Is Physical Therapy Covered by Insurance?

Is Physical Therapy Covered by Insurance?

Is Physical Therapy Covered by Insurance? Is Physical Therapy in-network with my insurance? Do I have to use my insurance for Physical Therapy?

These are extremely common questions and questions that I field almost daily. And as always, there is a short answer and a long answer - many times the short answer leaves out many valuable nuances and thus a longer answer is appropriate. 

Short answer - It depends. 

Although this answer is technically accurate, this terribly incomplete answer leaves plenty unanswered. The short answer offers zero clarity to a prospective patient and further muddies the water on Physical Therapists’ role in healthcare.

So, I present to you, the long answer:

In-Network / Insurance-Based Physical Therapy Clinics 

In many instances, physical therapy is indeed covered by your health insurance plan. Your insurance company may recommend going to a clinic within their network - thus making the clinic “in-network.”  While this seems like the easiest route to take in today’s healthcare landscape, this approach has many flaws and patient-centered PT services may not be the focus. 

Some examples of the shortcomings of the traditional insurance model of Outpatient Physical Therapy:

Physical Therapists typically have more than 1 patient at one time. 

It is customary for in-network PT clinics to schedule multiple patients at the same time for the Physical Therapist to juggle. And because PTs are seeing many patients at one time, these patients only get to see the PT for a small portion of the overall session while the remaining time is spent exercising independently or with a Physical Therapy Technician - thus minimizing quality time spent at each session and subsequently requiring more sessions.

Productivity Standards trump patient-first treatment.

These clinics notoriously place productivity standards on the treating PT by having a certain number of patients/day or week. These productivity standards, which can be traced back to insurance reimbursement rates being paid out to the clinic for treatment, result in many negative experiences for patients.

Insurance hoops to jump through to “check the boxes” before starting PT. 

Attempting to find an in-network PT clinic may also send a patient down a long path of unnecessary MD visits and unnecessary imaging studies (MRIs/X-rays) so the insurance companies can “check the boxes” prior to beginning PT services. This approach significantly delays beginning necessary physical therapy sessions.  

Unclear Insurance Jargon, Visit Limits/Caps, and Surprise Billing

Further complicating in-network PT clinics is the unclear insurance jargon, visit limits, and surprise billing. Many times, in-network clinics will run your insurance benefits “as a courtesy” to the patient. But let's be honest, do the majority of patients truly understand what their 80/20 coverage is, or what their eventual cumulative cost of co-pays/co-deductibles/co-insurances will be? 

Many times patients are lulled to a sense of security because they aren’t charged up front and are unaware they will be receiving a bill for overages months later when the charges go through. Patients are then “surprise billed” thousands of dollars and don’t have much of a leg to stand on due to every in-network contract stating the patient understands their own insurance benefits. 

Not all bad, there are some pros to In-Network

There is an overwhelmingly large number of in-network PT clinics to choose from, which technically qualifies as a pro in the event you need a specific location in relation to your home or work. 

There are even some hard to find insurance plans that have unlimited physical therapy/preventative treatments that also cover 100% of the patient’s costs - yet these are rare. 

Out-of-Network / Private Pay PT / Cash Based Physical Therapy

On the other hand, there has been an increase in out of network physical therapy clinics popping up around the country from PTs looking to deliver a direct to patient model of healthcare. 

And there are many reasons why this model is far exceeding both patient expectations and providing superior results for patients. 

Insurance does NOT dictate treatment in an Out of Network model

In this model, Physical Therapists are not limited to insurance guidelines or restrictions on which treatments are covered by your insurance plan. In other words, if your PT feels that your diagnosis/injury warrants the use of dry needling, adjustments, cupping/scraping, massage, or all of the above, you can receive this treatment regardless of insurance coverage.

Transparent Billing/Financial Clarity

Additionally, this model provides financial and billing transparency. Physical Therapists in this model lay out the cost of each session on the front end and every patient is fully aware of the cost associated with a treatment session or plan of care.

One on One Treatments - Less Overall Sessions Required

Moreover, out of network / private pay physical therapy clinics typically provide one on one sessions between the PT and the patient. This, without a doubt, leads to higher quality of care and ability to listen to patients and answer all questions regarding their diagnosis. This generally leads to less required sessions per week - and less overall sessions required for the entirety of the course of treatment.

Your Physical Therapist can deep dive into the Root Cause of your symptoms/diagnosis

Many times the pain in your arm is coming from your neck, and the pain in your heel is due to your lumbar spine (or so many other things). In the insurance model, clinicians may be limited on the total treatment they can provide because “Insurance will only pay for treatment on my heel (etc).” But in the Private Pay Physical Therapy, your Physical Therapist isn’t confined to one body part and will utilize the entire session to address all necessary structures needed, even if it's another part of the body.

Putting This Together 

Admittedly, in the world of healthcare, paying for a service up front seems like a “backwards” way to proceed, being that patients are typically paying health insurance monthly premiums for medical “coverage.”  

But in many, many cases, choosing an out of network clinic can ultimately come out cheaper than attempting to search for an in-network clinic! But how?

Because when you work with an out of network provider, you are likely working with a Specialist Physical Therapist - as opposed to a generalist PT - and thus will need significantly less overall sessions. And despite the out of network sessions appearing to be more expensive than the co-pays presented by your insurance benefits, the overall volume of in-network visits offset this cost in favor of private pay. Also, many insurances cover ~80% of the cost of the session - but what even is the cost? Does anyone ever check? How does a patient know what will be billed for the remaining 20%? This could amount upward to $100 or more per session - and with in-network plans of care ranging from 12 - 36+ visits, this unknowingly adds up very quickly.

What does this mean for you?

Ultimately, it is and will always be patient choice and preference on which style of clinic resonates with you. 

So when you ask yourself, is Physical Therapy covered by my insurance? The answer is generally “yes,” but you can now see that you have pros and cons to consider on using your insurance for an in-network clinic or going direct to PT treatments with Direct Access Out of Network services. 

At Flow Physical Therapy and Wellness in Lafayette, LA, we fully believe in the Out of Network model for Physical Therapy services. Why? Because:

In-Network Traditional PT compared to Flow Physical Therapy and Wellness

• We have seen our patients benefit from one on one sessions.

• We have witnessed massive wins and improvements in a fraction of the number of visits required elsewhere.

• We have experienced the difference of uninterrupted PT services with our patients - allowing full attention to be given to our patients to uncover the true source of your symptoms.

• We believe in providing the right treatment for the right patient - not simply the treatment insurance will allow or reimburse the clinic for.

• Lastly, removing the insurance barriers in order to keep the patient as the center of treatment is a huge component of true healthcare between practitioner and patient. 

Click the button below to experience how the modern era of patient-centered, Direct Access, Out of network Physical Therapy leads to faster patient outcomes so you can get back to living your pain-free life!

Click Here for Out of Network Physical Therapy

Dr. Patrick Thompson, PT, DPT, OCS, Dip. Osteopractic

Owner of Flow Physical Therapy and Wellness

337-366-1703