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PPTS Healthy Times Newsletter
February 2010
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Physical Therapy & Your Insurance: A Patient's Guide to Getting The Best Coverage
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The best way to take care of your health is to take an active role in your own health care. To do this, you need to know about your options and your rights as a patient. Patients across the country are becoming better educated and demanding more and better options from their health insurance companies. The right to physical therapist services is an important option, and it is your right as a patient.
Federally qualified HMOs are required to have physical therapy in their benefits packages.
Why Physical Therapy?
- Physical therapists are experts in how the musculoskeletal and neuromuscular systems function.
- Physical therapist services are cost-effective. Early physical therapy intervention prevents more costly treatment later, can result in a faster recovery, and reduces costs associated with lost time from work.
Patients pay less when they have direct access to physical therapy services. However, there can be a temptation under managed care to terminate services prematurely. A study conducted to determine whether direct access to physical therapy services was cost-effective found that patients who went directly to a physical therapist had fewer episodes of care, and services were ultimately less costly.
What Do Physical Therapists Do?
Physical therapists help restore function, improve mobility, relieve pain, and prevent or limit permanent physical disabilities of patients with injuries or disease. They also restore, maintain, and promote overall fitness and health.
The following list contains some of the most common reasons to see a physical therapist:
· Back conditions
· Knee problems
· Shoulder/arm
· Neck conditions
· Sprains/muscle strains
· Ankle/foot problems
· Carpal tunnel syndrome, hand/wrist problems
· Hip fracture
· Post-surgical rehabilitation
· Rehabilitation after a serious injury (eg, broken bones, head injury)
· Stroke rehabilitation
· Problems with balance
· Disabilities in newborns
· Burn rehabilitation
· Pre-/post-natal programs
· Incontinence
· Women's health
In most states you may see a physical therapist without a doctor's referral, but be sure to check your health insurance plan to see if physical therapist services are covered without a physician's referral.
What Can You Do to Improve Your Physical Therapy Coverage?
Talk with your employer/benefits manager. The employers who contract and pay for employee health care plans often have the most influence with insurers.
Employers are interested in keeping their employees on the job and their premiums low, so providers who can help employees prevent injuries and avoid recurrence (as well as promote a healthy lifestyle) have particular appeal to them. Arrange a meeting with your human resources director or whoever is responsible for negotiating the terms of the company's insurance plan.
Ask your human resources director or insurance company the following questions to determine if your current benefits package gives you access to appropriate physical therapy services:
- Is your physical therapy benefit "bundled" with those of other providers of care? Physical therapy services should be listed separately in the benefit language so that access to necessary services is not compromised.
- Does the benefit language permit access to physical therapists for each condition during the year? Benefit language should permit treatment of more than one condition in a calendar year (eg, ankle fracture in January and low back injury in July.)
- Does the benefit language permit access to physical therapists for each episode of care? A person may require more than one episode for the same condition. For example, someone with arthritis may receive physical therapy intervention for knee weakness in an attempt to avoid surgery. While this is often successful, some patients may require surgery.
- Does the benefit language ensure coverage that facilitates restoration of function? Benefit language that restricts physical therapy care to a 60 or 90 day period imposes an arbitrary limit on recovery. In determining an appropriate physical therapy benefit that will allow an individual to return to his or her previous level of function, benefit language should reflect the normal amount of time that it takes to recover from an injury or from surgery.
- Does the benefit language ensure coverage that promotes functional independence for those with chronic conditions? Someone who has a chronic condition may need to be seen periodically by a physical therapist. The physical therapist will determine if the individual's home program, equipment, or adaptive devices should be modified. (For instance, children requiring orthotic devices will need modifications to those devices as they grow.) Benefit language should ensure that someone with a chronic condition may receive the kind of care that promotes personal safety and the greatest degree of function possible.
Choosing a Health Plan
Millions of Americans are offered a choice of health plans through their employers, but the question is- What makes a good health care plan? Here are some things to consider when choosing a health plan:
Are you choosing a plan simply because it is the cheapest?
This may not be the best way to go. Some inexpensive plans have a high deductible and no comprehensive coverage.
Is the plan accredited by the National Committee on Quality Assurance?
This is a good indicator of quality.
Are your current doctors and specialists in the plan? If not, make sure you will be able to see a certain provider or specialist, such as a physical therapist, without too much added expense and difficulty.
Is physical therapy coverage adequate? If you should have an injury or illness requiring rehabilitation, you will need a plan that offers an unlimited number of visits to a physical therapist or that allows for the number of visits to be extended if needed.
Are there lifetime limits on benefits? If so, you could face a serious financial crisis if you or a covered member of your family suffers a major illness or injury.
Does the plan have an out-of-pocket maximum? In this case, once you have a paid a certain amount (usually several thousand dollars) the plan would cover the rest.
How does the plan handle grievances and appeals? The procedure should be simple, timely, and accessible.
Does the plan permit use of outside doctors, specialists, or hospitals? Called "point-of-service" option, this would allow you to see a provider, such as a physical
therapist, who is not in your plan. There may be an additional cost, but it may be worth it.
What is the plan's disenrollment rate? A high rate of members leaving the plan annually may indicate customer dissatisfaction.
Source: www.apta.org
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Bike MS: Round Up Ride 2010
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On March 27-28th, 2010 the 24th Annual Bike MS: Round Up Ride will host more than 1,000 participants as they ride over 150 miles in two days to make a difference in the lives of people living with multiple sclerosis.
The event takes place in historic Florence, AZ. The race is designed to provide a scenic, challenging ride for both the experienced cyclist or energetic novice.
In March 2009 they raised over $550, 000 for MS research and local programs for clients, family and caregivers.
The National Multiple Sclerosis Society, founded in 1946, is a voluntary health agency dedicated to mobilizing people and resources to drive research for a cure and to address the challenges of everyone affected by MS.
Multiple sclerosis is a chronic, often disabling disease, of the central nervous system affecting the brain and spinal cord. MS impacts the lives of more than 2.8 million Americans. One new case of MS is diagnosed every hour. MS usually strikes adults in the prime of life -between the ages of 20 and 50-and affects women twice as often as men. The progress, severity and specific symptoms of the disease cannot be predicted.
Tricia Grossman from our Mesa-Gateway clinic will be participating and is looking to raise some money for this very worthwhile cause. If you'd like help donate on behalf of Tricia Grossman to the National Multiple Sclerosis Society please call our Mesa-Gateway clinic at 480-357-6500 or
email Tricia Grossman at triciag@pptsonline.com
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CPR/AED Classes @ Physicians Physical Therapy Service
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 Remembering about the heart isn't only about Valentines' Day but is
also a good time to remind those who are required to have CPR
certifications up to date.
PPTS hosts CPR/AED Certification/Re-Certification Classes. The course
is instructed by Captain Jay Arthur of the City of Phoenix Fire
Department. At the conclusion of the course all those who attend
will receive a 2-year CPR/AED official certification.
Upcoming Classes:
PPTS @ Arrowhead
18275 N. 59th Ave K #164
Glendale, AZ
602-588-0320 arrowhead@pptsonline.com
February 18th, 2010
6:30-830pm $20 p/person
PPTS @ Mesa-Gateway
3035 S. Ellsworth Rd. #128
Mesa, AZ
480-357-6500 mesagateway@pptsonline.com
February 25th, 2010
6:30-8:30pm $20 p/person
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