A: The short answer is “no.”

In Montana, patients have “Direct Access” to healthcare. You can immediately receive services by a licensed physical therapist without a prior physician’s referral.

NOTE: Some insurance providers may require a physician’s referral for reimbursement or a signed “Plan of Care” by a physician within 30 days of starting therapy. Contact the Member Services department of your insurance provider to find out if a referral is required. Their number is listed on the back of your insurance card or online at their website. Also, let us know if your insurance provider requires a signed “Plan of Care” by your physician and we will handle the logistics of getting the signature.

A: This is plan-dependent. Prior Authorization (PA) is a review by your insurance provider to determine if they will cover physical therapy services - even before you’ve had your first visit.

Contact the Member Services department of your insurance provider to find out if prior authorization is required. Their number is listed on the back of your insurance card or online at their website.

When you call Member Services, ask these questions:

1. Does my insurance plan require “Prior Authorization” for physical therapy?

2. Does this requirement apply to the initial evaluation, or only to follow-up treatment sessions?

A: Understanding insurance lingo is the first step. Every plan is unique; here is a general guide to help you identify your coverage potential.

• PPO & POS Plans: Generally offer the highest potential for reimbursement. These plans usually allow you to choose providers that are out-of-network, though your out-of-pocket costs may be higher.

• HDHP (High Deductible) Plans: If you have an HSA-qualified plan, you can use your HSA/FSA funds for all PhysioWorks services, regardless of your network status. This is often the most tax-efficient way to pay for services.

• HMO & EPO Plans: These are "Closed Networks." They typically do not reimburse for care that is out-of-network, unless it is an emergency or has been pre-authorized by the insurer.

When you call Member Services, ask these questions:

1) Do I have “Out-of-Network” coverage for physical therapy?

2) What is my annual deductible, and how much of it has been met for the year so far?

3) What is the “Allowable Amount” or percentage of reimbursement for my sessions once the deductible is met?

4) Is a physician's referral, physician's signature on the "Plan of Care," or “Prior Authorization” required for out-of-network coverage?

DISCLAIMER: The insurance landscape is complex and constantly shifting. This guide is for educational purposes only. To ensure you have the most accurate information regarding your financial responsibilities, we always recommend contacting the Member Services department of your insurance provider.

A: PhysioWorks currently takes the following insurances as an “In-Network” provider:

• Original Medicare (Part B)

• Blue Cross Blue Shield of Montana

• Allegiance

• Montana State Fund

• Worker's Compensation

PhysioWorks also accepts:

• Medicare Supplement Plans (Medigap)

• HSA & FSA Accepted

For all other insurances, PhysioWorks is considered “Out-of-Network.” Many insurance plans include out-of-network coverage. Contact the Member Services department of your insurance provider to find out if your plan has out-of-network coverage. Their number is listed on the back of your insurance card or online at their website.

A: "Allowed Amount" is the maximum amount an insurer chooses to pay for a service. It does not always reflect the actual cost of the service, but rather what the insurer is willing to pay. Your reimbursement is calculated as a percentage (e.g., 60% or 80%) of their allowed amount – not the actual rate.

A: Medicare has strict regulations and restrictions. Your coverage depends entirely on the specific type of plan you have.

• Original Medicare (Part B): Yes. PhysioWorks accepts Original Medicare as an in-network provider.

• “Privatized” Medicare Advantage Plans (Part C): It depends. Private insurance companies manage Advantage plans. We can only accept your plan if we are in-network with that specific company (such as Blue Cross Blue Shield or Allegiance). If your Advantage plan is managed by a company we are not in-network with (like Humana or UnitedHealthcare), your care will be considered out-of-network.

WELLNESS, HEALTH & FITNESS

PhysioWorks also offers proactive wellness, health, and fitness services as self-pay for all clients, regardless of their insurance plan.

These services are considered non-covered, non-medically necessary, and non-skilled by insurance standards, meaning they cannot be billed to Medicare or any other insurance. We do not provide a Superbill, and clients cannot file a claim for reimbursement. We will provide you with our rates in advance and interested clients will sign a simple form acknowledging that these services are strictly self-pay.

DISCLAIMER: The insurance landscape is complex and constantly shifting. This guide is for educational purposes only. To ensure you have the most accurate information regarding your financial responsibilities, we always recommend contacting the Member Services department of your insurance provider.

