February 11, 2013 at 4:59 am #4354iced teaParticipant
I recently had my first physical therapy experience and I am hoping I can get some help to better understand if I’ve been billed appropriately. I feel that the services provided were very low quality yet the cost was much higher than I expected, even with insurance. Forgive me for such a long post but I wanted to make sure I covered all the details. I plan to file an appeal with my insurance provider but any guidance would be greatly appreciated.
In late Sept I found out I had a herniated disc in my neck. Following an MRI and a steroid shot, I recovered for 2 weeks. Then I met with my doctor and he determined that I was at 90% strength. I was advised by my doctor to do physical therapy. A prescription was written for PT exercises, specifically for strength rebuilding.
My physical therapy: I ended up finding a local, in-network physical therapy provider, had a consultation and then 3 follow-up visits, all over a period of about a month. The initial consultation was pretty brief. I explained the nature of my injury, and the trainer had me move my head and arms in a few different ways to check if I felt any pain. I didn’t. That was that.
During each follow-up visit I started with 10min on the hand cycle machine with no supervision.
The manual therapy: Then the trainer had me lie down and she moved my head back and to each side, asking if it hurt. It didn’t. I didn’t get any massage or kneading of the muscles. I recall her once saying that she was adjusting my cervical spine. I don’t remember specifically what happened at that time. I think it was like a stretch of my back. All of this part of each session lasted 2-3 minutes.
The rest of the exercises: The rest of each visit comprised of a series of exercises. These were the exercises in order of execution.
– I’m sitting with my back straight, and I simply roll my chin back to form a double-chin, hold it for a few seconds and then release – 30 reps
– the same exercise while I lay down with my face off the edge of the mat, the gravity making this one more challenging than the first exercise – 20 reps
– then, while lying down and resting on my elbows, I lifted my head up and looked out face-forward, held it for a few seconds, then returned to original position – 20 reps
– then what the trainer called ‘W’s,’ where I stood up and held my arms out to form a W, and flexed my back straight, hold for a few seconds, then release. – 20 reps
– then I sat on a type of row machine with 40lbs resistance and pulled towards my chest, then released slowly – 20 reps
– then I held a small medicine ball against the wall in my right hand and moved my hand in a circular motion, first clockwise, then counterclockwise – 20 reps of each; then switched to left hand and repeated
During the second follow-up, I also did an exercise where I rested my chest on a large exercise ball, and using 5lb weights did butterflies outward and then at a more forward angle for 10 reps each.
I remember all of the exercises very well especially because I wrote them down while I was there. I recorded everything so I’d have proper notes and be able to do the exercises at home. The therapist didn’t facilitate this.
Time spent under the trainer’s supervision:
– During the first of my follow-ups, the trainer spent about 3min on the manual therapy portion and about 25min teaching me how to do the exercises.
– During the second and third follow-ups, the trainer spent about 3min on the manual therapy portion and no more than 15min telling me which exercises to do, checking if I’d done them, etc.
The rest of the time during these visits I was doing the exercises independently. If an exercise took me 7 minutes, the trainer might at times ask me if I’d done all 20 reps yet. Other than that there wasn’t really interaction. My trainer had new patients coming in every 15-20min so she was busy with them, too. There were times where I would finish an exercise and go over to my trainer helping another patient, and have to interrupt her to let her know I was done. There were other times where the trainer would just be sitting with her colleagues at their desk in front of computers talking.
I finally received the bill last week. With my insurance, I’m responsible for a 20% coinsurance.
For the consultation, I owed almost $40. For the follow-up visits, I owed $65 each. The contracted rates for the follow-ups were about $330.
For the follow-ups, I was charged for 1 unit of manual therapy plus 3 units of physical therapy exercise (15min per unit).
What my insurance provider’s policy says about billing for physical therapy (from their web site):
· Therapeutic Exercises — Instructing a person in exercises and directly supervising the exercises. Purpose is to develop and/or maintain muscle strength and flexibility including range of motion, stretching and postural drainage. Therapeutic exercise is performed with a patient either actively, active-assisted, or passively (e.g., treadmill, isokinetic exercise lumbar stabilization, stretching, strengthening). Therapeutic exercise is considered medically necessary for loss or restriction of joint motion, strength, functional capacity or mobility which has resulted from disease or injury. Standard treatment is 12 to 18 visits within a 4- to 6-week period. Note: Exercising done subsequently by the member without a physician or therapist present and supervising would not be covered.
I’ve read that technically, the “8 minute rule” only applies to Medicare but most insurances follow suite with what medicare does. Under the 8-minute rule, I believe I should have been billed as follows:
– Follow-up 1 – 3min for manual therapy, about 25min for exercises, = 2 units of physical therapy exercises
– Followups 2 and 3 – 3 min for manual therapy, 15 min for exercises, = 1 unit of physical therapy exercises
The manual therapy should not have been billed as its own unit under the 8-minute rule.
I called my insurance provider because I was struck by the cost. The rep was nice enough to check the cost if I’d been billed for the same services by another physical trainer in my area. I picked one from the insurance company’s list and the 20% coinsurance would have come to $14 a follow-up visit. Simply put, if the contracted rates are relatively high at the provider I chose, then I would expect relatively high quality service.
I came across a Yelp page about the PT provider. Though I recognize that consumer reviews are just a small sample, all of them gave the provider a 1 or 2 (ie. very low scores) and all but one of the reviewers complained about how they got so little one-on-one interaction with the trainer or any supervision at all. It seems I am not alone here.
What the physical therapist had to say:
I called the physical therapy provided afterwards and inquired about the manual therapy charge, as that one seemed the most surprising and I figured I’d start there. I spoke with a not-very-nice rep from the provider’s office who challenged me to explain what manual therapy was. After I explained — the internet makes this very easy to understand – I spoke with the physical trainer. I explained how I didn’t receive any substantial manual therapy and that any sort of service of this nature lasted only a matter of a few minutes. She said that the sessions were so long ago so she didn’t remember any details, but she had ‘manual therapy’ in her notes and it said ‘she’s adjusted my cervical spine.’ She said that constituted manual therapy, and that it didn’t matter how long the manual therapy lasted. It it was provided, she said, it would be billed and that was how physical therapy was billed. She told me she had nothing to do with the costs after insurance dealt with the charges, and there was nothing that she could do.
Lack of communication:
Throughout the experience there was no communication regarding procedures and costs. Before I had my initial consultation, I called the PT provider and asked if they could give me an estimate for physical therapy exercises given my insurance. They said they couldn’t, since each patient’s case and treatment were unique.
Then during my physical therapy visits, the therapist never explained anything to me about which procedures she would recommend. For example, she never asked if I wanted manual therapy, which was not on the prescription from my doctor. There was absolutely no transparency.
In the end what am I paying for?
I’ve read that with physical therapy, what you are paying for is not just the procedure, but the expertise of the person who recommended the treatment. This comes in the form of direct supervision, guidance on how to do the exercises, etc. My experience seemed to be pretty much just the procedure, and most of it I did independently. This has been a very costly venture that resulted in only a little bit of info.
I’d hope that physical therapists would want to ensure their patients are getting something of value when they enter their clinic. Would my physical trainer have been satisfied paying my rate for that level of service? I doubt it.
I could have discharged myself after the first follow-up visit had I known nothing would change with the services provided. I ended up sticking with it because it was doctor’s orders to get physical therapy, but after the 3rd follow up I just got fed up and discharged myself, doing all the exercises at home. Thankfully, I didn’t continue with the program or my bill would be even higher.
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