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

Pinecone Physio is currently an out-of-network provider for most insurance companies. The list of Pinecone Physio in-network insurance plans is updated regularly for 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 out-of-network with 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 "out-of-network" refers to health care providers who do not participate in an insurance company's rules and regulations. This does not mean these providers are not covered by your health insurance. Most insurance plans provide out-of-network benefits, but the provider is not bound by the insurance company’s rules and regulations.

Pinecone Physio accepts new and existing patients with all types of commercial insurance plans as an out-of-network provider. We can help you verify your out-of-network benefits, help you understand your out-of-pocket costs, and provide you with a superbill, upon request, if you plan to seek reimbursement from your insurance plan.

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

It comes down to quality over quantity. 

Quality care is what will get you better, faster. As an out-of-network provider with most insurances, we are choosing to see fewer patients in a day to ensure an extremely high level of attention and care for each patient. Going out of network with 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. This leads to a “patient mill” style of physical therapy that doesn’t help patients or our healthcare system and undermines how we want to treat patients. We take pride in doing what’s right for our patients instead of what’s right for a large 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 percutaneous needling tenotomy (PNT), functional dry needling, class IV laser therapy, extracorporeal shockwave therapy (ESWT), red light therapy, Vielight therapy, non-surgical spinal decompression, and sports performance packages, fitness, wellness, and prevention are not covered by most insurance plans. In this case, we will collect for these treatments at the time of service.

Evaluations for physical therapy, wellness, 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. The discounted self-pay price below applies to evaluations for physical therapy, wellness, sports rehab, and golf rehab. For someone using insurance for a physical therapy evaluation, the typical codes/charges would be (1EV, 1TE, 1MT, 1 TA, 1 NMR) at a cost of $420.  

*** If self-pay, then apply a 43% self-pay discount = $240

Follow up treatments: 

The majority of patients will need follow-up visits, typically 4-10 depending on the condition being treated. Follow up appointments can vary from 15 minutes to 1 hour depending on your needs and budget. The rates for self-pay are discounted as follows:

- 15 min: $60

- 30 min: $120

- 45 min: $180

- 1 hour: $240

- 75 min: $300

- 90 min: $360

Follow-up appointments include physiotherapy, wellness, sports rehab, golf rehab, cupping, Graston® Technique, Active Release Technique®, blood flow restriction therapy, and kinesiotape. 

Add-on treatments, with an additional fee, include point of care ultrasound imaging, percutaneous needling tenotomy (PNT), functional dry needling, class IV laser therapy, extracorporeal shockwave therapy (ESWT), red light therapy, Vielight therapy, and non-surgical spinal decompression. 

Assuming you book 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 and any add-on treatments. This results in a very low cost compared to advanced imaging, surgery, or injections.

Prices for add-on treatments (not covered by insurance):

Please note the prices below are in addition to the cost of the required initial evaluation, follow up appointments, and any time for additional treatments The rates for self-pay are discounted as follows:

- Functional Dry Needling: 3 or more muscles: $60

- Class IV Laser Therapy: $60 each or 6 treatments for $270

- Extracorporeal Shock Wave Therapy (ESWT) involving the musculoskeletal system: $60 each or 6 treatments for $270

- Red Light Therapy: $39 each or monthly membership options listed at pineconephysio.com

- Vielight Therapy: $39 each or monthly membership options listed at pineconephysio.com

- Non Surgical Spinal Decompression: $60 each or package options listed at pineconephysio.com

- Point of Care Ultrasound Imaging: $140 for each limited area within a joint or extremity.

- Ultrasound Guided Percutaneous Needling Tenotomy (PNT): Varies based on area with an average cost of $240. Please contact our office.

Additional considerations: 

Pinecone Physio 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 for self-pay patients. 

Methods of payment can vary and include cash, check, personal credit cards, healthcare savings account (HSA), or flexible spending account (FSA). 

If you are having difficulty affording to pay amounts as frequently as you need care, simply ask to speak to our owner about 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 for a mutually agreed upon monthly amount which can be set up with a card on file. 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.

