Explanation of cash vs. insurance based practice model

The question comes up frequently why Boundless LLC is a cash based service rather than taking insurance. The most simple answer is simplicity. By staying out of the world of insurance and all the extra red tape that it entails, I can remain a “one man shop” and keep my prices affordable. Dealing with the extra paperwork insurance entails would require me to charge substantially more to recoup my time. Some individuals with high deductibles or per-visit co-pays will actually spend less on a cash-pay practice vs. going through traditional insurance.

Insurances and Medicare (which most insurance mirrors) are particular about treatment being only for a specific diagnosis, provided only with a doctor's referral, only if there is medical necessity, and only for“skilled” treatment techniques. Let me break these down as why following these criteria would not allow Boundless to stay so boundless!

Specific Diagnosis:  In traditional therapy patient's are assigned one or two diagnosis which must be the strict focus of treatment. The very premise of Myofascial Release (MFR) is to look at the mind and body as a whole, and realize that a seemingly completely unrelated body area may be part of the reason you are having pain. You may feel relief of symptoms in you hip while having mouth work done (yes, really, that's what happened to me!), or many other unique body connections may arise that an insurance reviewer is just not going to understand. Therefore denials of coverage would be likely.

Doctor's referral: Many individuals have everyday nagging aches and pains that they do not feel warrant a trip to the doctor. These individuals may still choose to enjoy MFR for wellness or preventative purposes, or even just as a “feel good” treat. My goal for Boundless is to help individuals take more ownership of their own health and wellness, therefore they are welcome without a doctor's order,  and may return at will for follow up visits.

*Please note: As a licenced physical therapist I have the duty to refer to a physician if I identify any health concerns that are outside of my scope of practice. I do advise seeing a doctor prior to Myofascial Release in the event of new injuries.

Medical necessity: Treatments that fall in the categories of “prevention”, “wellness”, or “fitness” are typically not considered medically necessary. If that fact bothers you, perhaps you understand why I am so motivated to work outside of this model! I believe it is highly necessary for our society to start focusing on wellness to address our current healthcare crisis!

“Skilled” treatment techniques:  This phrase means that services are not only provided by a physical therapist, but that they have such a complexity that they can ONLY be provided by a physical therapist. This is where the waters get muddy. There is no doubt that doing MFR takes great skill. But it is a skill of feel that can be learned by anyone. A well trained massage therapist may be as skilled as I am in the technique, and insurances wouldn't cover their services.  A mother may learn to treat her child, or an individual learn self-care techniques, and insurance will not step up and pay them. The easiest way to avoid the muck of this muddy water is to stay out of it!

If you have further questions regarding the decision to keep Boundless as a cash-pay practice, feel free to ask. Just know that there has been much thought and research that has gone into this decision, and it is the decision that feels to me to be most legally and ethically correct. I promise that I will make every effort to provide a high quality service that will feel worth every penny!

References:

Though many more references are available, these are the website resources I have used as part of my research and decision making.

CMS: Therapy Guidelines

APTA: Direct Access Guidelines

APTA: Definition of Medical Necessity

Web PT: Medicare Guidelines

Web PT: ABNs

Web PT: Should PTs Enroll as  Medicare Providers