Question 1

What is cash-based PT?

Accepted Answer

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 therapist to focus attention on providing the best possible service. Payment for services may be done using 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 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 physical therapy practice and comply with all legal requirements.

Question 2

Can my insurance be billed for cash-based PT services?

Accepted Answer

It depends on your insurance company. Nearly all insurances, with the exception of Medicare and Medicaid will provide some reimbursement for services  that are considered "out of network" depending on your plan.

Out of Network is a category of benefits for providers who are not contracted with the insurance company directly. The insurance plan will allow some coverage, but usually at a lower amount.  Academy West is considered an out of network provider and many patients choose to receive services "out-of-network" in order to see a PT of their choice.

It is beneficial to get in touch with your insurance company and find out if you have "out of network benefits" for physical therapy and what the coverage reimbursement rate is. If your plan allows for out of network coverage, we can provide you with a "superbill" or receipt for the services at Academy West, which you would submit to your insurance.

Question 3

Academy West is an "out-of-network" provider, what does that mean?"

Accepted Answer

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.

Question 4

How do I find out what my insurance benefits really are?

Accepted Answer

We've taken care of it by providing this 1-page checklist. Give your insurance company a call and find out the necessary information. Plus, you'll likely understand your benefits a little better.  After all, this is your insurance provider, understanding what they provide you is crucial.

Question 5

How do I submit a claim to my insurance?

Accepted Answer

The process is actually pretty simple: Academy West will provide you with a "super-bill" or receipt at the time of service, and you may submit that document 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, but be sure to not wait too long because most insurance companies have a time frame for filing a claim.

Question 6

My insurance is Medicare - are there any special rules that apply to PT services?

Accepted Answer

So many rules.
 
Academy West does not have a relationship with Medicare, which 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 requirements 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.