Cash-Based Physical Therapy
What is cash-based PT?
In a cash-based treatment model like Academy West, the PT 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. Each patient pays at the time of service, allowing the terapist to focus attention on providing the best possible service while keeping administrative costs low. Payment for services may be done using actual cash, check, credit or debit card (including HSA).
In a more traditional physical therapy setting, they use insurance-determined CPT codes for physical therapy services, which uses a complex matrix of "timed codes" and "untimed codes" to determine what will and won't be reimbursed. This results in confusing and complex patient bills and EOB's, as the amount billed to insurance will vary visit to visit based on the exact services provided that day. It also results in PT practices hiring armies of office staff to manage the amount of documentation and paperwork that is required by insurance companies. Cash-based billing eliminates this confusion and allows for claraity in decision making on the part of the patient and their provider. Documentation for evaluations, teatment visits, and progress notes are performed just like any physical therapy practice and comply with all legal requirements.
Can my insurance be billed for cash-based PT services?
Most likely yes. Nearly all insurance companies, with the exception of Medicare, Medicaid and a few HMOs, will provide payment for services received "out of network". This means that you can choose to see a PT who is not a participating provider with your insurance company, like Academy West. Many patients choose to receive services out-of-network in order to see a PT of their choice. The end goal of documentation and billing is the same for any PT: to be paid for their services provided. With cash-based services, it is the patient who is waiting for reimbursement rather than the provider.
There are currently more than 900 medical insurance companies in the United States. We have contracts with none of them on purpose.
Academy West is an "out-of-network" provider, what does that mean?
This means that Academy West has not entered into contract with individual insurance companies to receive reimbursement basecd on their contracted rates. There are MANY insurance companies, each with their own contracted rates and regulations, and our time and energy is best spent working with patients and not jumping through hoops. Keep in mind that "in-network" provider status is a contract based on mutual interest, and is not currently based on education, experience, skills, or treatment outcomes. There are currently more than 900 medical insurance companies in the United States.
Academy West charges well below the national average submitted to your insurance in a typical fee for service outpatient practice. We can charge less because the simplified cash-based fee structure streamlines billing and does not require hiring extensive personnel or paying exorbitant fees to a third-party billing service. This allows the focus of our energy and time to be patient care, and allows you to make informed decisions regarding the costs of your health care. It's your money, spend it in a way that matters to you. If we were an "in-network" provider who "took your insurance" we would be forced to charge twice or even three times as much money for the same services to feed the system.
How do I find out what my insurance benefits really are?
We've taken care of it by providing this 1-page checklist. Call your insurance company with this in hand and in less than 10 minutes you should know what is covered. Plus, you'll likely understand your benefits a little better. Afterall, this is your insurance provider, understanding what they provide you is crucial.
How do I submit a claim to my insurance?
The process is actually pretty simple: Academy West will provide you with an invoice or "super-bill" at the time of service, and you may submit that invoice and receipt to your insurance company for reimbursement. The invoice has all of the necessary information (business name, 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, or at any other interval, typically up to one year following your treatment visit.
My insurance is Medicare - are there any special rules that apply to PT services?
So many rules.
Academy West does not have a relationship with Medicare, whcih means patients who wish to submit to Medicare for reimbursement for
treatment that Medicare normally covers may not be treated at Academy West. However, the list of
conditions that Medicare does not cover is significant and includes any issue that began greater than 1 year from the start of PT service, wellness care, maintenance care, and more. In other words, you may be treated here if your condition is chronic (>1 year), or is considered maintenance or wellness care. Additionally, breathing performance is not really on Medicare's radar. However, Medicare is exceedingly complicated and if you are denied reimbursement, that is a risk you take. Failure to comply with Medicare rules in every case, even with best intent, could result in federal investigation, fines, or other legal action. The Medicare Benefit Policy Manual is available in full as a series of downloads at CMS.gov; outpatient physical therapy benefits are discussed in Chapter 15, which is currently 289 pages.
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 requrements and have been prescribed by their physician. In some cases, a Medicare beneficiary may pay cash for services that are no longer considered medically necessary, for example a "maintenance" or "wellness" program.
We offer Performance training as well as an alternative for those with Medicare benefits.