Recent legislature has affected care at Pinecone Physio. If you have been following the news, you are likely already aware that Congress failed to stop a Medicare pay cut within the federal budget deal signed on Saturday, March 9, 2024. 

There was a 3.37% average physician pay cut (varied by specialty) that took effect January 1, 2024, and has been threatening Medicare patients’ access to high quality care. The legislation signed on March 9, 2024, mitigated these Medicare pay cuts by an extremely marginal amount. 

Learn more: https://www.ama-assn.org/practice-management/medicare-medicaid/latest-medicare-physician-pay-cut-shows-desperate-need

The 2024 Medicare payment changes vary by specialty, with primary care and behavioral health professionals seeing a net increase in payments, but professionals in physical therapy, occupational therapy, radiology, and certain surgical specialties seeing the largest cuts. Unfortunately, we are seeing a Medicare payment cut ranging from 5-20% at Pinecone Physio for billing codes we utilize, including the therapeutic activities we provide involving direct one-on-one patient care. In addition to these cuts, the “Multiple Procedure Payment Reduction” (MPPR) reduces payment even further for therapy services that are longer than 15 minutes. In the recent federal budget deal, Congress failed to stop the Medicare cuts that directly affect care at Pinecone Physio. With these cuts in place, Medicare currently reimburses Pinecone Physio approximately $35 for fifteen-minute treatment appointments, and only $110 for one-hour treatment appointments of one-on-one patient care with a Doctor of Physical Therapy. Commercial insurance programs, such as Aetna, have decided to follow a similar payment schedule. 

The American Medical Association has opposed these payment cuts and rightfully expressed concerns that loss of revenue could force physicians to opt out of the Medicare program, leading to access problems for Medicare beneficiaries. The President of the American Medical Association, Jesse M. Ehrenfeld, MD, MPH, stated, “Physicians are the only providers who do not receive automatic inflation updates to their Medicare payments, and they are the only group experiencing a payment cut this year despite high inflation. Adjusted for inflation in practice costs, Medicare physician pay declined 30 percent from 2001.”

We wish to provide advanced, high quality, effective, unique, convenient care at Pinecone Physio, with treatment recommendations made by highly trained medical professionals opposed to treatment limitations dictated by federal and commercial health insurance companies.

Based on this, the following changes will go into effect at Pinecone Physio:

Pinecone Physio will continue to be an authorized participating provider for TRICARE beneficiaries. We are happy to accept new patients utilizing TRICARE benefits for reimbursement and thank you for your service to our country.

As of the current date, Pinecone Physio will continue to be a participating provider for Medicare, but is unable to accept new plans of care for patients utilizing Medicare for reimbursement of in-person appointments for medically necessary services. Currently scheduled patients utilizing Medicare are welcome to continue treatment at Pinecone Physio through their current plan of care. After your plan of care, we can discuss referrals, if necessary, and additional wellness options. We will accept new and existing patients with Medicare as self-pay patients for in-person prevention and health promotion services not covered by Medicare, such as overall physical health, prevention, mobility, sports performance, and alternative pain management techniques. 

We will continue to accept new plans of care for Medicare patients hoping to have a therapy program created, which they can then follow at home. The initial evaluation will be in person (when medically necessary), then the patient will receive education on how to utilize a user-friendly therapy app that allows the patient and doctor to directly interact, chat, ask questions, and describe how the program is progressing. This is known as remote therapeutic monitoring, is currently covered by Medicare, and each program will usually include 8 to 16 weeks of therapy progressions to help the patient achieve their therapy goals.  

As of June 30th, 2024, Pinecone Physio will no longer participate as a network provider for Aetna, Aetna Medicare Advantage, Aetna Signature Administrators, Meritain Health, and affiliated Aetna insurance programs. This means Pinecone Physio will be considered an out-of-network provider for ALL commercial health insurance plans and Medicare Advantage plans available in Northern Nevada. 

The term "out-of-network" refers to health care providers who do not participate in an insurance company's rules and regulations. This does not mean these providers are not covered by your health insurance. Most insurance plans provide out-of-network benefits, but the provider is not bound by the insurance company’s rules and regulations.

