Pain Relief and the Myth of Physical Therapy Co-Pays
By
Walt Fritz, PT
Physical Therapist at the Pain Relief Center in Rochester, NY
There was a time when typical co-pays for physical therapy treatment ranged between $10-15. This
sounds like a pretty good value, right? But today, as health maintenance organizations (HMO’s)
strive to cut back on costs, typical co-pays now commonly $40. This is not an unreasonable amount
of money to co-pay for treatment, if you are getting value out of the visits.
The Pain Relief Center Physical Therapy was started ten years ago with a very different business
model. As an “out-of-network” provider of physical therapy services, we do not accept insurances
directly; therapy sessions are paid for at the time of service. The patient is given a receipt with all
necessary codes and information to allow them to submit the receipt to their health insurer for
reimbursement. If the patient has ‘out-of-network” physical therapy covered in their policy, they will
be reimbursed based on the terms of their contract. If they are in doubt, we suggest that they call
their insurer and ask the very specific question “do I have coverage for out-of-network” physical
therapy in my contract?” The response should be a simple yet or no. If the answer is “yes”, ask what
the coverage entails. They will typically receive a response telling them they have a certain amount
to pay up front (the co-pay) and then the insurer will reimburse them a certain percentage of the
approved amounts after the co-pay has been met. If the reply is “no” to the question of out-ofnetwork coverage for physical therapy, the patient will not be reimbursed for treatment at the Pain
Relief Center.
Given all of the apparent hassles and up-front expenditure of monies, why would anyone choose to
pursue out-of-network physical therapy? It should be a simple answer; value. If you are achieving
your goals from a physical therapy provider who is an in-network physical therapist, then there is
no reason to look elsewhere. But, if you are feeling like there is something missing, you have options.
One of the most common complaints that we hear from new patients is that they went through a
course of physical therapy for a condition (let’s use back pain as an example) and they felt no
change, or maybe felt worse afterward. They tell me that the therapist pushed an exercise based
(strengthening) model with them, and the exercises did not seem to help. We would typically ask
that patient if the physical therapist used any form of stretching with them, and the patient would
often tell me that they did, but little effort was put into this or it seemed to make them worse.
Further inquiry revealed that there was little hands-on therapy, also called manual therapy, where
specific areas of the body were evaluated for tightness that could be contributing to or causing the
pain. The patient went to physical therapy three times a week for six weeks performed their
exercises in the PT gym with little direct attention from the physical therapist. If progress was not
not made, they would be questioned to determine if home exercise program was being followed (often a
2-3 page list of exercises that is almost setting the patient up for failure. How many patients follow this to
the letter? And, if they don’t, the therapist blames the lack of follow-through on the patient’s part for the
lack of progress). Does this sound familiar?
So let’s do the math: three sessions per week for six weeks at $40 co-pay per visit = $720. This is a fair
amount of money for all people, but not a bad sum if a patient’s goals are met. But what if the pain or
problem still exists after the PT is completed or their health insurer has cut them off from additional
therapy?
The form of manual therapy utilized at the Pain Relief Center focuses on a hands-on modality referred to
as Myofascial Release (MFR). Over the years of utilizing MFR at the Pain Relief Center, we have found that
the vast majority of patients will begin to feel some sort of lasting, positive change in three sessions at the
most. Some patients have met their goals after three sessions, while others are just beginning to scratch
the surface of their pain or problem, but all should begin to “get it”. If they are not feeling any lasting
change after three sessions, they are typically referred on to someone who may be better able to help.
But, most find that the manual therapy, hands-on physical therapy provided at the Pain Relief Center
makes sense. The Pain Relief Center excels in connecting pain with underlying tightness from injury or
surgery/scar tissue. It is a vastly different approach that what is commonly thought of as physical
therapy.
So, if myofascial release is so effective, why don’t other “traditional” physical therapy clinics offer this
modality? Well, some do, but ask for the experience of the practitioner. Walt Fritz, PT, the owner of the
Pain Relief Center, has over 20 years of experience in myofascial release and teaches this hands-on
modality nationally. What kind of experience are you finding when you call around? How many
accredited continuing education hours has the therapist spent in myofascial release training and what
percentage of their work day is spent utilizing this modality? Also, the myofascial release approach at the
Pain Relief Center is quite labor intensive. Sessions run 50 minutes in length, all of which is direct, handson time with the licensed physical therapist. Physical therapy practices that run under the HMO model
are not able to devote this sort of time to one patient.
Let’s return to the financial aspect of this conversation. The typical patient spends $720 during a course
of 18 HMO “covered” physical therapy sessions. For comparison, a 50-minute session at the Pain Relief
Center costs $120. Multiply this by 18 sessions (which is a LOT of hands-on myofascial release therapy,
by the way), subtract the co-pay ($250 in this example, which is a very common co-pay), then calculate
that the patient will be responsible for 25% of the balance. 18 sessions, paid for through an out-ofnetwork plan as described here, would end up costing the patient $477 (vs. $720 from an in-network
physical therapist)! Both are good values, if they deliver on the intended promise. The choice is really up
to you, the patient.
Some conditions are not well suited to a manual therapy, myofascial release approach. If a prospective
patient calls the Pain Relief Center for post-surgical knee rehabilitation, for instance, they will be referred
on to a traditional physical therapy practice. But, if pain or similar issues is what bring you to physical
therapy, a manual therapy, hands-on approach, such as myofascial release, may be just what you need.
Read more at the website, www.RochesterPainRelief.com or call 585-244-6180.
©Copyright 2012 Walt Fritz, PT and the Pain Relief Center