FREQUENTLY ASKED QUESTIONS

WHAT CONDITIONS DO YOU TREAT?

With over 20 years of experience we are happy to offer high quality care for a wide variety of conditions including neck pain, back pain, shoulder pain, knee pain, foot and ankle pain, and jaw pain (often called TMD or TMJ dysfunction).  We have helped many patients come back after surgeries of all types including ACL repair, rotator cuff repair and spinal surgeries.  We also have extensive experience treating chronic pain, deconditioning, balance disorders (including fall risk management), and vertigo.  Our treatment focuses on helping you get back what is important to you: gardening, sledding with your kids or grandkids, going after a new personal best back squat, or returning to sport.

WHAT TYPES OF HEALTH INSURANCE DO YOU ACCEPT?

We work with Medicare as a Non-participating provider, and are otherwise out of network with insurances.  This allows us to provide high quality services that are patient centered and not driven by a third party.  We provide resources to assist our clients to pursue reimbursement if they have out of network benefits, as well as information on Maine's "Right to Shop" law which requires insurances to reimburse patients at in-network rates in some situations.  Please see below for much more information regarding Out of Network benefits and Maine's "Right to Shop" law.

DO I NEED A DOCTOR’S REFERRAL?

With the exception of Medicare, no you do not need a referral to see a physical therapist in the state of Maine.  Some insurances do require a referral for reimbursement for out of network visits.  Check with your insurance for further details.  We have created a specific FAQ sheet for Out of Network information.

WHERE DO YOU SEE PATIENTS?

We are excited to offer our services in two locations: We are located at 23 Aldrich Ave. in Norway, Maine (*next to TruStrength Athletics) and at 34 Center St. in Auburn, Maine (across the street from Goldworks and in the same building as Maine Dentistry and Perfect Balance).  We offer mobile services for an additional travel fee.

WHAT IS YOUR NEW PATIENT PROCEDURE?

We will have a brief interview over a phone call to get some information regarding your needs and answer any questions you may have about our services.  We will send you our intake forms which can be completed entirely online.  The first visit will focus on assessing your injury (for physical therapy) and/or movement (for a functional mobility screen).  Be sure to wear loose, comfortable clothing (athletic apparel is a good bet).

COVID-19 AND RESILIENCE

We take the health of our patients and community very seriously.  While it's not possible to reduce risk to nothing, we take significant precautions to keep you and our staff safe.  We do require masking during our sessions.  All equipment is disinfected before and after each treatment session.  Our one on one and mobile treatment settings remove the worry of crowded waiting rooms or clinics.  You will be screened before each session and if necessary we will reschedule the visit if you are experiencing symptoms.

 

OUT OF NETWORK FAQS

WHAT ARE OUT OF NETWORK BENEFITS?

Healthcare providers will often contract with insurance companies and are then “in-network.” Other healthcare providers may not contract with an insurance company (there are many reasons for this) and provide “out of network” services.  Your insurance company may provide “out of network” benefits.  This generally means that if you would pay the cost of the service up front, but then can submit to your insurance company for reimbursement for some or all of the cost.  The amount of reimbursement varies depending on the plan.

HOW DO I CHECK MY OUT OF NETWORK (OON) BENEFITS?

Your insurance’s website will usually list out of network benefits on their website.  Prior to seeing your OON provider, it’s a good idea to call your insurance company to see if your specific policy has OON benefits, and if so check if there are any requirements for reimbursement.  For example, your insurance may require you to have a referral from your doctor in order to qualify for reimbursement.  Some questions you should ask when you are on the phone:

  1. How much of my deductible has been met this year?

  2. What is my out-of-network deductible for outpatient physical therapy?

  3. What is my out-of-network coinsurance for outpatient physical therapy?

  4. Do I need a referral from an in-network provider to see someone out-of-network?

  5. How do I submit claim forms for reimbursement? (Claims are forms that are sent to your insurance company to receive reimbursement for sessions you paid for out of pocket.  We recommend you use Reimbursify, an app that makes this process easier).

HOW DO I GET REIMBURSED?

Once any prerequisites are met (i.e. getting a referral from your provider if necessary) you would pay for your physical therapy appointment at the time of service.  Your therapist will provide you a superbill which you can then use to submit for reimbursement.  You can do this yourself, or utilize a service such as Reimbursify to make this process easier.  Your reimbursement amount may depend on your deductible, coinsurance, and cost for the service.

WHAT’S A DEDUCTIBLE? WHAT’S COINSURANCE? 

Your deductible is the amount of money you need to pay before your insurance will reimburse for services.  Your insurance may have a separate deductible for “out of network” providers.  For example, if you spent $1,500 on your therapy and your out of network deductible is $1,000 and then your insurance pays for 100% of services, you would need to pay the $1,000 before insurance would cover the remaining $500. 
Coinsurance is the percentage of the service fee that you, the consumer, is responsible for paying.  For example, if your coinsurance responsibility is 30% of the cost of a session, and a session costs $150, you would be responsible for $50.
Your insurance also may have a maximum “allowed amount,” which caps the amount of money the insurance will cover per session. For example, if the maximum allowed amount for a session is $100 by the insurance, then with a 30% co-insurance you would be reimbursed a maximum of $70.  So if a session cost $150, your insurance would reimburse you $70 and you would be responsible for the remaining $80.

CAN I USE MY HEALTHCARE SAVINGS ACCOUNT (HSA) OR FLEXIBLE SPENDING ACCOUNT?

Yes, regardless of whether or not you are submitting for reimbursement from your insurance provider you can use an HSA or FSA to pay for physical therapy services.

 

MAINE'S RIGHT TO SHOP LAW

WHAT IS THE RIGHT TO SHOP LAW?

A new law became effective January 1, 2019 that requires health insurance plans to pay for certain services, including physical therapy, by out of network providers if the service cost less than the average paid to all in-network providers in the state or the average the insurance carrier pays its network providers. This gives you the power to shop for the best price and best quality services regardless of whether the provider is in-network or not. The insurance carrier must treat the claim as if it was provided by an in-network provider – which means you pay an in-network co-pay/co-insurance and the payment of the claim is applied to your in-network deductible and out of pocket max, not a separate out of network deductible and out of pocket max.

WHAT HEALTH PLANS MUST FOLLOW THIS LAW?

  • Individual health insurance plans purchased in Maine or on healthcare.gov.  

  • Employer-sponsored health plans that are fully insured by a Maine insurance company.  

  • Maine state employee health plans.

WHAT HEALTH PLANS DON'T NEED TO FOLLOW THIS LAW?

  • Self-insured health plans that large multi-state employers frequently offer.  

  • HMO plans

  • Out of state health plans that are not governed by Maine law.

WHAT IS THE PURPOSE OF THIS LAW?

The Right to Shop law encourages consumers to shop for lower cost services and ensure health plans do not punish consumers for choosing out of network services that actually cost less than in-network services.

HOW DO I USE THE RIGHT TO SHOP LAW?

  • Compare our out of network charges after applying our cash-payment discount to the estimated average for the PT service codes on www.comparemaine.org.

  • If our charges are less, contact your health plan to notify them you will be exercising your right to choose to see us as an out of network provider to confirm you are eligible. 

  • If your health plan says you are not eligible, we may need to dig deeper – health plans are not used to consumers using this law yet and may give you erroneous information about your eligibility.

  • We will give you a receipt (aka “Superbill”) that you can send to your health plan.  You will have to be assertive and demand compliance with the law since this law is new and has not been used much.