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Physical Therapy Billing — Behind the Curtains: The World of Insurance Companies and Payers
For a private practice, the world of insurance companies and payers (Medicare and private payers) is a complex and intimidating one.
Nitin Chhoda explains the differences between government and non-government payers to help you better understand the ‘insurance scenario’ so you can make a better decision about the payers you’d like to get enrolled with.
The list of payers of a physical therapy billing in a practice can be long and complex.
Government programs, private insurance companies, auto liability insurance, and workers’ compensation programs all pay for physical therapy services and rehabilitation.
Even within private health insurance companies, physical therapy billing is incredibly complex.
Insurance companies have the power to impose very specific limitations on services provided. Each type of insurance provider will have specific requirements for enrollment and treatment.
Private Insurance Companies
Private insurance companies that cover the costs of physical therapy billing and treatment include automobile liability insurance, workers’ compensation insurance providers, and health insurance companies. Workers’ compensation systems are usually tied into the public system, and there are public providers of workers’ compensation insurance.
However, there are also private companies that work similarly to private health and liability insurance companies.
For physical therapy billing purposes, these companies will expect Current Procedural Terminology (CPT) codes in the Physical Medicine section. These codes help to standardize physical therapy billing as well as other health care services billing for particular procedures and treatments.
Payment policies can be different from company to company. Most physical therapy billing staff will already know that the only way to get claims approved is to follow the policy of each company to the letter.
Any minor mistake can be cause for rejection or denial of a claim. In particular, physical therapy treatments are often limited in number of visits or to a maximum dollar amount each year.
Other Physical Therapy Services
Physical therapy may also be lumped together with other rehabilitative services, making the pool of covered treatment even smaller if the patient is seeing other specialists, including speech-language pathology, occupational therapy, and even chiropractic work.
Physical therapy billing and practices must contract with individual health care insurance companies to determine the payment levels for service. For liability and workers’ compensation payment levels, there are often legal requirements set by each individual state.
Medicare and Other Government Programs
Medicare, Medicaid, and other government programs, such as county health coverage programs, operate separately and differently than private insurance, and each program has specific rules to follow for physical therapy billing.
In fact, for Medicare, the type and amount of payment is determined by where the physical therapy services are provided.
Different billing procedures are used for in-home physical therapy and treatment within a clinic. The services that apply to most physical therapy private practices are outpatient services. Medicare has an annual cap for physical therapy billing and services that is increased each year.
More Government Programs
Under Medicaid, physical therapy is considered an option service, but one that is still covered by most states. 39 states cover physical therapy even as an optional service, and in all states there are exceptions for “medically necessary” physical therapy and for inpatient hospital physical therapy.
Other governmental programs include services through the US Dept of Veterans Affairs and under the Individuals with Disabilities Act.
Physical therapy billing for all of these services can be overwhelming and confusing. There are many problems with the system, but physical therapy documentation software is making it a bit easier to handle the specifics of each program.