Do You Need A Referral For Physical Therapy

In many states, you often won’t need a referral to access physical therapy, but it’s important to note that this can vary between individual clinics. All 50 states allow for direct access to physical therapists. Direct access is when you do not need to go to a doctor before seeking physical therapy services. Although direct access applies to all 50 states, certain states will limit their services, such as allowing treatment for a specific amount of time without a doctor’s referral which is typically 30 days. Along with limiting treatment days, certain clinics may limit treatments or treatment plans without a referral. Currently, only 20 states have unrestricted direct access laws, making them more accessible without a referral. For these 20 states, you can do a self-referral. However, each clinic may have its own policies and restrictions, so it’s a good idea to reach out to the specific clinic you’re interested in to get the most accurate information.

Referrals and Medical Provider 

Each medical provider has different policies on whether you need a referral from them. Blue Cross-Blue Shield and Aetna typically allow for direct access, however, each plan varies, so before booking an appointment with a clinic check to see if your plan requires a referral. Medicaid referral policies are specific to the state, so make sure to check the rules regarding direct access based on the state you are seeking physical therapy services. Reaching out to your state Medicaid office can help clarify these policies. Similar to Blue Cross-Blue Shield, and Aetna, Medicare generally allows for direct access to physical therapy services without a referral. It’s important to note that policies can change, and the best way to get accurate and up-to-date information is to contact your insurance provider directly. This can usually be done through the customer service number on the back of your insurance card. Additionally, you can consult with the physical therapy clinic you plan to visit, as they often have experience dealing with various insurance providers and can guide you through the process.

How to Schedule an Appointment Without A  Referral

Scheduling an appointment with a healthcare provider, particularly for services like physical therapy, can be a straightforward process, especially when no referral is required. Always do your research and see which clinic offers direct access. As stated previously, direct access means you can schedule an appointment without needing a referral from a healthcare provider. Typically, all 50 states and the District of Columbia have approved direct access to physical therapists. It is also important to note that before making an appointment, you should call ahead to make sure the clinic is covered through your insurance. When making your first appointment they will always ask you for your insurance information, so have it on hand when you go in. 

What Does Insurance Cover 

Insurance coverage for physical therapy appointments can vary based on the type of insurance plan you have and the specific policies of your insurance provider. Here’s a general overview of what different types of insurance may cover for physical therapy:

 Private Health Insurance (e.g., Blue Cross Blue Shield, Aetna):

Many private health insurance plans cover physical therapy services. Coverage often includes a certain number of visits per year, with the option for additional sessions if medically necessary. Co-payments or co-insurance may apply, requiring you to pay a percentage of the therapy cost. Some plans may also have an annual deductible that needs to be met before coverage kicks in.

Medicaid

Medicaid coverage for physical therapy varies by state. In many cases, Medicaid provides coverage for necessary and medically prescribed physical therapy services. Depending on the state and the specific Medicaid plan, pre-authorization requirements or a physician’s referral may apply.

Medicare

Original Medicare (Part B) typically covers medically necessary outpatient physical therapy. This includes evaluation and management services, therapeutic exercises, and other treatments. Medicare Advantage plans (Part C) may have different coverage options, and beneficiaries should check with their specific plan for details.

Workers’ Compensation

If your need for physical therapy arises from a work-related injury or illness, workers’ compensation insurance may cover the costs of therapy. Requirements for pre-authorization and adherence to the approved provider network may apply.

Auto Insurance (Personal Injury Protection – PIP):

In cases of injuries resulting from auto accidents, personal injury protection (PIP) coverage in auto insurance may cover physical therapy expenses. This coverage can vary by state and policy.

Tricare (Military Health Insurance):

Tricare, the health insurance program for uniformed service members and their families, generally covers physical therapy services. Beneficiaries may need a referral or authorization from their primary care manager.

Make sure you understand the specifics of your insurance coverage by reviewing your plan documents or contacting your insurance provider directly. Key considerations include the number of covered visits, any co-payments or deductibles, and whether pre-authorization or a physician’s referral is required. Additionally, confirming that the physical therapy clinic is in-network with your insurance provider can help avoid unexpected out-of-pocket expenses.

Do You Need A Referral for ACHPT? (CTA)

AH Concierge Physical Therapy aims to simplify having access to physical therapy and prioritizing convenience. To schedule an appointment, kindly contact us today for more information on the services we provide to ensure we can best suit your needs. We aim to make physical therapy better suited for you.

As a provider outside typical insurance networks, we do not have any contracts with insurance companies. That being said, we are still here for you! We’re happy to send a courtesy bill to your insurance, but it’s vital to know your plan. Coverage may vary, and for Medicare patients, acceptance depends on factors like secondary insurance. We’re a non-participating Medicare provider, meaning they usually reimburse 80% of approved service costs. We are here to make this process seamless and help you navigate this process.