Physical Therapy & Your Insurance: A Patient's Guide to Getting the Best Coverage

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:

1. 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.

2. 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).

3. 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."

4. 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.

5. 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.