Frequently Asked Questions
Do You Accept Insurance?
Because of the increasing difficulties (time and expense) in collecting insurance reimbursement, many private practicing physical therapists are opting for payment at the time of service, and will provide patients with a superbill for services that can be submitted by the patient to their insurance carrier, HSA or FSA for reimbursement.
I have chosen a hybrid model, limiting the insurance companies that I am in-network with to Blue Cross of Idaho, Medicare, and Cigna. I am out of network with all others, and I do require payment in full at the time of service. I am happy to provide you with an itemized superbill that can be submitted to your insurance for reimbursement.
It is your responsibility to contact your insurance prior scheduling to determine your benefits, deductible, whether or not a physicians referral, or pre-authorization are required, and your plan's reimbursement rates. My rates are comparable to Blue Cross of Idaho in-network rates. I am happy to submit the claim on your behalf if your plan is associated with my EMR system and does not require any additional registration. Otherwise, I can send you the completed claim form. I do have a pre-paid treatment plan at a reduced cost for direct pay clients.
Please visit this site to compare regional in-network and out-of-network rates for the following commonly billed CPT codes: 97161, 97110, 97112, 97116, 97140, 97530 and 97750.
https://www.fairhealthconsumer.org/medical/results
The Medicare/CMS fee schedule has reduced reimbursement for physical therapy services in 2022, and is set for an additional 5% reduction in 2023, a trend that is not favoring Medicare beneficiaries, or their trusted providers. Because Medicare does not permit beneficiaries to seek services from non-participating providers, I have chosen to contract with Medicare, otherwise I would no be able to provide physical therapy services to eligible clients. Some managed Medicare plans may not cover services if the beneficiary choses to seek care with an out of network provider. In this case, plans may fall into the commercial insurance category which are not held to this regulation. You are welcome to contact me to determine if your plan falls into this category.
Fitness classes are non-covered services.
Do I need a Doctor’s referral?
Idaho is a direct access state, meaning that clients can seek the services of licensed physical therapists without a physician's referral. Your insurance carrier may require a physican's referral and pre-authorization for treatment in order for your services to be reimburseable. In some cases, I may request that you see your physician before beginning or continuing treatment, if there is a concern about your condition.
Will Insurance Cover Fitness Classes or Courses?
The majority of insurance carries will not cover these services. Please check with your carrier for plan details. These services are not offered as part of any physical therapy treatment plan and cannot be submitted for reimbursement as physical therapy.
Good Faith Estimate
Effective January 1, 2022.
New protections are in effect for consumers of healthcare services to ban surprise billing, balance billing, and a number of others.
The rules primarily impact those who get coverage through their employer, although there are rules to help consumers who don’t have insurance or choose self-pay options.
According to the CMS website, the rules do not apply to people with coverage through programs like Medicare, Medicaid, Indian Health Services, Vetereans Affairs Health Care, or TRICARE.
YOU HAVE THE RIGHT TO RECEIVE A “GOOD FAITH ESTIMATE” EXPLAINING HOW MUCH YOUR MEDICAL CARE WILL COST.
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit http://www.cms.gov/nosurprises.
PATIENT-PROVIDER DISPUTE RESOLUTION PROCESS
CMS makes clear that good faith estimates may differ from actual services, items, or charges. If the actual billed charges are more than $400 higher than the good faith estimate, the patient may initiate the patient provider dispute resolution process. The patient initiates this process by submitting a notification to HHS within 120 calendar days of receiving the initial bill containing the excessive charges.
Upon receipt of the notification, HHS will assign a Selected Dispute Resolution entity to review the dispute and any documentation submitted by the patient and provider. The SDR entity then will make a separate determination for each service or item as to whether the provider or facility has demonstrated that the difference between the billed charge and the estimated charge reflects the costs of a medically necessary service or item, and is based on unforeseen circumstances that could not have reasonably been anticipated by the provider or facility when the good faith estimate was provided.