A: Yes. Physical therapy is a qualified medical expense. You can use your Health Savings Account (HSA) or Flexible Spending Account (FSA) to pay for physical therapy services at PhysioWorks.

While Wellness, Health, and Fitness services are not covered by insurance, clients may be able to use their HSA or FSA cards to pay with pre-tax dollars (Note: Please check with your HSA/FSA administrator regarding eligibility requirements for wellness services, such as a Letter of Medical Necessity).

A: Coverage rules vary depending on your specific insurance plan:

• Hard Visit Limits: Many plans set a strict cap on the number of allowed visits per calendar year (e.g., 20 or 30 sessions total).

• Medical Necessity & Skilled Care: Other plans cover visits based on "medical necessity." Meaning care is covered as long as it requires the specialized skills of a licensed physical therapist—whether the goal is to improve your functional mobility, maintain your current level of function, or prevent further decline.

If you exhaust your insurance benefits for the year or reach your plan's annual visit limit, you can opt to continue care through our self-pay option.

When you call Member Services, ask them: Does my plan have a hard cap on the number of PT visits per year, or is it based on medical necessity?

A: No. An EOB (Explanation of Benefits) is a "receipt" from your insurance company, not a bill.

It is a statement showing the "math" of your coverage—what we billed, what your insurance covered, and what your remaining responsibility might be.

Do not pay the insurance company. They do not collect your patient responsibility; we do.

Wait for an invoice from PhysioWorks. We will only bill you for the final "Patient Responsibility" amount once the insurance claim is fully processed.

A: In short, “In-Network” and “Out-of-Network” patients use their insurance to help pay for physical therapy services. “Self-Pay” patients and “Wellness” clients pay for their services out-of-pocket and do not use insurance.

• In-Network (INN): This means PhysioWorks has a formal contract with your insurance provider. We accept their "negotiated rate" for services, and we bill your insurance company directly. Your financial responsibility is typically limited to your plan's specific copay, coinsurance, and deductible.

• Out-of-Network (OON): This is a benefit provided by many insurance plans that allows you to see providers who are out of the network of your insurance provider - meaning they are not part of your insurance provider’s network (in-network). Not all insurance plans have out-of-network coverage. If your plan includes OON benefits, you pay at the time of service, and we provide you with a Superbill (a detailed medical receipt) to submit to your insurer for reimbursement.

• Self-Pay: With our self-pay option, you pay for services directly out-of-pocket without involving an insurance company. This is ideal if you do not have out-of-network benefits, prefer not to use your commercial insurance, or are receiving health, wellness, and fitness services. Self-pay clients do not receive a Superbill and do not submit claims for insurance reimbursement.

• Health, Wellness, and Fitness: These services are offered as self-pay to all clients. They are considered non-covered, non-medically necessary, and non-skilled by insurance standards, meaning they cannot be billed to insurance. We do not provide a Superbill, and clients cannot file a claim for reimbursement. We will provide you with our rates in advance, and interested clients will sign a simple form acknowledging that these services are strictly self-pay. We accept cash, major credit cards, HSA, and FSA cards for payment (please check with your HSA/FSA administrator regarding eligibility requirements for wellness services, such as a Letter of Medical Necessity).

A: PhysioWorks accepts Medicaid as a Secondary Payer. (CREDENTIALING PENDING)

• Medicaid as a Secondary: If you have a primary insurance plan (such as Original Medicare or private insurance) and Medicaid acts as your secondary "wrap-around" coverage, we can bill Medicaid for your remaining copay, coinsurance, or deductibles.

• Medicaid as a Primary: At this time, PhysioWorks is not accepting patients with Medicaid as their primary insurance provider.

A: No. PhysioWorks and Mobile Physical Therapy are NOT Home Health.

To qualify for Home Health services, you must be “homebound.” You do not need to be homebound to receive our services.

We provide the same professional services as an Outpatient Physical Therapy Clinic but at a location that is convenient for you (home, office, gym). We do NOT provide Home Health services.

1. Submission: PhysioWorks bills your insurance provider electronically or by mail.

2. Processing: Your insurance provider reviews and processes the claim based on your specific plan.

3. EOB & Payment: Insurance sends you an Explanation of Benefits (EOB) and sends PhysioWorks a payment along with a statement of any remaining balance due by the patient.

