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Private Insurance vs Traditional Medicare Vs Advantage Plans for Physical Therapy

If you've been following us along on our journey, then you know that we are in the process of getting approved with Medicare. This has been an ongoing process since December of 2022 and we are currently awaiting the most recent decision on an update we made to our application (government paperwork is no joke!).


We are getting more and more calls regarding insurance coverage and figured we'd pop a blog out to explain how our clinic operates in regards to insurance to cover some frequently asked questions.


In General:

Age Fit Physical Therapy is a private pay clinic. We offer a fee for service model with single visit rates and discounted packages of visits for those dedicated to their rehab and wellness journey. You may be asking why we chose this.


Long story short- we choose to work for our clients, not the insurance companies. By remaining private pay, we can treat our clients to their full potential. That means we don't spend countless hours fighting for referrals, prior authorizations, and unnecessary documentation defending our every tiny thought process. This means we get to spend more time helping people meet their long term goals and resolve their problems. In the traditional clinic, PTs help people get back to baseline (because this is as usually as far as insurance is willing to cover). At Age Fit we get you better than baseline. Let's be honest, "baseline" is what made you need Physical Therapy to begin with, so why would you only want baseline. Our goal is to help you progress past baseline and partner with you for as long as you feel you need us so you can move with confidence for life.


We know we produce good outcomes and this happens because we consider the entire person, not just a single body part or single diagnosis. We could go on for paragraphs on how restrictive insurances can be on quality care, but we feel this was a good summative explanation.


Now, it is important to note that just because we are a private pay clinic, it doesn't mean you can't use your insurance. If wasn't that long ago, when clients paid their medical bills and then submitted their own claims to insurance for reimbursement. We're reminded of this by many of our current clients who follow this method. So how do you use it?


Step 1: know your numbers! Look back at some of our previous blogs for more information on what this means. You'll need to call your insurance and see if they mandate a referral or prior authorization and read your policy to understand what they will and will not cover. Check to see if you have out of network benefits. We do have a worksheet we can send to prospective clients with all the questions you should ask your insurance company and would be happy to pass that along via e-mail to anyone who needs guidance.


Step 2: come to therapy! At the end of your visit, our system will automatically produce a superbill. This document has all the information you need to submit your own claim to insurance for reimbursement.


Step 3: get paid! This is another area where you need to know your numbers, because they will deduct your copays and coinsurance from your reimbursement (money that you would have paid per visit to the clinic you attend anyway).


Note that as a healthcare provider, over 50% of our clients utilize their HSA to cover their visits.


Medicare:

As soon as we get approval, we will be accepting traditional Medicare clients. Our lead PT is a geriatric specialist with additional training in balance, vestibular, and fall prevention training. Medicare has proven to be one of the few insurances that can be relied on to do what they say (though we're currently questioning this nearly 6 months into the credentialing process). Their rules are black and white and they are fairly consistent regarding what is "medically necessary" and considered a "covered service." We follow CMS guidelines on covered services. Unfortunately, until we obtain our approval, our services remain private pay.


Medicare Advantage Plans:

Here's where things have gotten tricky. Advantage or replacement plans are far more prevalent now than just a few years ago. While we understand that these plans have some advantages (no pun intended) over the traditional Medicare plans, they are still run and owned by private insurance companies (ex: United Healthcare, Aetna, Humana, BCBS, etc.) and hold many of the same restrictions that their plans for the younger population holds. Therefore, we are not and will not ever be accepting these plans. Our clients with these plans follow the same steps for individually submitting their own claims for reimbursement as our younger generations of clients. For more information on traditional vs advantage plans, check out this link from CMS .


To sum it all up

We aren't your traditional clinic which allows us to help our clients as a greater capacity on an individual level. Our model allows us to remain one-on-one with our clients for 60-90 minute evaluations and 60 minute follow ups. We spend more time setting up quality home programs and have more ability to follow up with our clients between sessions and answer questions that may pop up. Outside of certain diagnoses and post surgical cases, we can see our clients for less frequent visits than the traditional clinic model which allows us to follow their wellness journeys and partner with them for far longer and with greater client satisfaction. We realize we may not be everybody's cup of tea and that's ok!

If you want to talk in greater depth about how Age Fit can help you or just want to ask more questions about our process, reserve a spot on our schedule for a Free Discovery Call using this link. We look forward to speaking with you!

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