Pricing model

true cost of using insurance

Do you know what your actual insurance costs are for physical therapy? Unless you have a government-sponsored insurance plan (i.e. Tricare, Medicare, Medicaid), using your insurance will probably cost you more than you think. Here's what you might pay using private health insurance:

Plans using Copays: If your insurance only requires a copay for each visit, it's easier to compare costs. If your copay is less than $50 per visit, it's probably cheaper to go to a clinic covered by your insurance rather than seeing me. But remember, this doesn't include what you paid to see your primary care doctor or orthopedic surgeon for a referral, nor does it cover any imaging like an x-ray or MRI.

Calculation:

• 2 visits per week for 12 weeks = 24 visits

• $50 per visit x 24 visits = $1200

  • Plus copays for primary care doctor and/or orthopedic surgeon and/or imaging (x-ray/MRI)

This number can go up or down based on your copay. Copays can be as low as $10 (rare) or as high as $100. Most clinics recommend 2-3 visits a week, but twice a week is usually enough. Rehab plans usually last about 12 weeks, though this can change if you're recovering from surgery.

Plans using Coinsurance: If your insurance has you pay coinsurance, the calculation gets tricky. You pay a percentage of the Maximum Allowed Amount instead of a flat rate per visit. This amount is negotiated between the clinic and your insurance and isn’t public knowledge. It varies from clinic to clinic, so you need to call each one to find out the true cost. BUT, coinsurance only kicks in after you’ve met your deductible. This means your insurance only starts paying a portion after you spend a certain amount on healthcare. Your premiums don’t count towards this amount.

Estimating Physical Therapy Costs with Plans Using Coinsurance: Most private insurance plans base their Maximum Allowed Amount on Medicare rates. In Nevada, a typical physical therapy visit may cost around $126.28. Let’s round it down to $100 and use numbers from my own high-deductible insurance plan for simplicity.

Numbers:

• Deductible: $6,500 per year (amount to spend before insurance pays)

• Coinsurance: 40% (percentage you pay once deductible is met)

• Theoretical Maximum Allowed Amount: $100 (amount clinic gets reimbursed per visit)

Calculation:

• 2 visits per week for 12 weeks = 24 visits

• If deductible isn’t met:

  • $100 per visit x 24 visits = $2400

    • Plus copays for primary care doctor and/or orthopedic surgeon and/or imaging (x-ray/MRI)

• If deductible is met:

  • $40 per visit x 24 visits = $960 + $6,500 deductible = $7460

    • Plus copays for primary care doctor and/or orthopedic surgeon and/or imaging (x-ray/MRI)

The total cost will vary based on your own deductible, coinsurance, and maximum allowable amount.

The bottom line: Using your insurance doesn’t always mean your physical therapy visits will be covered 100%.