Out-of-network physical therapy (PT) refers to receiving treatment from a physical therapist who does not have a contractual agreement with your health insurance provider. This means that your insurance plan may not fully cover the cost of your therapy, and you may be responsible for paying out of pocket for any expenses that are not covered.
Cash-based PT, on the other hand, refers to paying for PT services directly with cash or credit card, without going through an insurance provider. This can be an option for individuals who do not have insurance coverage, or who prefer to receive therapy without going through the insurance process.
Both out of network and cash-based PT can offer benefits, such as greater flexibility in scheduling and treatment options, but it's important to weigh the potential costs and benefits before making a decision. If you have health insurance, it may be helpful to check with your provider to understand your coverage options and any associated costs.
Insurance coverage for PT can vary depending on the individual's insurance plan and the nature of their injury or condition. In general, insurance companies typically cover a certain number of physical therapy sessions per year. This number varies depending on the insurance plan, but it can range from a few sessions to several dozen. The insurance company will usually require the patient to get a referral from their primary care physician or a specialist before approving physical therapy sessions. The referral will typically include information about the patient's injury or condition and the recommended course of physical therapy treatment. Once the referral is submitted, the insurance company will determine whether the treatment is medically necessary and covered under the patient's plan. If it is approved, the insurance company will typically cover a percentage of the cost of each session, with the patient responsible for the remaining amount. In some cases, insurance companies may only cover certain types of physical therapy or limit the number of sessions for a particular injury or condition. It's important for patients to check their insurance plan's coverage details and limitations before starting physical therapy to ensure they have a clear understanding of their out-of-pocket costs.
At FHPT, our clinicians have years of prior experience working in traditional PT. We have seen how insurance companies have ruined not only our profession, but our physician and other allied health colleagues. This leads to frustrated patients who feel like they're another number and early practitioner burnout as most hospitals and clinic are only worried about financial metrics at the end of the day. While we may not change the way our national healthcare system operates, we chose to take a stand against it. We operate as a cash-based PT service which can also provide you documentation to give to your insurnace company for partial reimbursement. In this aspect we can reap the benefits of both of these models and mitigate any negatives.
PT is an essential component of many people's healthcare journeys. Whether recovering from an injury or managing a chronic condition, physical therapy can help individuals improve their mobility, reduce pain, and regain their independence. However, traditional PT can come with high costs, strict insurance requirements, and limited treatment options. Cash-based PT offers a viable alternative to traditional therapy, with many benefits that can improve outcomes and save patients money. Here are some of the key benefits of cash-based physical therapy:
1. Greater Flexibility in Treatment Options
With cash-based physical therapy, patients have greater flexibility in choosing their treatment options. Traditional physical therapy providers are often bound by strict insurance requirements that dictate which treatments are covered and for how long. In contrast, cash-based physical therapy providers are not beholden to these requirements and can provide a wider range of treatments to meet individual patient needs. This can include hands-on manual therapy, dry needling, cupping, and other treatments that may not be covered by insurance.
2. More Personalized Care
Cash-based physical therapy also offers patients more personalized care. Traditional physical therapy providers are often under pressure to see as many patients as possible in a given day, which can limit the amount of time they spend with each patient. In contrast, cash-based physical therapy providers typically see fewer patients per day and can offer longer appointment times. This allows them to provide more focused attention to each patient and develop a more personalized treatment plan.
3. Faster Recovery Times
Cash-based physical therapy can also lead to faster recovery times. With more personalized care and a wider range of treatment options, patients are able to address their specific needs and work towards their goals more efficiently. This can result in faster healing times and a quicker return to normal activities.
4. Lower Costs
Finally, one of the most significant benefits of cash-based physical therapy is lower costs. Traditional physical therapy providers often require patients to meet high deductibles or co-pays, which can result in significant out-of-pocket expenses. Cash-based physical therapy providers, on the other hand, often charge lower overall costs for their services. Additionally, because they do not need to deal with insurance providers, they can offer more straightforward pricing and fewer surprise bills.
Example Scenario:
Tom is 42 year-old male who is healthy with no remarkable past medical history. He, his wife, and two daughters are all covered onto his private health insurance (Blue Cross, UMR, Aetna, Cigna, etc.) which he pays $1,250 a month for coverage. He is a business manager by trait, and likes to participate in CrossFit and HIIT group classes. One day, Tom trips over the edge of large box when performing box jumps and sprains his ankle. He goes to urgent care where he is negative for fractures or serious pathology and is referred to physical therapy. He has not met his family deductible of $15,000 when he is then eligible co-insurance and co-pays according to his plan. This also applies for his out-of-pocket maximum of $25,000.
In traditonal insurance-based PT patients pay set rates as determined by their health insurance with the PT clinic they select. The PT then bills for timed and untimed CPT codes for each session. The average physical therapy session last between 30-60 minutes and is billed accordingly to time and interventions utilized that session. This cost can be anywhere from $100-400 before you have met your deductible. Even when a patient reaches their deductible, physical therapy is considered a specialty practice by most health insurance companies in Louisiana. This means you are liable for at a higher co-payment rate than a primary care or other routine visit.
