What do I do if I have limits on insurance visits?

This can be a tricky situation. However, with some foresight, creativity, communication, partnership, and determination it is possible to make a situation of limited insurance visits work.

Here are a few ideas:

  • Plan ahead and schedule surgery at the later end of your insurance year (keep in mind when you might be allowed to start PT after surgery. For surgeries like hip arthroscopy and total joint replacement you might be allowed to start PT right away. For a periacetabular osteotomy surgery (“PAO”) your surgeon may not want you to start PT for 6-8 weeks). For example, if you have 20 insurance visits per year and you are having a PAO a potential therapy schedule could look like this:
    • 4-6 visits to focus on “pre hab” (4-6 visits)
    • Surgery late September/early October
    • Start PT 6 weeks post-op and attend PT 2x/week for 6-8 weeks (16 visits)
    • New Insurance Year (by this time you are about 12-14 weeks post-op)
    • Continue PT 1-2x/week as needed to return to baseline level of daily function.
    • If you have athletic or high-level vocational or recreational goals, consider focusing on home programming for a few months and saving some insurance visits for months 6-12 to focus more intensively on higher level skills once you are further into healing and fully cleared for all activities.
  • Discuss private pay/cash-based options with your physical therapist/clinic. Some cash-based therapists and standard clinics will be willing to work out special deals with patients who are post-operative to make frequent therapy services more affordable if insurance won’t cover the cost. If you will be paying out-of-pocket for therapy services and cost is a major consideration, you might even consider doing some therapy practice “shopping” to find out what these rates might look like when you choose your therapist/practice.
  • Have an open conversation with your therapist about your therapy visits and how you can partner together to best plan how to use those visits. While most PTs do try to make the effort to pay attention to the insurance plan and have a sense of how many visits their patients have, it can be difficult for a busy PT to keep track of insurance information. Ultimately it is up to you as the patient to understand your insurance plan and to make sure that your medical providers are also aware of any limitations (although if you have questions, your insurance company can help and many clinics also have non-clinical staff who have knowledge in this area). Some variables that you might discuss with your therapist that may impact your plan of care include:
    • How many therapy visits you have?
    • What resources do you have beyond those? For example, can you afford out-of-pocket therapy visits? Do you belong to a gym or can you afford to get some therapy equipment to carry out the majority of your therapy program more independently?
    • What is your surgeon’s therapy protocol/expectations for therapy? How can this be modified to best-meet your needs?
    • What is the projected course of your recovery? Do you have unique health-related comorbidities that could slow your recovery process (ex. decreased bone density/at risk for slow bone healing, at risk for slow tissue or wound healing, chronic pain, connective tissue disorder, psychiatric conditions that might limit recovery?) If you are likely to require a prolonged course of rehab, it will be especially important to talk about how to best-use insurance visits. Spreading therapy visits out and focusing on home programming in between might be beneficial. It might even be beneficial to have a close family member or friend attend sessions with you so that they also can learn basic therapy techniques and movements to look for while you are doing your exercises so that they can help reinforce these at home or in the gym setting.
    • Do you have athletic goals or require high levels of physical function for work or life/recreational activities? If so, you might want to be especially thoughtful about how you use your insurance visits. Full recovery from hip surgery can take 6-12 months, if not longer. If you are in this situation and have limited visits you might talk about spreading therapy visits out earlier on to save some for a more intensive episode of care in the 6-12-month range when you can focus on higher level activities.

In addition to discussing these with your PT, it is also important to discuss them with your surgeon, especially before surgery. Sometimes it is possible for a surgeon to negotiate more visits with an insurance company. Other times there are “hard limits” on the number of visits. Regardless, it is important for your surgeon to understand any limitations you may have around post-operative PT. He/she and your PT may also be able to communicate and collaborate around your plan of care to make sure that you are set up for success!