Because of rising costs and declining insurance reimbursement rates, which often have a negative impact on patient care, many healthcare providers in the United States (including College Hill Pilates and Physical Therapy LLC) have transitioned to a cash-based business model, meaning that they are out-of-network for all insurance carriers. This enables healthcare providers to give their patients the attention and care they need, without having to worry about insurance companies attempting to influence or even dictate how that care is provided. Meanwhile, customers of most insurance carriers are free to submit their expenses for reimbursement after the fact.
Medicare Restrictions on Cash-Based Physical Therapy
Unfortunately, due to current US healthcare laws, this is not the case for Medicare beneficiaries seeking physical therapy services. According to Section 1848(g)(4)(A) of the Social Security Act:
For services furnished on or after September 1, 1990, within 1 year after the date of providing a service for which payment is made under this part on a reasonable charge or fee schedule basis, a physician, supplier, or other person . . . shall complete and submit a claim for such service on a standard claim form specified by the Secretary to the carrier on behalf of a beneficiary . . .
This means that any time a Medicare beneficiary receives a service that is covered under Medicare, the healthcare provider has to submit a claim to Medicare. Most cash-based healthcare providers can simply opt out of Medicare in order to serve Medicare beneficiaries, but physical therapists are (unfairly, in our opinion) not allowed to opt out. As a result, the only way for cash-based physical therapy practices to comply with the law is to not see Medicare beneficiaries at all.
There is, however, one exception. According to Chapter 15 of the Medicare Benefit Policy Manual (the same document that excludes physical therapists from being able to opt out):
The only situation in which non-opt-out physicians or practitioners, or other suppliers, are not required to submit claims to Medicare for covered services is where a beneficiary or the beneficiary’s legal representative refuses, of his/her own free will, to authorize the submission of a bill to Medicare.
HIPAA rules reflect this exception as well. According to page 5628 of the Federal Resister Vol. 78, No. 17 (page 384 of the linked document):
Thus, if a Medicare beneficiary requests a restriction on the disclosure of protected health information to Medicare for a covered service and pays out of pocket for the service (i.e., refuses to authorize the submission of a bill to Medicare for the service), the provider must restrict the disclosure of protected health information regarding the service to Medicare in accordance with § 164.522(a)(1)(vi).
In other words, a cash-based physical therapy provider is allowed to see a Medicare beneficiary only if that beneficiary insists on not involving Medicare.
When can CHPPT see Medicare beneficiaries?
Therefore, if you are a Medicare beneficiary, there are only two scenarios in which CHPPT can see you:
- For Pilates one-on-sessions or group classes – Because Pilates is not covered by Medicare and therefore cannot be billed to Medicare, you are free to schedule and pay for those services out-of-pocket without any restrictions.
- If you are clear and adamant that you do not want to involve Medicare – If you insist, of your own free will, that Medicare not be notified of, billed for, or involved in your physical therapy care in any way, please contact CHPPT before scheduling an appointment.
If you do want to use your Medicare benefits for physical therapy, we would be happy to refer you to a participating Medicare provider.