Good Faith Estimate

For cash payment

Type of Service: Outpatient Physical Therapy

Provider Fees:

Initial Evaluations: 90-120 minutes

  • 97161 Physical Therapy Evaluation – Low Complexity $100.00
  • 97162 Physical Therapy Evaluation – Medium Complexity $100.00
  • 97163 Physical Therapy Evaluation – High Complexity $100.00
  • 97164 Physical Therapy Re-Evaluation $100.00

Type of interventions: Sessions may consist of any combination of the following

  • 97032 Electrical Stimulation $15.00/unit*
  • 97035 Ultrasound $15.00/unit
  • 97110: Therapeutic Exercise $30.00/unit
  • 97112: Neuromuscular Re-education $35.00/unit
  • 97116: Gait Training $30.00/unit
  • 97140: Manual Therapy $30.00/unit
  • 97530: Therapeutic Activities $35.00/unit
  • 97535: Self-Care/Home Management Training $35.00/unit
  • 97760: Orthotic and Prosthetic Evaluation/Management $45.00/unit
  • 97763: Orthotic and Prosthetic Management $50.00/unit

*One unit is for 8-22 minutes.

Frequency/Duration:

  • Up to 3 sessions weekly for up to 90 days
  • OR specific frequency/duration on script
  • OR number of sessions requested by patient/client
  • OR not yet scheduled

Option 1: Paying Upfront for Potential In-Network Coverage

You have chosen to pay out-of-pocket (cash, check, or card) for services today that your insurance may not cover, even though we are an in-network provider with your plan. By signing below, you agree to pay for your session(s) in full at the time of service, with the understanding that we will still submit a claim to your insurance company on your behalf. Please note that reimbursement is not guaranteed.

  • If your insurance covers the session: Once we receive their payment, we will refund your original cash payment, minus any required co-pays, co-insurance, or deductibles.
  • If your insurance denies the claim: Our practice will keep your original payment in full to cover the cost of your care.

Option 2: Paying Upfront for Out-of-Network Services

Because we are out-of-network with your insurance plan, you agree to pay for your physical therapy session(s) in full at the time of service.

At your request, we will submit a claim to your insurance company on your behalf so you can seek personal reimbursement. Please keep the following in mind:

  • Reimbursement is not guaranteed: Your insurance company may deny the claim entirely.
  • Payouts may be lower: Because we are out-of-network, your insurance may reimburse you at a lower rate than an in-network provider, resulting in a higher out-of-pocket cost for you.
  • Reimbursement goes to you: If the claim is approved, the insurance company will send the check directly to you.
  • Important Note: Regardless of whether your insurance approves, denies, or pays out a lower amount for the claim, our practice keeps your full original payment. No refunds will be issued by this clinic, as your payment covers the direct cost of your care.

Option 3: Paying Upfront / Declining Immediate Insurance Submission

You agree to pay for your physical therapy session(s) in full at the time of service and have chosen not to have our practice submit a claim to your insurance at this time.

While you retain the right to submit this claim to your insurance on your own after the fact, please be aware of the following guidelines regarding future reimbursement:

  • Submission Deadlines: Most insurance companies require claims to be submitted within a specific time window. If you file past this deadline, your insurance will deny the claim.
  • If we are In-Network and the claim is approved: Once we receive the insurance reimbursement, we will refund your original cash payment minus any required co-pays, co-insurance, or deductibles.
  • If we are Out-of-Network and the claim is approved: The insurance company will reimburse you directly based on your out-of-network benefits. Our practice will keep your original cash payment in full.
  • If the claim is denied: Regardless of our network status, our practice keeps your original payment in full to cover the cost of your care.

Option 4: Paying Upfront / Adding Insurance Later

You agree to pay for your physical therapy session(s) in full at the time of service because you do not currently have health insurance.

If you obtain insurance coverage during your course of care, you may request that we submit claims for your past sessions. Please keep the following guidelines in mind:

  • Submission Deadlines: Insurance companies enforce strict deadlines for submitting claims. If your new policy was not active at the time of service, or if the submission window has passed, the claims will be denied.
  • If your new plan is In-Network: If the claims are submitted on time and approved, we will refund your original cash payments minus any co-pays, co-insurance, or deductibles required by your new plan.
  • If your new plan is Out-of-Network: If the claims are approved, the insurance company will reimburse you directly based on your plan’s out-of-network benefits. Our practice will keep your original cash payment in full.
  • If the claims are denied: Regardless of the network status, our practice keeps your original payment in full to cover the cost of the care already provided.

Adding Retroactive Insurance That Requires Pre-Approval

If you obtain health insurance after your care has started, and that policy is backdated (retroactive) to cover past sessions, we can attempt to submit backdated claims for you. However, if your new insurance requires a “prior authorization” for physical therapy, the following rules apply:

  • We must request “Backward Permission” (Retrospective Authorization): Because the policy was not active during your visits, our practice must submit your medical records to your new insurance company to ask them to retroactively approve your past sessions.
  • Approval is determined by the insurance company: Your insurance company will audit your past medical records. They hold the sole authority to approve or deny this retroactive request.
  • If the retroactive authorization is approved: We will file the claims. Once we receive payment from the insurance company, we will refund your original cash payments minus any co-pays, co-insurance, or deductibles required by your new plan (for in-network care).
  • If the retroactive authorization is denied: If the insurance company refuses to backdate the authorization, they will deny the claims. In this case, our practice keeps your original cash payment in full to cover the services already provided.

Materials Fees: There will be a materials fee added for the distribution of therapeutic equipment that becomes yours and is for your use at home between therapy sessions.

  • Therabands (up to 3 levels) $12.50
  • Theraputty (up to 3 levels) $25.00

If you need more than 3 levels, then there will be a charge of $4.00 each additional theraband, and $8.00 each additional theraputty.

Borrowed Equipment: There may be equipment that is lent to you during your time in therapy with the intention of returning it by your last session. If it is not returned or is returned in poor condition, the cost of the borrowed item will be added to your account equaling $25.00.

Additional purchases you make yourself: Depending on your condition, you may also need an over-the-counter orthotic. This type of equipment is not covered by insurance and is not given to you by your physical therapist. If the item is needed, please purchase it yourself at a local store or online. Prices vary depending on the need, but will likely cost less than $100.00

The current Good Faith Estimate (GFE) is only an ESTIMATE based on usual, customary, and reasonable charges and the needs of the patient/client at the time of the original GFE. The final charge may differ. However, the final charge cannot be $400.00 or more over the original estimate. If the final charge does exceed $400.00 or more over the original estimate then the patient/client has a right to dispute the final charge with the Department of Health and Human Services within 120 days of the date on the original bill. Choosing to resolve a dispute will not affect quality of care from the provider or prevent care in the future. For more information go to https://www.cms.gov/nosurprises or call 1-800-985-3059.

If the appointment was scheduled 3 business days in advance of the appointment, then the GFE must be presented to the patient/client no later than one business day after the day of scheduling.

If the appointment was scheduled 10 business days in advance of the appointment, then the GFE must be presented to the patient/client no later than three business days after the day of scheduling.

The GFE is not a contract, therefore signing the GFE does not obligate the patient/client to obtain services from the physical therapist. The patient/client is able to decline services prior to payment.

GFE is valid for 12 months from date of signing. There may be services recommended in the future by the physical therapist that are not reflected in the original GFE. Patient/client must be notified of any changes to the original GFE and a new GFE must be issued to reflect the new changes.