Currently, we only accept workers’ comp and auto insurance, but we are in the process of becoming credentialed with Medicare, Medicaid, and TRICARE. We have included instructions for Medicare, auto (PIP), and workers’ comp below to assist you with understanding these complex insurances. As an alternative, we offer self-pay services that streamline the billing process for both parties. We will happily discuss rates over the phone or in person during your first visit.

Medicare

 

MY INSURANCE CARRIER IS MEDICARE - ARE THERE ANY SPECIAL RULES THAT APPLY TO PHYSICAL THERAPY SERVICES?

For Medicare beneficiaries, outpatient physical therapy services are typically covered under Medicare Part B if deemed medically necessary to treat a disease or condition. Medicare regulations prohibit physical therapists from accepting cash payments from Medicare patients for services that may be covered under Medicare, even if prescribed by a physician and meeting all treatment requirements.

However, there are exceptions. Medicare beneficiaries may pay out-of-pocket for services that are considered non-medically necessary, such as maintenance or wellness programs (but not typically physical therapy). Additionally, cash payments may be allowed for services exceeding the Medicare therapy cap (currently $2,330 per year as of 2024), following Medicare fee schedule limits.

It's important to adhere to Medicare rules to avoid potential federal investigations, fines, or legal actions. For more detailed information, the Medicare Benefit Policy Manual is available for reference on CMS.gov, specifically in Chapter 15 discussing outpatient physical therapy benefits.

 

Auto/PIP Insurance

 

Oregon Personal Injury Protection Insurance (PIP) ensures coverage for all Oregon non-commercial auto insurance policies, offering no-fault medical and wage loss coverage. In the event of an auto, bicycle, or pedestrian accident, your auto insurance guarantees a minimum of one year and $15,000 in no-fault medical coverage as of 2024. Additionally, PIP covers wage loss, essential services, and extends to all occupants of the car, pedestrians, and cyclists involved in accidents with motor vehicles. If you lack auto or health insurance, the other driver’s insurance should cover your medical expenses.

 

Who does personal injury protection cover? PIP covers all car occupants, pedestrians, and cyclists struck by a car.

 

What does Oregon personal injury protection cover? It covers medical bills up to one year or $15,000, wage loss up to $3,000 for 52 weeks, and essential services loss up to $30 a day.

 

How much wage loss will my PIP insurance pay? PIP pays up to 52 weeks of wage loss, maxing out at $3,000 per month.

 

Will my insurance company pay all of my medical bills? While required to pay reasonable and accident-related medical expenses within the first year, insurers may deny payment, sending patients to an insurer-selected doctor who may dispute the necessity of treatment.

 

What can I do if they refuse to pay my medical bills? If not at fault, pursue the at-fault driver’s insurance; if at fault, sue or request arbitration with your insurer.

 

Is there anything I can do to reduce the likelihood of PIP denial? Seek treatment from medical doctors rather than alternative practitioners, as PIP is less likely to deny medical bills from MDs, DOs, or DPTs.

 

Do I have to pay my insurance company back for my PIP benefits? Repayment depends on legal action; often, attorneys negotiate with insurers to waive repayment from settlements.

 

What happens if my medical expenses exceed my PIP coverage? Healthcare insurance typically covers additional amounts, or providers may agree to wait for payment until case resolution.

 

Am I limited to what doctors I see? No, you're free to choose your doctors, even if you have Kaiser or other healthcare systems. PIP is obligated to cover reasonable and necessary treatments of your choice.

 

Workers' Comp

 

In Oregon, workers' compensation insurance is designed to provide benefits to employees who suffer work-related injuries or illnesses. If you're a patient seeking physical therapy under Oregon's workers' compensation system, here's an overview of how the process works:

 

Initial Steps and Reporting

 

1. Report the Injury: Immediately report your work-related injury or illness to your employer. This is a critical step, as delays can affect your eligibility for benefits.

 

2. Employer's Responsibility: Your employer will file a claim with their workers' compensation insurance carrier. They should provide you with a claim form (Form 801), which you need to complete and return.

 

3. Medical Examination: Visit a medical provider who is authorized to treat workers' compensation patients. The provider will assess your condition and determine if physical therapy is necessary as part of your treatment plan.

 

Physical Therapy and Authorization

 

1. Referral and Authorization: If your authorized medical provider prescribes physical therapy, they may refer you to a physical therapy clinic; however, you may choose where you receive your care so long as they are an authorized provider. In Oregon, you do not need a separate referral from your primary care physician if you’re seeing an authorized workers’ compensation provider.

 

2. Insurance Approval: Your workers' compensation insurance carrier must authorize the physical therapy treatments. This involves reviewing the referral and treatment plan submitted by your medical provider.

 

Receiving Physical Therapy

 

1. Treatment Plan: Once authorized, the physical therapist will develop a personalized treatment plan aimed at aiding your recovery and facilitating your return to work. This plan is based on the nature and severity of your injury.

 

2. Sessions and Monitoring: You will attend scheduled physical therapy sessions. The frequency and duration of these sessions will depend on your injury and recovery progress. The physical therapist will document your progress and report back to your medical provider and the insurance carrier.

 

Costs and Coverage

 

1. Covered Expenses: Workers' compensation insurance covers the cost of your physical therapy sessions, including any necessary equipment or supplies prescribed by your physical therapist.

 

2. No Out-of-Pocket Costs: As a patient, you should not incur any out-of-pocket expenses for approved treatments related to your work injury. The insurance carrier handles all payments directly with the healthcare providers.

 

Follow-Up and Adjustments

 

1. Ongoing Assessment: Throughout your treatment, your progress will be regularly assessed. Adjustments to your therapy plan may be made based on your recovery and any additional medical evaluations.

 

2. Return to Work: The goal of workers' compensation is to help you recover and return to work as soon as safely possible. Your physical therapist will work in conjunction with your medical provider to determine when you are ready to resume your job duties, either in a full or modified capacity.

 

Disputes and Appeals

 

1. Dispute Resolution: If there are disagreements about the necessity or extent of your physical therapy, these can be addressed through the workers' compensation system. Both you and your employer’s insurance carrier have the right to request an independent medical examination (IME) or a hearing before the Oregon Workers' Compensation Board.

 

2. Appeals Process: If your claim is denied or you disagree with any decisions made by the insurance carrier, you have the right to appeal. This involves filing a request for a hearing with the Workers' Compensation Board and possibly attending mediation or a formal hearing.

 

Conclusion

 

Navigating Oregon’s workers' compensation insurance system for physical therapy can seem complex, but understanding the steps and your rights can help ensure you receive the necessary care for your recovery. Promptly reporting injuries, following up with authorized medical providers, and adhering to prescribed treatment plans are key to a smooth process. Always communicate with your healthcare providers and the insurance carrier to address any issues that arise during your treatment.