Planning for the Cost of Care: Self-Pay or Insurance?

Pinecone Physio is currently an out-of-network provider for many insurance companies. The list of Pinecone Physio in-network insurance plans is updated regularly for our new clinic and can be found below. 

Even if we are not an in-network provider with your insurance, most insurance companies provide you with out-of-network benefits, allowing you to see providers in and/or out of your plan.

At Pinecone Physio, our goal is to simplify the overall experience of receiving high quality healthcare. Before ever booking a session with us, you will have full transparency in how much your session costs. Are we the cheapest option in town? Not always, but we offer some of the highest quality, most effective, most unique, and most convenient physical therapy choices in the Reno, Nevada market. 

The term "in-network" refers to health care providers who are a part of your insurance plan’s network of providers. Usually, your insurance plan has negotiated a discount with these providers. This means providers who are in-network provide services at a lower cost to your insurance company. While this is very effective at controlling the cost of care, it can come with consequences to the patient such as shorter appointment times and your doctor managing a higher patient volume.

The term  "out-of-network" refers to health care providers who do not participate in your insurance company's rules and regulations. This does not mean these providers are not covered by insurance. Most insurance companies provide you with out-of-network benefits which allows you to see providers in and/or out of your plan, but the provider is not bound by the insurance company’s rules and regulations.

It comes down to quality over quantity.  

Quality care is what will get you better, faster. As an out-of-network provider with some insurances, we are choosing to see fewer patients in a day in order to ensure an extremely high level of attention and care to each patient.  Going out of network with certain insurance companies allows us to have more one on one time with our patients, resulting in you reaching your goals faster. Insurance companies don’t look at patient care the same way we do. They put providers like us through the ringer to become “in-network” which means receiving significantly less reimbursement for treatments. The only way to offset our operational costs is to see more people in a day... A LOT more. That leads to a “patient mill” style of physical therapy that doesn’t get people better, and undermines how we want to treat patients. We just can’t, and won’t, participate in that.  We take pride in doing what’s right for our patients instead of what’s right for a larger corporation or insurance company.  

This is how appointments and billing works if Pinecone Physio is out-of-network for your insurance:

• We confirm with you how much your session will cost.
• We collect the cost of the full session from you at the time of service. 
• We provide you with a “superbill” receipt that you can use to submit to your insurance company upon request. Pending your out of network coverage, your insurance company will reimburse you directly for services. To be perfectly clear, every insurance company’s reimbursement rates are different and may be less than Pinecone Physio's rates.

This is how appointments and billing works if Pinecone Physio is in-network for your insurance: 

• We confirm your insurance details with you.
• We contact your insurance company to confirm your eligibility and your plan details for physical therapy, including your current payments towards your deductible,  your co-insurance percentage, and your copayment amount for specialists.
• Depending on your coverage, this is what we collect from you at the time of service:
•  If your deductible has not been met: We collect the full cost of the session from you and submit paperwork to your insurance so they can add it to the amount you have paid toward your deductible. 
• If your deductible has been met, but your plan has co-insurance: We collect the co-insurance percentage of the visit. For example, if you have met your deductible and your co-insurance percentage is 20%, your insurance pays 80%, and you pay 20%. Your insurance plan determines the co-insurance percentage.
• If your insurance plan has a specialist copay amount without needing to meet the deductible: We collect the specialist copay amount. A Physical Therapist is considered a specialist by most insurance companies.  Most insurance plans require patients to pay more to see a specialist. For example, your doctor visit may be a $25 co-pay and a specialist may be a $60 co-pay. Or, your insurance may require you to meet your deductible when seeing a specialist.
• Uncovered treatments: Some treatments, like functional dry needling, sports performance packages, and non-surgical spinal decompression therapy are not covered by most insurance plans. In this case, we will collect for these treatments at the time of service and provide you with a “superbill” receipt upon request.

Evaluations for physical therapy, sports rehab, and golf rehab: 

Pinecone Physio evaluations are extremely thorough and typically last 75 to 90 minutes. This allows us to look at multiple regions of your body, delve deeper into a longer history of your symptoms, and more complex issues. For someone using insurance, the typical codes/charges would be (1EV, 1TE, 1MT, 1 TA, 1 NMR) at a cost of $420. 

***If self-pay/cash then apply 43% self-pay/cash discount = $240  

Follow-up appointments including physical therapy, sports rehab, golf rehab, spinal decompression, cupping, Graston® Technique, Active Release Technique®, blood flow restriction therapy, kinesiotape, Parkinson Wellness Recovery®, and post-Covid recovery:  

The majority of patients will need follow-up visits, typically 4-10 depending on the condition being treated. Follow up appointments vary from a minimum of 15 minutes up to 1 hour depending on your needs. If using insurance, the typical codes/charges would be (1 MT, 1 TE, 1 NMR, 1 TA) and the amount you pay will vary depending on your coverage, deductible, co-insurance percentage, and copayment for specialists.   

***The rates for self-pay/cash are discounted as follows: 

• 15 min: $60
• 30 min: $120
• 45 min: $180
• 1 hour: $240 

Assuming booking 30-minute follow-ups (for an episode of care with 4-10 visits) this translates into a cost range of $480 to $1200. Please note this is in addition to the cost of the required initial evaluation. This results in a very low cost compared to imaging, surgery, injections, or months of spinal manipulation.  

