Physical Therapy and 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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