I just had someone calling asking how I bill. I briefly explained Helping Hands Rehab’s billing process. But this wasn’t quite what she was looking for. She asked me: “Why do therapists bill so much when I am only there about 45 minutes?”. I thought, okay, lets discuss billing.
FYI:
1. Corporate therapy facilities (on just about every street corner and places that have multiple therapy sites fall into this category) are answerable to shareholders, so they are supposed to make a profit.
2. Doctors sometimes gets “perks” to refer to these clinics. This might be in the form of a bonus (if they have an ownership stake in the therapy clinic) or in the form of “fun” activities—Sports ticket, concert tickets, etc.
3. Incidentally, there is a law, which is called the Starck Law, that states a physician who owns their own therapy clinic cannot exclusively refer patients to their own clinic.
So, what does this have to do with billing? It’s simple. It relates to where the doctors send you for therapy and thus, how you get billed.
Now for billing 101:
1. Billing is based on 15 minute billed “units”. Therefore, 3 units of therapeutic exercise is 45 minutes of therapeutic exercise.
2. All billing is based on “Medicare” rules. Which breaks down to if a therapy site accepts Medicare, they have to bill everyone the same. Everyone will get charged for example $300/hour for the same services. Now each insurance pays what they pay. Therapy clinics are either “in-network” or “out-of-network”. In-network means they have agreed to a discounted reimbursement rate. So that $300 that is billed, might be only reimbursed at $100. My lowest paying insurance pays me $70 for that $300 billed amount, my best payer pays me $160. Medicaid, which I no longer take, pays a whopping $36/hour. Obviously, we hope to have more clients w/the $160/hour range. Some doctors only “send out” their Medicaid patients to other therapy clinics and don’t use their own therapists due to the low reimbursement.
3. Medicare also has what is called the “8-minute rule”. This means that if a therapy performs an activity for at least 8 minutes, it can be billed. BUT…Medicare billing must also include a “total treatment time”. This means that in a 45-minute treatment session, you can only be billed for 3 total units. Other insurances don’t have to include the total treatment time. (Some insurances don’t even state that a therapist has to do a specific billed treatment for the minimum 8 minutes.) This means that if they follow the 8-minute rule, they can charge more. For example (for a 45 min appt): Therapist spent 8 min doing each of the following: ultrasound, manual therapy, therapeutic exercise, dry needling, biofeedback, and neuromuscular re-education. This equals a total of 48 minutes, but 6 billed units. At least 3 of these units are billed at about $85/unit. The others at about $50/unit. The total billed for this treatment would be $405.00. The Medicare patient would be billed $255.00 assuming the therapist would charge the highest cost units. Helping Hands Rehab believes in ethical billing. That means you are not being charged for 6 units when you are here for 45 min. Yes, we are limiting our own income, but we believe we have a moral obligation to not overbill. This is one of the reasons we started Helping Hands Rehab. No corporation should tell a therapist how to bill.
4. You can self-pay at any time. This is usually a significantly discounted rate from the billed amount. My self-pay rate is $75/visit, regardless of what I do.
Now let’s discuss Insurance 101:
1. Medicare does not allow Medicare patients to be seen with another patient at the same time. This means that if you are a Medicare patient, the therapist should not be seeing anyone else in your time period. The only way they can, is if they bill a “group” charge which means you are billed at a lesser rate. You are in your right to specify with your therapist that you don’t want them seeing anyone else in your time period. Obviously, if it is a for-profit facility, or a facility where they get bonuses based on productivity, they will not do this. Other insurances may or may not follow this rule. Helping Hands Rehab only sees patients one at a time the majority of the time.
2. Most insurances require you to see a “Qualified” therapist—one they have vetted and that have the credentials to be a provider for them. Some places have assistants which is ok as long as they are licensed (PTA/COTA/ATC). Some facilities have people with minimal training (often called an aide) observing and or participating in your therapy which is sketchy at best. Medicare states you have to be seen by a licensed therapist. Technically, if the licensed therapist is in the same room as the “aide”, it supposed to allowed. But I certainly don’t want to be seen by an aide. Helping Hands Rehab has no aides or even licensed assistants.
3. You are allowed to go anywhere for therapy that your insurance will cover (unless you are going to self-pay, then you can go anywhere). This means that you don’t have to go to the physician owned clinic that is far away, or the busy clinic that treats you like a number, not an actual person who is concerned about their condition or injury. At Helping Hands Rehab, we treat patients with a wholistic approach. Your goals are our goals in treatment.
I’m sure this is clear as mud. Sorry, insurance is not an easy subject. If you have any further questions or concerns about therapy and billing, please don’t hesitate to reach out to us. We look forward to hearing from you!