4. Final Balance: You receive a statement from PhysioWorks for any remaining balance (such as a co-pay, coinsurance, or deductible).

NOTE: Please keep in mind that insurance timelines vary. Your Explanation of Benefits (EOB) is not a bill. We will review all insurance payments first and only send you a statement if there is an official patient balance remaining. 

How the process works:

1. Upfront Payment: Payment for services is processed on the day of your visit.

2. The Superbill: You will receive an itemized medical receipt (Superbill) containing all of the necessary information your insurance provider needs to process a reimbursement.

3. Submission: Submit the Superbill to your insurance provider. Follow their instructions to avoid delays in reimbursement.

4. Direct Reimbursement: Your insurance provider sends a check directly to you, as long as, your plan includes out-of-network benefits.

NOTE: When submitting your Superbill to insurance, make sure the claims agent knows the Place of Service (POS) is '12' (Home/Residence). Insurance systems often default to an office setting (POS 11). This small discrepancy is a common barrier that can delay your reimbursement.

A: Out-of-network reimbursement depends entirely on your specific health plan:

• Out-of-Network Deductible: Most plans have a separate deductible for out-of-network care. You must satisfy this specific deductible before your insurance will reimburse you. (Note: Payments made toward your in-network deductible usually do not count toward this).

• Co-Insurance: Once your out-of-network deductible is met, insurers typically reimburse a percentage—usually 50% to 80%—of their standard allowed rate for physical therapy.

Because out-of-network policies vary widely, we recommend calling the Member Services number on the back of your insurance card before your first visit to ask these four quick questions:

1. Do I have a separate Out-of-Network deductible from my In-Network deductible?

2. What is my Out-of-Network deductible amount, and how much of it have I met so far this year?

3. Once my out-of-network deductible is met, what percentage of care is reimbursed?

4. Does my plan require prior authorization or a doctor's referral for out-of-network physical therapy reimbursement?

A: Generally, it takes between 30 days to 6 weeks after you have submitted your claim and they have received it. If it’s been longer, contact your insurance provider.

A: Unfortunately, this is not an uncommon experience. Denials are often attributed to minor administrative mistakes or simple coding mismatches that are easily correctible.

1. Check your EOB: Look at the Explanation of Benefits (EOB) sent by your insurer. It will list a specific "Reason Code" explaining why the claim wasn't paid.

2. Contact Member Services: Call the number listed on the back of your insurance card or online at your insurer’s website.

3. Ask the Agent: "Why was this claim denied, and what information is missing to process it correctly?"

4. Get a Reference Number: Before hanging up, ask the agent for a Call Reference Number. This makes it easy to track down your case and conversations you've had with your insurance provider, without having to start over.

Next Steps: Once you have the specific reason for the denial and a reference number, reach out to us. We can provide additional documentation, clinical notes, or coding corrections (like verifying POS 12) needed to help you resubmit the claim successfully.

NOTE: While PhysioWorks is in your corner and will provide all necessary clinical evidence and documentation to support your claim, your insurance provider is the final arbiter of your benefits. We cannot guarantee reimbursement or overturn a final decision made by your insurer. Ultimately, the financial responsibility for all services provided remains with the patient.

A: We offer a wide range of care to meet your needs—from insurance-based rehab to specialized health, wellness, and fitness services.

Because care is tailored to your specific goals and insurance plan, prices vary depending on a few key factors:

• Insurance Coverage: Is your insurance in-network, out-of-network, or are you paying out-of-pocket?Have you met your insurance deductible for the year?

• Plan Details: Every insurance sets is its own negotiated rates and "Allowable Amounts" for physical therapy services, which determines your copay, coinsurance, or deductible responsibility.

• Health, Wellness & Fitness Services: These services are offered at a fixed, transparent self-pay rate, separate from insurance-based rehab.

We believe in total financial transparency. Contact us before your first visit, and we will help to verify your insurance benefits or provide our clear self-pay rates.

A: If we are in-network with your insurance provider, your financial responsibility is determined by your specific plan's "negotiated rate."

• Copay: A fixed flat fee (e.g., $40) set by your insurance that is due at every visit.

• Coinsurance: A percentage (e.g., 20%) of the negotiated rate for each service provided.

Your copay or estimated coinsurance is processed automatically on the day of your visit using the method of payment on file. Once your insurance processes the claim:

• If you overpaid: Any extra money will either be credited toward your next visit or refunded back to you. Bottom line: you get every penny back.

