Payment information

It can be confusing as to whether you should use therapists who are in-network & accept your insurance or an out-of-network private practice therapist so one element to consider is your overall cost with an in-network therapist.

Check your policy (or call your provider) and determine your deductible, coinsurance, and copay for in-network physical therapy vs. out-of-network costs.

I have a patient that has BCBS MI and just this year he changed to a high-deductible policy for his family because it has a lower monthly cost. Most high-deductible policies offer a health savings account (HSA) or flexible spending account (FSA), where funds are contributed throughout the year via payroll. These funds are still being deducted from a paycheck but are able to be used for many other healthcare services and purchases. 

Due to his high deductible ($9200) both in and out-of-network, he might still pay out of pocket for all of his therapy services, whether the provider is in or out-of-network, until that deductible is met unless he has a copay or coinsurance. When claims for services are submitted through insurance, the charges are typically higher due to the specific contract that therapy company has with the insurance carrier. Each company (ATI, Athletico, Team Rehabilitation, etc.) has a different contract with the insurance company PER the insurance company.

*Note: There are so many different policies that sometimes in-network services could be covered 100% with a $45 co-pay and out-of-network (OON) could be covered 50% after the deductible is met. So you'll have to check your specific policy.

Physical therapists do not bill for services in dollar amounts but rather billing codes and time. For example, if a person's therapy session lasts 60 minutes and he/she does exercises or balance activities or works directly with the therapist and then ends with a cold pack, the therapist would provide a CPT code for the exercises (97110) as well as how long the patient was doing those exercises, another CPT code for balance activities (97112 or 97530 depending upon the type of activity) and how long the patient was doing balance activities, another code for manual therapy (97140), and the time they spent together, and so forth. All of those codes and times should equal 60 minutes or the amount of time the patient was in their care.

The claims submitted to insurance are then applied to the deductible and can vary from each session depending upon what was done that session.

A copay is a set amount a member/patient pays for each visit and coinsurance is a percentage that the patient/member would pay for each visit. So if the visit CPT codes and times add up to $250, per the therapy company's contract with the insurance provider, the patient would be responsible for a percentage of that amount. For example, if the visit charges were $250 and the patient has a 20% copay, he/she would be responsible for $50 that session, and the remainder could be applied toward the deductible; it depends upon the individual contract with the insurance company. UGH...right? There are so many variables and nuances to contracts with insurance companies.

Okay, so our patient above would cover a $50 copay, or coinsurance in our case, per in-network visit, and most in-network PT clinics want to see patients two to three times per week, so he would pay $100-150 per week.

When it comes to private practice, we're not obligated to any requirements from the insurance companies to see patients three times per week, and we're not limited on how long the patient can stay or how long the patient can attend therapy, and we're not limited to which treatments we can provide, which allows us to implement any and all interventions that would be best for you and expedite your return to the things you love without pain.

Not to further complicate things (but this really is crazy complicated), in 2024 BCBS limited physical therapists with how long each visit was in that they refused to pay for any visit that was longer than 45 minutes. They do not pay for certain manual interventions, they do not pay for dry needling, they do not pay for cold packs or iontophoresis, and minimally for electrical stimulation. This also applies to Medicare Advantage members; we were not paid for any time over 45 minutes.

BCBS is once again trying to decrease the amount they pay for physical therapy services in 2025. They are trying to enact a plan to reduce reimbursement where the highest-cost CPT code is paid 100% and the remaining codes are paid at 50% of the fee schedule...but I digress.

So when it comes to private practice, you (the patient) and I (the owner) can decide ourselves what would be the best course of action for your particular needs. Since we are not held to any restrictions, your therapy would be highly personalized and for a slightly higher cost or maybe the same amount depending upon how many visits are needed.

Furthermore, if you have OON benefits, a Superbill can be submitted, and you could be reimbursed IF the insurance company decides that the care you're receiving fits their "medical necessity" definition...but that's another blog post. :-)

Please feel free to email with any questions or concerns. We are literally here for you and for your best interests. 

B Well -

Beth