Concierge Physical Therapy: How Cash-Based and Membership PT Works

What the term means

"Concierge physical therapy" has no official definition. It is used for physical therapy practices that are paid directly by patients instead of by insurers. You may also see it called cash-based, private-pay, or out-of-network physical therapy.

These practices commonly describe:

• Longer sessions, one-on-one with a licensed physical therapist
• The same therapist at every visit
• Flexible scheduling, sometimes in your home, office, or gym
• Payment by session, by package of visits, or by monthly membership

As with medical practices, these are descriptions, not guarantees. What you receive depends on the individual practice.

Varies by practice. There is no standard for what "concierge" means in physical therapy. Ask how long sessions are, who delivers them, and what a package or membership includes.

How it differs from insurance-based physical therapy

Neither format is better by definition. Many insurance-based clinics provide excellent, attentive care, and a posted cash price says nothing about quality.

Do you need a referral?

Often not. The American Physical Therapy Association reports that all 50 states and the District of Columbia allow some form of direct access, meaning you can be evaluated and treated by a physical therapist without a physician's referral.

Two cautions:

• State rules vary. Some states limit how many visits or which treatments are allowed before a referral is needed.
• Your insurer may still want one. Direct access is about what the law permits, not what your plan will pay for.

Insurance and cash-based physical therapy

A cash-based practice generally does not bill your insurer. That does not always mean you bear the whole cost.

• If your plan has out-of-network benefits, you may be able to submit a claim yourself. Ask the practice for an itemized receipt with the codes your plan requires.
• If your plan has no out-of-network benefits, you will likely pay the full price.
• Ask whether you can use a health savings account or flexible spending account, and confirm with your account administrator.

Before choosing cash-based care, find out what in-network physical therapy would cost you. If your copay is low and local clinics have good availability, paying cash may add little.

Using insurance and a concierge membership together

Concierge physical therapy is not always an either-or choice. Some practices bill your insurance for the visits your plan covers and offer a separate membership or package for services your plan does not cover. If a practice works this way, you may be able to keep using your insurance for covered treatment and pay directly only for the extras.

What "non-covered" means

A non-covered service is one your health plan does not pay for. For patients seeing an in-network therapist, the American Physical Therapy Association gives these examples of non-covered services:

• Treatment beyond the number of visits your plan has authorized
• Maintenance therapy
• Fitness services

Which services fall into this group depends on your plan, not on the practice. The same service can be covered under one plan and excluded under another.

How the two payments fit together

The limit to know about

A membership can pay for non-covered services. It should not be an extra charge for treatment your plan already covers. In-network therapists are generally obligated to accept the insurer's payment for covered care, and APTA advises practices to follow each insurer's contract. For people with Medicare, the rule is firmer, as the next section explains: covered services must be billed to Medicare, and only non-covered services can be billed directly to the patient.

Questions to ask a practice that offers both

1. Do you bill my insurance for covered visits, and are you in my plan's network?
2. Which services does the membership include, and can I see the list in writing?
3. Has my plan confirmed those services are not covered?
4. If a membership service turns out to be covered by my plan, how is that handled?
5. Can I stop the membership and keep coming for insurance-covered visits?

Varies by practice and by plan. Not every concierge practice bills insurance, and not every plan treats the same services as non-covered. Confirm both with the practice and with your insurer before you pay.

Medicare has different rules for physical therapists

This is the most important thing to understand if you have Medicare, and it differs from the rules for physicians.

A physician can formally opt out of Medicare and contract privately with Medicare patients. Physical therapists cannot. The Centers for Medicare & Medicaid Services lists physical therapists among the providers who are not eligible to opt out, and CMS's benefit policy manual explains that physical therapists in independent practice are not within the opt-out law's definition of a physician or practitioner.

The American Physical Therapy Association spells out the consequences in its guidance for cash practices:

• If a physical therapist provides a Medicare-covered service to a Medicare beneficiary, the therapist must be enrolled in Medicare and a claim must be submitted to Medicare.
• If the service is not covered by Medicare, the therapist can collect payment directly from the patient.

APTA is direct about this: there are no exceptions that allow physical therapists to bypass these requirements.

What this means for you

• If you have Medicare and need therapy that Medicare covers, expect a legitimate practice to bill Medicare or to tell you it cannot treat you for that service on a cash basis.
• A therapist can provide both kinds of service to the same Medicare patient. According to APTA, the therapist must be enrolled and file claims for the covered services, and the non-covered services can be billed directly to you.
• Direct payment is appropriate only for services Medicare does not cover. APTA gives fitness services as an example of a non-covered service.
• Be careful with any practice that offers to treat a Medicare-covered condition for cash "off the books." That puts the therapist out of compliance and leaves you without Medicare's protections.

What does it cost?

Prices are set by each practice, and we have not found a reliable published survey to cite, so we do not quote a typical figure. Ask for:

• The price per session and the session length
• Package or membership prices, and how unused sessions are handled
• Any separate charge for the initial evaluation
• The cancellation and refund policy

Checking a physical therapist's license

Physical therapists are licensed by each state. There is no single national lookup, but the Federation of State Boards of Physical Therapy maintains a page that links to every state's license verification site.

Confirm that the person treating you is a licensed physical therapist or a licensed physical therapist assistant working under a therapist's supervision, as your state requires.

Questions to ask before you pay

1. Who will treat me at each visit, and what license do they hold?
2. How long is each session, and is it one-on-one?
3. What is the price per session, and what do packages or memberships include?
4. Will you give me an itemized receipt I can submit to my insurer?
5. I have Medicare. How do you handle Medicare-covered services?
6. What happens to unused sessions if I stop early?
7. Will you share your findings with my physician?

Where physical therapy fits with concierge medicine

Physical therapy is one of several services now offered on a membership or direct-pay basis. For the wider picture, see concierge medicine specialties. For how memberships relate to your coverage in general, see does insurance cover concierge medicine?