Can I Use My Insurance for Private-Pay Physical Therapy? How Superbills Work

It’s one of the first questions we hear from people in South Bend, Granger, and Mishawaka: If ECPT is private pay, can I still use my insurance?

The short answer: ECPT doesn’t bill insurance directly, but many people with commercial insurance can get part of their cost back through their plan’s out-of-network benefits. We provide an itemized invoice, often called a superbill, that you submit to your insurance company yourself. Here’s how that works, which plans tend to reimburse, and what to ask before your first visit.

What “private pay” means at ECPT

Private pay means you pay ECPT directly at the time of service, instead of us sending a claim to an insurance company. We go over cost with you before your first visit, so you know what to expect.

Because an insurance company isn’t setting the terms, your plan of care is built by you and your Doctor of Physical Therapy: how often you’re seen, how long visits last, and where they happen. Your first visit is a full 60 minutes, one-on-one, and your therapist comes to your home, office, or private gym.

How out-of-network reimbursement works

1. You pay for your visit.

2. We give you an itemized invoice (a superbill).

3. You submit it to your insurance company, usually through the member website or app, by mail, or with a claim form your insurer provides.

4. Your insurer applies it to your out-of-network benefits. If you haven’t met your out-of-network deductible, the amount usually counts toward it first. After that, many plans reimburse a percentage of what they consider the “allowed amount.”

Two terms are worth knowing. The allowed amount is what your plan decides a service is worth, and it can be less than what you paid. Out-of-network coinsurance is the percentage of that allowed amount you’re responsible for, and it usually costs more than in-network coinsurance.

Which plans usually reimburse out-of-network care?

The type of plan matters more than the name on the card. According to HealthCare.gov:

• PPO plans let you use providers outside the network for an additional cost. These are the most likely to reimburse.

• HMO plans generally don’t cover out-of-network care except in an emergency.

• EPO plans cover services only from in-network providers, except in an emergency.

Employer plans vary a lot, even with the same insurance company. The only way to know your benefits is to ask.

What’s on a superbill

A superbill is an itemized record of your care that your insurer uses to process a claim. It typically includes:

• your therapist’s name, credentials, and provider identification numbers

• the dates of your visits

• diagnosis codes and procedure codes for the care you received

• the amount you paid

Some insurers also ask for a referral, a prescription, or visit notes before they reimburse. If yours does, let us know.

Five questions to ask your insurance company

Call the member services number on your card and ask:

1. Do I have out-of-network benefits for physical therapy?

2. What is my out-of-network deductible, and how much of it have I met?

3. What percentage of out-of-network physical therapy is reimbursed?

4. Do I need a referral or prescription to be reimbursed?

5. How do I submit a superbill, and how long does reimbursement usually take?

Write down the date, the name of the person you spoke with, and the call reference number. Reimbursement depends on your plan, so we can’t guarantee what your insurer will pay, but these answers will give you a realistic picture.

What about Medicare, HSAs, and FSAs?

ECPT is a private-pay practice and does not bill Medicare. HSA and FSA cards can’t be used for ECPT visits.

Is private pay worth it?

For many of our patients, the value is in what they don’t have to do: drive to a clinic while recovering from surgery, sit in a waiting room, or share an appointment with other patients. Every visit is one-on-one with a Doctor of Physical Therapy, from start to finish.

It isn’t the right fit for everyone, and we’d rather talk that through with you before you schedule than after.

Questions about your plan?

Request care or call or text (574) 686-7313. A Doctor of Physical Therapy will follow up within 24 hours, and we’ll go over cost before your first visit. For the full picture of visits, scheduling, and payment, see How It Works. We see patients across South Bend, Granger, Mishawaka, and Michiana and in Niles, Edwardsburg, and Cassopolis, Michigan.

This article is general information, not insurance or legal advice. Coverage depends on your plan.