Our practice will accept new and existing patients with all types of insurance plans as an out-of-network provider. We can help you verify your out-of-network benefits, help you understand your out-of-pocket costs, and provide you with a superbill, upon request, if you plan to seek reimbursement from your insurance plan. 

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

Please note 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. 

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
• Prominence
• 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 clinic. Even if we are not currently an “in-network” provider for your insurance plan, when you log into the patient portal, you may provide your insurance information so we may help you plan and verify your out-of-network coverage for physical therapy, including accumulations towards your deductible, upon request. 

Learn more: 

What doctors wish patients knew about Medicare physician payment: https://www.ama-assn.org/practice-management/medicare-medicaid/what-doctors-wish-patients-knew-about-medicare-physician

AMA: Patients, physicians continue to endure Medicare cuts: https://www.ama-assn.org/press-center/press-releases/ama-patients-physicians-continue-endure-medicare-cuts

Physical Therapy for Prevention and Health Promotion

Medicare only pays for what it determines as medically necessary covered benefits. Although you and your health care provider(s) may have valid reasons to believe prevention and health promotion therapy services would improve your lifestyle and your abilities, Medicare does not consider the following physical therapy services medically necessary. You may self-pay for these services:

Annual PT visit as recommended by the American Physical Therapy Association (APTA) to:

- Screen for movement impairments

- Optimize movement

- Promote health, wellness, and fitness 

- Slow progression of impairments of body functions and structures

- Reduce activity limitations and participation restrictions 

Therapy services for the:

- General good of patients

- General welfare of patients

Therapy services to promote:

- Overall fitness

- Flexibility

- Improvements in recreational activities

- Optimal functional capacity

- Minimizing risk of impairments and functional limitations

Therapy services involved in:

- Prevention

- Promoting health

- Wellness

- Fitness

 Add-on treatments listed previously (not covered by insurance)

For more information you may reference:

Medicare Benefits Policy Manual

Excerpt from Section 220.2 - Reasonable and Necessary Outpatient Rehabilitation Therapy Services (Rev. 255, Issued: 01-25-19, Effective: 01- 01- 19, Implementation: 02-26-19) 

Services that do not meet the requirements for covered therapy services in Medicare manuals are not payable using codes and descriptions as therapy services. For example, services related to activities for the general good and welfare of patients, e.g., general exercises to promote overall fitness and flexibility and activities to provide diversion or general motivation, do not constitute therapy services for Medicare purposes. 

Medically Necessary Physical Therapy (Defined by Insurance Plans, Not Medical Professionals)

Most insurance plans have narrowed the definition of “medically necessary” physical therapy to only include and be covered by insurance when patients need improvement in activities of daily living (ADLs). This involves activities such as: bathing, communication, dressing, feeding, grooming, personal hygiene, self-maintenance, skin management, and toileting.

Treatments and therapies that are intended to specifically improve activities beyond this, or what are known as Instrumental Activities of Daily Living (IADL), are not covered by most insurance plans. These include activities such as: leisure activities, hobbies, sports, recreation of all types even if suggested as part of a physical therapy treatment plan, community living skills, home management skills, meal preparation, laundry, use of public transportation, motor vehicle driving evaluations and skills needed for driving  - this includes automobiles, trucks, motorcycles and bicycles; or personal safety preparedness. 

This is even true if your Doctor of Physical Therapy and Medical Doctor both agree these activities will be helpful for your overall health, you have a referral for physical therapy, and if your Doctor of Physical Therapy has suggested these activities as part of your physical therapy treatment plan.

Doctors of Physical Therapy are experts in rehabilitation and habilitation, with the expertise to improve your overall health and avoid preventable health conditions. Although prevention and health promotion therapy is not considered "medically necessary" by most insurance plans, you may self-pay for physical therapy services beyond what most insurance plans define as "medically necessary" to improve  your quality of life.

For more information you may reference your specific health insurance benefits policy.

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.