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.

• [list the plans…with more to come]

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. Coverage depends entirely on the type of Medicare plan you have. (CREDENTIALING PENDING)

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

• “Privatized” Medicare Advantage Plans (Part C): "No." PhysioWorks does not accept or bill Medicare Advantage Plans at this time.

WELLNESS, HEALTH & FITNESS

For clients that still want to work with PhysioWorks we offer wellness, health, and fitness services as a self-pay, out-of-pocket expense.

These services are categorized as non-covered, non-medically necessary, and non-skilled by insurance standards, meaning they cannot be billed to insurance. Health, wellness, and fitness clients do not receive a Superbill and do not seek reimbursement from their insurance provider. All wellness services are given a Good Faith Estimate (GFE) regarding our most up-to-date rates. Clients will sign a form acknowledging that Medicare will not cover these wellness services and they are strictly a self-pay, out-of-pocket expense.

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.

Wellness, Health, and Fitness services aren't covered by traditional insurance but patients may use their HSA or FSA cards to pay for these services using pre-tax dollars.

A: Many in-network plans have a hard cap on the number of sessions allowed per calendar year (e.g., 20 or 30 visits). Other plans use "Medical Necessity," meaning they will pay as long as we can prove you are still making progress.

If you exhaust your benefits for the year, you can continue to receive medically necessary, covered, and skilled physical therapy services on a self-pay, out-of-pocket basis.

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: These patients pay for services out-of-pocket. They choose to pay for their care directly without involving an insurance provider. This is often the choice for those without OON benefits, those who choose not to use their insurance, or clients receiving health, wellness, and fitness services. Self-pay patients do not receive a Superbill and do not seek reimbursement from their insurance provider.

• Health, Wellness, and Fitness: These clients pay for these services out-of-pocket. These services are categorized as non-covered, non-medically necessary, and non-skilled by insurance standards, meaning they cannot be billed to insurance. Health, wellness, and fitness clients do not receive a Superbill and do not seek reimbursement from their insurance provider. Health, wellness, and fitness services aren't covered by traditional insurance but patients may use their HSA or FSA cards to pay for these services using pre-tax dollars.

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

• Medicaid as 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 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: Billing cycles can be complex, and exceptions are common.

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: You must first meet your annual deductible before your insurance provider will contribute toward your reimbursement.

Once your deductible is met, insurers typically reimburse a percentage—usually 50% to 80%—of the rate they allow for out-of-network physical therapy.

Ask your insurer for an Advanced Explanation of Benefits (AEOB). By providing them with the Good Faith Estimate we give you, your insurance can generate a pre-visit breakdown showing exactly what they will reimburse – even before your first visit.

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: Their number is 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 for a Call Reference Number. This allows us to easily track down your case if needed without having to start the process over.

Next Steps: Once you have the specific reason for the denial and a reference number, reach out to us. We can then provide the 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.

Key factors to consider:

• Insurance Coverage: Is your insurance in-network, out-of-network, or are you self-pay. Have you met your insurance deductible for the year.

• Plan Details: Every insurance plan has different negotiated rates and "Allowable Amounts" for physical therapy services.

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

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

• Copay: A flat fee (e.g., $40) due at every visit.

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

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, any adjustments (overpayment or underpayment) will be reflected on your next statement.

A: 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 and Self-Pay rates are based on a transparent fee schedule that reflects sustainable clinic practices and our 1-on-1, mobile service model. These rates are competitive with the market standards for mobile physical therapy services and provided to you in advance with a Good Faith Estimate, allowing for total price transparency before your first session begins.

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 can submit that Superbill and your Primary EOB to your Secondary insurance to see if they will reimburse you for the costs your Primary didn't 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.

Our No Surprises Guarantee:

• Good Faith Estimate & Rates in Advance: We provide every self-pay and out-of-network patient with our rates and a Good Faith Estimate (GFE) before your first visit. This includes anyone utilizing our health, wellness, and fitness services.

• 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 exceeds our estimate by $400 or more, you have the right to a federal review.