many cases, the out-of-pocket expenses for a course of physical therapy will actually be LESS for services provided at Tidal Sports Rehab & Recovery. In large part, this is due to the ability to charge less per visit, with these charges being well below the national average charge submitted to insurance in a typical outpatient practice. Tidal Sports Rehab & Recovery can charge less because the simplified cash-based fee structure streamlines billing and does not require hiring billing personnel or paying fees to a third party billing service. This allows Tidal Sport's staff to focus all energy on patient care, and allows patients to make informed decisions regarding the costs of their health care choices.
You say cash-based PT can save me money, but I still don't get it. Can you show me the math?
A 60 minute evaluation will be billed to insurance companies at anywhere between $225 to nearly $300 for that evaluation alone. Then about $175-$225 for a follow-up. So:
1 evaluation (45-60 minutes) + 3 physical therapy visits (30-45 minutes) = 135-195 minutes.
1 evaluation ($275-$300) + 3 physical therapy visits ($175-$225) = $800-$975 billed to insurance.
Sometimes the insurance company will show a “discount” on a patient’s EOB (Explanation of Benefits) and an amount like this will come out to $700-$850 after discounts are applied. That “discount” ultimately reduces the clinic’s bottom line. Guess how clinics typically respond after a number of discounted rates come in? (Hint: They stop accepting that type of insurance, they prioritize patient's with other insurance companies ahead of you, or they base your treatment on what codes they will be reimbursed more for- instead of what is best for you.)
In this scenario you are spending $3.58-$4.35 per minute in the clinic. If this clinic happens to use support staff (aides, techs, or assistants) to administer care then you are spending only a fraction of that time with your actual therapist.
In this day and age, it is likely that your deductible is going to be well over $1000 per year. This means that you will be responsible for the entire bill (which you will not receive until about 4-8 weeks later). SURPRISE! You wind up with a bill much larger than you expected and, in the meantime, you have likely been attending additional sessions adding more to your tab not realizing how much it is costing you per session. With a high deductible, your insurance company doesn't pay anything- they just get you a "discounted rate" which, in the end, many times is still more than the cash-based rate that we charge! This scenario doesn’t even factor in copays per visit if you have them...
This one is pretty simple.
1 evaluation (60 minutes) + 3 physical therapy visits (3 x 60 minutes) = 240 minutes
1 evaluation ($100-$150) + 3 physical therapy visits (3 x $100-$150) = $400-$600 billed to patient upfront or paid in installments.
No copays, no deductibles, no out-of-pocket maxes to meet (which are rarely ever met without some sort of medical catastrophe).
That equates to $1.67-$2.50 per minute in the clinic. Not only does this route get you a better dollar per minute ratio, but it also gets you the following:
-A therapist who is not drowning in paperwork
-A therapist who is not drowning in other patients
-A therapist who crafts a plan of care that is not predicated on
"playing the game” of insurance authorization
-A clear and concise plan towards the goals that matter to you and your
quality of life.
***Not to mention that most insurance plans still allow for out-of-network benefits and will accept itemized invoices from the cash-based provider for partial reimbursement to you (Making it even CHEAPER per minute!)
Can you see Medicare/Medicaid Patients?
No. Outpatient physical therapy services are generally covered under Medicare Part B, provided the service is considered medically necessary to treat a disease or condition. Under current Medicare regulations, it is illegal for a physical therapist to accept cash pay from Medicare patients for services that may be covered under Medicare, even if the services provided meet all treatment, documentation, and HIPAA requirements and have been prescribed by their physician