• If you underpaid: You will be billed or charged for the remaining balance required by your insurance plan.

A: Rates depend on whether you are using insurance or paying out-of-pocket.

In-Network Rates: Are determined by a formal contract between PhysioWorks and your insurance provider. We agree to accept their "negotiated rate" for services, and your specific plan (copay, coinsurance, or deductible) dictates your final out-of-pocket responsibility as shown on your Explanation of Benefits (EOB).

Out-of-Network & Self-Pay Rates: Are set using a transparent, flat fee schedule. These rates reflect the convenience, high quality, and undivided attention of our 1-on-1 mobile care model, while remaining competitive with the local market for mobile physical therapy.

A: Payment information is securely stored and encrypted with a third-party payment processor. Your data is never stored on our local systems.

The primary method of payment is selected during patient intake and processed automatically on the day of your visit. You will receive an electronic receipt via email; out-of-network patients will also receive a Superbill for reimbursement.

A: This is known as “Coordination of Benefits (COB).” How we handle your billing depends entirely on our network status with each of your plans. Here are the four possible scenarios:

NOTE: Coordination of Benefits rules are set by the insurers, not the provider. Always provide both insurance cards during your patient intake.

SCENARIO 1: Both Plans are In-Network

• The Process: We bill your Primary insurance first. Once they process the claim, it typically "crosses over" automatically to your Secondary insurance.

• Your Responsibility: You generally pay little to nothing out-of-pocket at the time of service, depending on your specific plan's coverage for coinsurance and deductibles.

SCENARIO 2: Both Plans are Out-of-Network

• The Process: You pay our full rate at the time of service. We provide you with a Superbill (detailed medical receipt).

• Your Responsibility: You submit the Superbill to your Primary insurance. Once you receive their Explanation of Benefits (EOB), you then submit that EOB along with our Superbill to your Secondary insurance to seek additional reimbursement.

SCENARIO 3: Primary is In-Network / Secondary is Out-of-Network

• The Process: We bill your Primary insurance directly.

• Your Responsibility:

  • • You pay your required copay or coinsurance at the time of service based on your primary insurance. We then provide you with a Superbill for that specific out-of-pocket amount.

    • You submit our Superbill and your Primary EOB to your Secondary insurance. They will determine if—and how much—they reimburse you for any costs your Primary insurance did not cover.

SCENARIO 4: Primary is Out-of-Network / Secondary is In-Network

• The Process: This is the most complex. Because we are out-of-network with your primary, you pay our full rate upfront. However, because we are in-network with your secondary, we are contractually obligated to bill them after your primary has made a determination.

• Your Responsibility: You submit our Superbill to your Primary insurance first. Once you receive their EOB, you must provide it to us. Then we bill your Secondary insurance.

A: The “No Surprises Act” is a federal law that protects you from unexpected medical bills. It ensures that you have a clear understanding of your healthcare costs before you receive care or treatment.

• Who it Applies to: Good Faith Estimates (GFEs) are provided to patients who are uninsured, self-pay/cash-pay, or choosing not to use their insurance for clinical physical therapy services.

• Who it Does Not Apply to: If you are using your insurance—in any capacity—you will not receive a GFE.

Our No Surprises Guarantee:

• Rates in Advance: We provide every self-pay and out-of-network patient with our rates in advance. This includes anyone utilizing our health, wellness, and fitness services.

• Good Faith Estimate: We provide every self-pay patient with a Good Faith Estimate (GFE) prior to their first visit.

• Price Certainty: These estimates outline the total expected cost of your care based on your Plan of Care and our current fee schedule, so you can make informed decisions about your health without the worry of "bill shock."

How the Estimate Works:

Our Good Faith Estimate is based on our initial clinical findings, your specific goals, and your individualized Plan of Care. Because every body heals differently, your therapist may recommend more or fewer sessions as you progress. If your plan of care changes significantly, we will provide you with an updated estimate so you always have full control over your healthcare investment. GFEs are valid for up to 12 months of recurring care. 

NOTE: A Good Faith Estimate is not a contract and does not require you to obtain services from PhysioWorks.

Your Rights: If the cumulative total of your bills for services substantially exceeds our estimate by $400 or more, you have the right to initiate a federal dispute review process.