Additional Services and Packages

Information on the cost of additional services and packages can be found on the following pages:

• Functional dry needling
• TPI golf rehabilitation packages
• Non surgical spinal decompression packages

Additional Considerations

Pinecone Physio is is dedicated to the Northern Nevada community and the breathtaking environment surrounding us. Special pricing and discounts are provided for several organizations, professions, volunteers, environmental programs, and community heroes. Ask our owner or staff for additional details. Discounts are only applied when no insurance is used. 

Methods of payment can vary and include cash, check, personal credit cards, healthcare savings account (HSA), or flexible spending account (FSA). If using insurance, the amount due at the time of service varies depending on your coverage. Please see the section above on how appointments and billing works if Pinecone Physio is an in-network provider for your insurance.

If you are having diffiulty affording to pay amounts as frequently as you need care, simply ask to speak to our owner about our community discounts, payment plans, or a sliding scale based on need. Your health is our number-one priority. As such, we are happy to arrange a payment plan that works with your budget. That way, you can pay for your care over a timeframe that works for you and you can receive the care you need to get back to doing what you love. 

We understand that insurance plans and payment for healthcare services could not be more confusing. To understand insurance, it feels like you have to learn an entirely new language. Not to mention, most healthcare bills are entirely unpredictable. We would like to remind you it is your responsibility to understand your insurance plan, but we will also try to help along the way. Here are some terms you should know:

Premium:  This is the amount you pay for health insurance each month. 

Deductible:  This is the total amount you pay for health care services before your insurance plan starts to pay. 

Co-pay:  This is the fixed amount you pay out of pocket for covered services. Your co-payment for physical therapy it is usually associated with a "specialist office visit" and your insurance plan may also require you to pay co-insurance in addition to your co-payment. Be aware that co-payments typically do not count towards your deductible, but they do usually count towards your out of pocket maximum. 

Co-insurance:  This is the percentage amount of a covered service you pay, separate from any co-payment or deductible from your insurance plan. It is common for insurance plans to require you pay 20% and they pay 80% of the allowed medical expense. This is usually something you need to pay in addition to any co-payment or deductible payments.    

Out of pocket maximum:  The maximum amount you pay toward your covered services in a year. This usually includes deductibles, co-payments, and co-insurance, but does not include your premiums.  

Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA): These are ways to save on qualified medical costs by using pre-tax money. If you leave your job, funds in your FSA may be forfeited, while any funds in an HSA are yours to keep. Sometimes these funds expire at the end of the year, so don't let it go to waste! 

In-Network Provider: The term "in-network" refers to health care providers who are a part of your insurance plan’s network of providers. Usually, your insurance plan has negotiated a discount with these providers. This means providers who are in-network provide services at a lower cost to your insurance company. While this is very effective at controlling the cost of care, it can come with consequences to the patient such as shorter appointment times and your doctor managing a higher patient volume.

Out-of-network Provider: The term  "out-of-network" refers to health care providers who do not participate in your insurance company's rules and regulations. This does not mean these providers are not covered by insurance. Most insurance companies provide you with out-of-network benefits which allows you to see providers in and/or out of your plan, but the provider is not bound by the insurance company’s rules and regulations.

 Pinecone Physio is currently an "in-network" provider for the following insurance plans:

Commercial Insurance Plans:

• Aetna: Referral not required for Aetna Health Network Only HMO, Open Access Aetna Select EPO, Aetna Open Access Elect Choice EPO, Aetna Open Access Managed Choice POS, Aetna Choice POS II, Aetna Health Network Option, Open Choice PPO plans. Referral required from your physician for Aetna HMO, Aetna Select EPO, Quality Point of Service (QPOS), Managed Choice POS, Aetna Signature Administrators plans. 
• Nevada PEBP Aetna Signature Administrators PPO: Referral not required.
• Prominence PHCN HealthFirst HMO: Referral required from your physician.
• Prominence PHCN PPO: Referral not required.

Medicare and Medicare Advantage Plans:

• Aetna Medicare Advantage PPO: Referral required from your physician. 
• Aetna Senior Choice Medicare Advantage: Referral required from your physician.
• Medicare Part B: Referral required from your physician.
• Prominence Medicare Advantage: Referral required from your physician.
   

Note that contracts with insurance payers may change; for the most accurate information please refer to your insurance payer's online provider directory. A referral from your healthcare provider for services at Pinecone Physio does not ensure services will be covered as "in-network" by your health plan. Authorization by your health plan may be required to obtain "in-network" services. 

Pinecone Physio is an "out-of-network" provider for the following insurances. You can still see us as an "out-of-network" provider, but make sure to check your out-of-network benefits:

• Anthem Blue Cross Blue Shield
• Cigna / American Specialty Health (ASH)
• Hometown Health Plan
• Senior Care Plus Medicare Advantage Plan
• Senior Dimensions Medicare Advantage Plan
• Silver Summit (Ambetter)
• United Health Care (Optum)

The list of Pinecone Physio in-network insurance plans will be updated regularly for our new clinic. Even if we are not currently an “in-network” provider for your insurance plan, when you log into the patient portal, please provide your insurance information so we may expedite billing your insurance company if we become in-network providers. We can also help you plan and verify your out-of-network coverage for physical therapy, including accumulations towards your deductible, upon request.