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THE DESIGNATION

"A person will probably need to see an anesthesiologist or physiatrist once for a specific condition. On the other hand, it can take a total of 10 physical therapy visits to return the patient to their pre-injury condition."

THE HIGH COST OF SPECIALIST CO-PAYMENT DESIGNATION FOR PHYSICAL THERAPISTS:

What it means to Patients

Health insurance carriers now designate physical therapists as “specialists” for purposes of member co-payments, just like cardiologists or surgeons. This enables health plans to impose the higher specialist co-pay on patients for each physical therapy visit; the lower primary care co-pay was previously applied to physical therapy services.  

Physical therapy is routine health care and requires a series of visits in a relatively concentrated period of time, usually over the course of several weeks.  As a result, the amount of the co-pay can have a significant impact on an individuals ability to afford -- and access -- that care.

While on the surface it may seem logical for physical therapists to be considered specialists because of their extensive training and expertise in the treatment of musculoskeletal diseases and conditions, this classification acts as a barrier to medically necessary care because of the frequency which patients need to access their services and is in reality more akin to primary care specialties as a result.

To see how this designation unfairly impacts patients, consider this: A person normally only sees an anesthesiologist or physiatrist once or twice for a specific condition, while it can take 10 physical therapy visits to return the patient to their pre-injury condition. Given that both are deemed specialists by their health insurer for purposes of co-pays, in the case of the physiatrist, the patient would pay $40 out-of-pocket and the insurer would pay $70, while the health insurer would only pay the physical therapist $20 for all ten visits combined and the patient would be responsible for the remaining $400 or 95% of the cost of care. Patients are essentially forced to self-fund their physical therapy care even though it is a covered benefit under their health plan and for which they and/or their employers are already paying for through the cost of premiums.  

Anesthesiologist/Physiatrist (per visit) Physical Therapist
Average per visit allowable charge $110.00 Average per visit allowable charge $42.00
Specialist co-payment $ 40.00 Specialist co-payment $40.00
Insurer pays $70.00 Insurer pays $2.00
% Patient pays 36% % Patient pays 95%


It is important to note that limiting the cost of physical therapy co-pays does not increase or decrease the amount of reimbursement a physical therapy receives.  Instead it corrects the inequity of the patient being required to absorb a disproportionate amount of the total cost for the service as set by the insurance company.