Rates and Insurance

Capacity is a cash-based physical therapy practice or "out-of-network" provider. This means payment is collected at the time of service, and you are provided a receipt or "super bill" that you can submit to your insurance company for out-of-network coverage. Depending on your out of-network plan benefits, the insurance provider may reimburse you directly. If you want to understand more about what your insurance company will and will not reimburse, give them a call and have this insurance checklist ready. It is important for each person to understand exactly what their insurance covers.

Capacity Performance Therapy is not currently a participating provider with any insurance plans. Why? The answer is quite simple—we would not be able to provide the high level of care and individualized treatment that we do at the rates insurance companies currently pay for physical therapy treatment. Therapists at clinics that accept these insurance rates are required to see 2-4 patients per hour and usually spend an average of 15 minutes of one-on-one time with each patient while aides and technicians instruct patients in exercises. At Capacity Performance Therapy, you spend the entire hour with your therapist so that you will heal faster in fewer visits. While your first reaction may be that our method will cost you more money out-of-pocket- you will see below that our system will actually save you money while providing you with faster and better treatment. You will also be provided a free seamless process to get reimbursed by your insurance for care.

An average patient is asked to see a physical therapist two to three times per week. With a visit you will likely have a co-pay ($10-$40), you will pay 100% of costs until you meet your deductible, and you will pay a portion of the cost (co insurance often 20%) until you reach your out of pocket maximum (on average $8,000). Here are two examples of payment per session of insurance based physical therapy pending on if you have met your deductible or not.

After each session, our biller will create a superbill that will be submitted to your insurance company. That means all funds will be applied to your plan. Reimbursement is not guaranteed. Reimbursement for care depends on your plan. It is up to you to know your insurance plan and potential for reimbursement. Our goal is to make the process seemless. For this reason we will complete all the paperwork for you and ensure your insurance company processes claims appropriately.

Capacity does not have a relationship with Medicare, which means patients who wish to submit to Medicare for treatment reimbursement that Medicare normally covers may not be treated at Capacity.. Medicare is exceedingly complicated and if you are denied reimbursement, that is a risk you take. Failure to comply with Medicare rules in every case, even with best intent, could result in federal investigation, fines, or other legal action. The Medicare Benefit Policy Manual is available in full as a series of downloads at CMS.gov; outpatient physical therapy benefits are discussed in Chapter 15, which is currently 289 pages.

Under current Medicare regulations, it is illegal for a physical therapist to accept cash pay from Medicare patients for services that may be covered under Medicare, even if the services provided meet all treatment, documentation, and HIPAA requirements and have been prescribed by their physician. In some cases, a Medicare beneficiary may pay cash for services that are no longer considered medically necessary, for example a "maintenance" or "wellness" program.

Confused? So are we...give us a call and we can talk it through.

At Capacity Performance Therapy, we believe in cost transparency and your right to shop for high quality, cost-effective services. We will be happy to provide you with a “Good Faith Estimate” of our costs upon request or upon scheduling.

If you do not have health insurance or plan to self-pay for our services without asking for insurance reimbursement, we will provide you with a “Good Faith Estimate” of our costs when you schedule at least 3 days in advance. If you would like to request a Good Faith Estimate before scheduling, please call our office at 541-224-7485 or email us at info@capacitypt.com