Frequently Asked Questions About PT Services

Can a Physical Therapist treat in Pennsylvania without a Physician's referral?

Direct access or treatment by a Physical Therapist without a physician's referral was recently passed by the PA legislature in 2002. However, the provisions are as follows:

Licensee may apply to the board for a certificate of authorization to practice physical therapy under this act without the required referral.
A certificate of authorization to practice physical therapy without a referral under subsection (a) shall not authorize a physical therapist either to treat a condition in any person which is a nonneurologic, nonmuscular or nonskeletal condition or to treat a person who has an acute cardiac or acute pulmonary condition unless the physical therapist has consulted with the person's licensed physician, dentist or podiatrist regarding the person's condition and the physical therapy treatment plan or has referred the person to a licensed physician, dentist or podiatrist for diagnosis and referral.
The certificate of authorization shall be issued only to licensed physical therapists practicing physical therapy. The certificate of authorization shall be displayed by the certificate holder in a manner conspicuous to the public. The renewal of the certificate of authorization shall coincide with the renewal of the license of the licensee.

Understanding Reimbursement for Physical Therapy

Physical therapists are professional health care providers who are licensed by the state in which they practice. You can check with your state agency overseeing physical therapy licensure to make sure that your physical therapist is licensed and in good standing. You can also contact the state Physical Therapy Chapter.

Specialization

Many physical therapists specialize in treating specific areas of the body, such as the back, neck, knee, hand, or shoulder, or they may concentrate their practice on pre- and postnatal care, sports injuries, stroke rehabilitation, or one of many other areas or physical therapy. Physical therapists may also be certified by the American Board of Physical Therapy Specialties (ABPTS) in seven specialty areas of physical therapy: orthopedics, sports, geriatrics, pediatrics, cardiopulmonary, neurology, and clinical electrophysiology.

Freedom of Choice

While some states require a referral from a physician before you can receive physical therapy, the majority of states (39 to date) do not require a physician referral. You always have the freedom to choose your own physical therapist. Although a physician may refer you to a physical therapy facility in which the physician has a financial interest, you are entitled to seek treatment from the physical therapist of your choice.

Insurance

Most insurance policies cover physical therapy services when provided by a physical therapist. Ask the person providing your care if they are in fact a physical therapist, or a physical therapist assistant being supervised by a physical therapist. Physical therapists who are members of the American Physical Therapy Association (APTA) pledge to comply with the Association's Code of Ethics and Guide for Professional Conduct. APTA members maintain and promote high standards in the provision of physical therapy services.

An article titled "Understanding Insurance Coverage," appeared in PT - Magazine of Physical Therapy, October 1999. Copies of the article are available by calling 800/999-2782, ext 8511, or by sending the request via e-mail.

Insurance Facts for PA Consumers: A Consumers Guide To Health Insurance (posted 11.12.09)

Physical Therapy & Your Insurance: A Patient's Guide to Getting the Best Coverage (posted 11.12.09)

Source: American Physical Therapy Association (www.apta.org)

A Consumer Guide to Handling Disputes with Your Private or

Employer Health Plan

Source: Kaiser Family Foundation: http://www.kff.org/consumerguide/PA.cfm

Most people get their health care through some form of managed care plan, a health maintenance organization, preferred provider organization, or point-of-service option. Most of the time, people receive the care they need, but the potential exists for disagreements over the services that will be provided or paid for by health plans.

Health plans are required to follow state and federal rules for handling their enrollees complaints and appeals inside the health plan, known as an internal review. Many states have legislated additional procedures outside of the health plan, called external reviews or independent reviews, to provide an unbiased way to resolve disputes between patients and their health plans. An external review is a reconsideration of a health plans denial of service, with the review conducted by a person or panel of individuals who are not part of the plan. As of December 2004, 43 states plus the District of Columbia had legislated such procedures.

Anyone enrolled in a health plan should be familiar with their plans internal review process and any external review program in their state in case problems later arise. This guide will help you navigate your employer or private health plans internal grievance procedure, as well as any external review program your state may have. The guide is not applicable, however, for resolving disputes if you have Medicare or Medicaid coverage.

Pennsylvania

General Information and Internal Plan Review:

Pennsylvania distinguishes between grievances and complaints, and has separate procedures for each type of problem. A grievance is any request to have a review of a denial of a covered health service on the basis of medical necessity or appropriateness. A complaint relates to most other problems regarding health plan operations, quality of care or service, contract exclusions, or covered benefits.

Problems are initially filed with the health plan, which usually decides if the issue is a grievance or a complaint. If grievances are not satisfactorily resolved in their two-step process, they can be appealed for review by an independent utilization review organization. If complaints are not satisfactorily resolved in a two-step process with the plan, they may be appealed to either the Department of Health or the Insurance Department.

The External Grievance Appeal Process:

Whom to contact:	Your health plan
Who can appeal:	You or your provider (with written permission), or your authorized representative If your provider files the grievance, he or she will be responsible for the cost of the review if the denial is upheld by the independent utilization review organization.
What you can appeal:	Denials of coverage for services the health plan determines are not medically necessary or appropriate.
When you can appeal:	After denial for coverage has been appealed through the second level of the health plans internal process, you must appeal within 15 days from receipt of health plans decision.
What to send:	Enrollees name, address, and phone number Name of health plan Enrollee ID number Copy of denial letter Brief description of the problem Any additional material that supports your position.
What you must pay:	Up to $25
What will happen:	The health plan will notify the state. The state will assign your case to an independent utilization review organization. The review organization will evaluate your case and provide written notice to you, the health plan, and the Department of Health.
When you will get a decision:	In about 60 days
In urgent situations:	If delay will jeopardize your life, health, or ability to regain maximum function, you should work with your plan to facilitate an expedited review, which will result in a 48-hour turn-around time. Expedited reviews are also processed at the state level within two working days.

How to Get More Information:

Complaints or Grievances: Bureau of Managed Care, 888-466-2787
Complaints: Pennsylvania Insurance Department, 877-881-6388
www.health.state.pa.us (follow link to Provider and then to Managed Care)