I often get asked if I take insurance? Short answer: no, but there is more to this answer… There are many factors that go into high quality and value of healthcare. High-quality healthcare may not be directly covered by your insurance. If you come to see me, you don't have to HOPE and cross your fingers that you'll get a good physical therapist and get good healthcare, you WILL. Another bonus of working with me is that you and I will determine when you've met your potential, not an algorithm at an insurance company. Also, your treatment is completely up to you, me and your doctor, together without the insurance company's involvement. Also, you will work with me 100% of the time; you won't see an aide or an assistant for your follow up visits.
However, if cost is your main consideration in your healthcare, keep reading, and I'll give some examples on how this self-pay option may ultimately be cheaper than going to a facility that is in-network. Another note is my services can be covered by your HSA (Health Savings Accounts) and FSA (Flexible Savings Accounts). I am not in-network with insurance carriers, but we can create a “super bill” that contains all of the necessary codes (ICD-10 and CPT codes) for the insurance company. So you can submit that to your insurance company if you have out-of-network benefits.
Now let’s talk about a little math on how this self-pay option MIGHT be cheaper than using your regular insurance for physical therapy. It all really depends on your plan and contract with your insurance provider.
The biggest cost savings could be if you have a high deductible plan. Let’s speak in hypotheticals. Say you have a $10,000 high-deductible plan with an HSA (Health Savings Account). Potentially your employer may add money into your HSA as well (which is a nice perk!). Let’s say you see an “in-network” physical therapist, meaning they accept payment from your insurance and your plan. But keep in mind, cost and quality are not one in the same...
These are the commonly used CPT (Current Procedural Terminology) codes for physical therapy: 97162 (Moderate Complexity Physical Therapy Evaluation Charge--always an evaluation charge on your first visit), 97140 (Manual Therapy), 97110 (Therapeutic Exercise), 97112 (Neuromuscular Reeducation), and 97530 (Therapeutic Activities). The evaluation code is a “non-time based” charge, while the others are “timed-based,” and typically one unit is 8-15 minutes. There are some Medicare standards that I won’t get into here as that will get a little too complicated for this blog post, and because this is really geared towards private insurance, not government insurance.
On your first physical therapy visit, you will incur a Physical Therapy Evaluation Charge, plus 2 or more other treatment codes depending on the length of your visit. The large facility that I got actual numbers from has 40-45 minute physical therapy visits so that fits in that realm for charges.
These are the numbers that are actually billed out. (I called them).
Evaluation Code (one-time):
97162 (Moderate Complexity Physical Therapy Charge): $321
Treatment Codes:
97110 (Therapeutic Exercise): $95
97140 (Manual Therapy): $87
97112 (Neuromuscular Reeducation): $112
97530: (Therapeutic Activities): $119
*These are typically billed in increments of 15 minutes so you may see 1 unit or 2 units of 97110 (so that’s 1 or 2 x $95).
Hypothetical First Visits:
First visit at this large center, 40 minutes: 97162, 1 unit of 97110, 1 unit of 97530—> $321 + $95 + $119 = $535 for 40 minute evaluation and some treatment (limited because only 40 minutes).
First visit with me at Heie Health, 60 minutes = $180. No hidden fees. Flat fee. Full evaluation + treatment. And 20 minutes longer so I can include more treatment.
*Also, note I am very efficient, and really get a lot done in the first visit. I will uncover the root cause of your ailment(s), start treatment, and come up with a plan to get you back on the road to recovery.
Hypothetical Follow Up Visits:
Hypothetical 2nd visit (40 minutes) at large center charges:
1 unit of each: 97140, 97110, 97112—> $87 + $95 + $109 = $291
2 units of 97110, 1 unit of 97530—> 2($95) + $119 = $309 (and this example has no hands-on techniques)
*If it was a 45 minute appointment and the physical therapist did 4 different things that could be classified into 4 codes: 97140, 97110, 97112, 97530—> $87 + $95 + $109 + $119 = $410 (this is still reasonable billing as each code is different and a unit is typically 8-15 minutes…again, this is beyond this post but could be a possibility).
*Another side note, is there will be a “negotiated rate” that is negotiated between your healthcare provider and the insurance company. And this “negotiated rate” should be passed on to you as a consumer so make sure that you are not paying that full price in your deductible, if you have seen an “in-network” provider. When you look at your Explanation of Benefits (EOB) after a medical visit, you will see the “allowable amount” that the insurance company will pay for of the billable amount. Potentially it could be 50% of the billable amount. So the first visit at the large, in-network facility could cost around $268 to $535, which is still higher than $180.
2nd visit (and subsequent visits) with me at Heie Health:
45 minutes—> $120
60 minutes—> $140
And lots of hands-on or dry needling, and full-focused approach.
Also, I do have some 30 minute options that are $80 for specific patients, once I know you and your body 😊. The reason I can charge cheaper than the large facility is because I don't have all of the administrative costs associated with billing through insurance. I don't have to pay a coder, someone to send out the bill, someone to negotiate with the insurance company, etc.
So your evaluation (first visit) could cost $268 - $535 at the large center and $180 with me (plus 20 minutes longer). The follow up visits at the large center could cost $146 to $410 at 30-45 minutes! And your follow up visits with me are $120 or $140 for 45 and 60 minutes, respectively.
Now there are variations of these hypothetical scenarios, of course. If you met your deductible because you had surgery or other major medical expenses in the year, it could be cheaper at the larger facility because your insurance provider may actually pick up the tab. Also, if you have a co-pay plan, you may just have a co-pay for physical therapy that could range from $30-100. However, your insurance provider may cap you at 20 physical therapy visits a year, (or even 6 if bundled with a procedure), and you may need MORE physical therapy beyond that number. I just met a patient recently with that scenario because she had complications due to surgery, so she still needs physical therapy to get back to everything she wants to do. Also, I just treated a patient the other day, and she saw 12 different providers (who were in-network) before me with no improvement. After one visit, her issues were resolved so she could have saved time, copays, and anxiety over not knowing what to do by just seeing me the 1 visit.
I’m not trying to diss on the larger facility. There is a lot that goes into billing, etc., and they are billing appropriately. Healthcare is expensive and sometimes looking outside of the traditional approach, will help you get the best VALUE and QUALITY care you deserve. You also can see your “in-network” physical therapist, and see me for the extra care or for the other issues that are popping up around your body as you rehab. Insurance companies are not into individualized care for their consumers, and often the providers of the larger facility’s hands are tied because the insurance companies are making the decisions.
My main goal is to provide HIGH-QUALITY CARE (aka HEIE-QUALITY CARE😉) and to get you back to doing the things you love to do! 🥳 I can work with you to meet your goals and sometimes I only need to work with someone only once or twice! Any questions and to schedule, please call us at 612.778.6240.
Cheers!
Margi
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