So Tom visits a traditional outpatient physical therapy clinic where he is scheduled 3x week for 8 weeks for 45 minute treatment sessions. Let's say Tom pays a MINIMUM of $100 per visit. Tom has now paid $1,250 pre-tax for health insurance for 2 months, still is responsible for his family deducible resulting in $100 per visit post-tax for a total of 24 sessions. On top of that, a majority of the treatment time may be administered by a Physical Therapy Assistant (PTA) or Physical Therapy Technician (PT Tech) and not the evaluating PT.
Now hear me out.... What if Tom could still attend physical therapy regardless of health insurance, and come out cheaper and happier with his results returning faster to group classes? Tom could have a one hour one-on-one initial evaluation lasting 60 minutes, see a cash-based PT 2x week for 6-8 weeks for 45 minute one-on-one treatments with his Doctor of Physical Therapy EVERY TIME. Pricing would consist of a $150 eval charge and $99 per session with the option to get MAJOR DISCOUNTS to book his treatment sessions in bundles. I'm a visual learner personally, so let's get to the graphics.
​ | Cash-Based PT | ​Traditional Insurance PT | Out-Of-Network PT |
​Patient Control | Patients have control over the frequency of visits | Coverage is determined by the insurance company. Patients typically have to choose a provider in-network. Provider has control over PT frequency and duration of sessions. | Patients can choose any provider. Provider has control over PT frequency and duration of sessions. |
Cost-Effectivness | Increased cost effectiveness (more money saved) with each visit. Bundled services can greatly reduce overall price of plan of care. | ​Depends on health insurance benefits, deductible, out-of-pocket maximum and what your PT charges without your knowledge unless you request records. Typically the middle of the road in price. | Patients will typically pay the most for these services as they are responsible for a greater percentage with health insurance. |
Scheduling Flexibility | Patients can schedule easily online when it works for them. | ​Clinics have set times secondary to PT staff productivity. Difficult to find a time that works for most working patients or parents. | Clinics have set times secondary to PT staff productivity. Difficult to find a time that works for most working patients or parents. |
Customized Treatment Plans | Allows for the most flexibility in treatment plans as PT does not have to charge by insurance CPT codes | Based on chargeable time. Often cannot incorporate strength and condition and wellness (massage, personal training, basic nutritional education, etc.) as insurance will not pay the PT for these services. | Based on chargeable time. Often cannot incorporate strength and condition and wellness (massage, personal training, basic nutritional education, etc.) as insurance will not pay the PT for these services. |
Time With Therapist | Patients can elect how much time they want to spend with the therapist. One-on-one care with the same PT throughout entire plan of care. | Session length dictated by insurance and billable CPT units. | Session length dictated by insurance and billable CPT units. |
Recovery Speed | Cash-based often results in faster recovery times. | Recovery limited by insurance coverage for number of visits. | Recovery limited by insurance coverage for number of visits. |
Insurance + Paperwork | No insurance required. Only necessary intake forms which can be filled prior to visit. | Patients need to navigate insurance paperwork to ensure proper payment, authorization, and other tedious matters. | Patients need to navigate insurance paperwork to ensure proper payment, authorization, and other tedious matters. |
Cost Transparency | Cost listed on website and booking service. No hidden fees. | Typically wait for clinic to send out bill 1-2 weeks after initial evaluation. Insurance and billing errors can occur. | Typically wait for clinic to send out bill 1-2 weeks after initial evaluation. Insurance and billing errors can occur. |
Quality of Service | Same Doctor of Physical Therapy every visit who listens and understands your story the first time you tell it. | Most clinics utilize PTAs (assistants) and can change the PT of record based on staffing needs. This results in patients dealing with multiple personalities, treatment styles, and possible missed information from the previous session. | Most clinics utilize PTAs (assistants) and can change the PT of record based on staffing needs. This results in patients dealing with multiple personalities, treatment styles, and possible missed information from the previous session. |
Requires Primary Physician | Only required if a patient is not better within the first 30 days. | Depends on insurance, most often requires signature of referring physician for initial evaluation and reassessment visits. | Depends on insurance, most often requires signature of referring physician for initial evaluation and reassessment visits. |
Conclusion:
Cash-based physical therapy offers many benefits for patients seeking to improve their physical function and reduce pain. With greater flexibility in treatment options, more personalized care, faster recovery times, and lower costs, cash-based physical therapy can be an excellent option for patients looking to take control of their healthcare journey. If you are considering physical therapy, be sure to talk to your healthcare provider about the benefits of cash-based physical therapy and whether it may be right for you.
-Dr. Nick Fulco, PT, DPT, Cert. DN
Titleist Medical Professional
