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Physical Therapy & Your Insurance: A Patient's Guide to Getting the Best Coverage
The best way to take care of your health is to take an active role in
your own health care. To do this, you need to know about your options
and your rights as a patient. Patients across the country are becoming
better educated and demanding more and better options from their health
insurance companies. The right to physical therapist services is an
important option, and it is your right as a patient.
Federally qualified HMOs are required to have physical therapy in their benefits packages.
Why Physical Therapy?
- Physical therapists are experts in how the musculoskeletal and neuromuscular systems function.
- Physical therapist services are cost-effective. Early physical
therapy intervention prevents more costly treatment later, can result
in a faster recovery, and reduces costs associated with lost time from
work.
- Patients pay less when they have direct access to physical
therapy services. However, there can be a temptation under managed care
to terminate services prematurely. A study conducted to determine
whether direct access to physical therapy services was cost-effective
found that patients who went directly to a physical therapist had fewer
episodes of care, and services were ultimately less costly.
What Do Physical Therapists Do?
Physical therapists help restore function, improve mobility, relieve
pain, and prevent or limit permanent physical disabilities of patients
with injuries or disease. They also restore, maintain, and promote
overall fitness and health.
When Do You Need a Physical Therapist?
The following list contains some of the most common reasons to see a physical therapist:
- Back conditions
- Knee problems
- Shoulder/arm conditions
- Neck conditions
- Sprains and muscle strains
- Ankle/foot problems
- Carpal tunnel syndrome, hand/wrist problems
- Hip fracture
- Post-surgical rehabilitation
- Rehabilitation after a serious injury (eg, broken bones, head injury)
- Stroke rehabilitation
- Problems with balance
- Disabilities in newborns
- Burn rehabilitation
- Pre-/post-natal programs
- Incontinence
- Women's health
In most states you may see a physical therapist without a doctor's
referral, but be sure to check your health insurance plan to see if
physical therapist services are covered without a physician's referral.
What Can You Do to Improve Your Physical Therapy Coverage?
Talk with your employer/benefits manager. The employers who contract
and pay for employee health care plans often have the most influence
with insurers. Employers are interested in keeping their employees on
the job and their premiums low, so providers who can help employees
prevent injuries and avoid recurrence (as well as promote a healthy
lifestyle) have particular appeal to them. Arrange a meeting with your
human resources director or whoever is responsible for negotiating the
terms of the company's insurance plan.
Ask your human resources director or insurance company the following
questions to determine if your current benefits package gives you
access to appropriate physical therapy services:
- Is your physical therapy benefit "bundled" with those of other
providers of care?Physical therapy services should be listed separately
in the benefit language so that access to necessary services is not
compromised.
- Does the benefit language permit access to physical therapists
for each condition during the year?Benefit language should permit
treatment of more than one condition in a calendar year (eg, ankle
fracture in January and low back injury in July).
- Does the benefit language permit access to physical therapists
for each episode of care?A person may require more than one episode of
care for the same condition. For example, someone with arthritis may
receive physical therapy intervention for knee weakness in an attempt
to avoid surgery. While this is often successful, some patients may
still require surgery for the knee condition (eg, total knee
replacement), which may require post-operative physical therapy
treatment. The benefit language should support each "episode of care."
- Does the benefit language ensure coverage that facilitates
restoration of function?Benefit language that restricts physical
therapy care to a 60- or 90-day period imposes an arbitrary limit on
recovery. In determining an appropriate physical therapy benefit that
will allow an individual to return to his or her previous level of
function, benefit language should reflect the normal amount of time
that it takes to recover from an injury or from surgery.
- Does the benefit language ensure coverage that promotes
functional independence for those with chronic conditions?Someone who
has a chronic condition may need to be seen periodically by a physical
therapist. The physical therapist will determine if the individual's
home program, equipment, or adaptive devices should be modified. (For
instance, children requiring orthotic devices will need modifications
to those devices as they grow.) Benefit language should ensure that
someone with a chronic condition may receive the kind of care that
promotes personal safety and the greatest degree of function possible.
Give the attached educational brochure to your human resources director.
Send the attached educational brochure to your insurance company and ask for increased coverage of physical therapy care.
Choosing a Health Plan
Millions of Americans are offered a choice of health plans through
their employers, but the question is —What makes a good health care
plan? Here are some things to consider when choosing a health plan.
- Are you choosing a plan simply because it is the cheapest? This
may not be the best way to go. Some inexpensive plans have a high
deductible and no comprehensive coverage.
- Is the plan accredited by the National Committee on Quality Assurance? This is a good indicator of quality.
- Are your current doctors and specialists in the plan? If not,
make sure you will be able to see a certain provider or specialist,
such as a physical therapist, without too much added expense and
difficulty.
- Is physical therapy coverage adequate?If you should have an
injury or illness requiring rehabilitation, you will need a plan that
offers an unlimited number of visits to a physical therapist or that
allows for the number of visits to be extended if needed.
- Are there lifetime limits on benefits? If so, you could face a
serious financial crisis if you or a covered member of your family
suffers a major illness or injury.
- Does the plan have an out-of-pocket maximum? In this case, once
you have paid a certain amount (usually several thousand dollars) the
plan would cover the rest.
- How does the plan handle grievances and appeals? The procedure should be simple, timely, and accessible.
- Does the plan permit use of outside doctors, specialists, or
hospitals? Called "point-of-service" option, this would allow you to
see a provider, such as a physical therapist, who is not in your plan.
There may be an additional cost, but it may be worth it.
- What is the plan's disenrollment rate? A high rate of members leaving the plan annually may indicate customer dissatisfaction.
For more information about how physical therapy may fit into your
health care package, please contact the American Physical Therapy
Association Department of Reimbursement at www.apta.org or call
800/999-APTA, ext. 8511.
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