5 Criteria for Insurance Reimbursement

5 Criteria for Insurance Reimbursement

 By Michael K. Jones, Ph.D., P.T.

“Insurance reimbursement….do I have a chance of getting paid for medical exercise services”? I receive many calls from our MESs and PRCSs asking if they are eligible for insurance reimbursement for medical exercise services. The key to this answer lies in the “5 Medical Exercise Insurance Reimbursement Criteria”. If your client meets the criteria, there is a possibility of receiving reimbursement for medical exercise services

5 criteria every medical exercise client must meet for any possibility for insurance reimbursement are:

1. Insurance Coverage – The client must have insurance coverage through a third party insurance carrier. An example of a third-party carrier is Blue Cross/Shield or a carrier that manages motor vehicle accident claim or workers’ compensation claims. Medicare, Medicaid and governmental or provincial health care plans will not cover post rehab services. Your best possibility for reimbursement is through a workers’ compensation or motor vehicle accident claim.
2. Traumatic Injury/Surgery – The client must have sustained a traumatic injury and/or undergone major surgery. An example of this would be a client with a ruptured anterior cruciate ligament in the knee or a disc herniation in the lumbar spine resulting in surgery to correct the injury. These clients require long-term supervised exercise with a qualified post rehab professional after their discharge from physical therapy and/or chiropractic care.
3. Residual Functional Deficits – The client must have residual functional deficits that are present after the completion of physical therapy and/or chiropractic care. At some point, the client no longer needs physical therapy or chiropractic care; but there are still functional deficits that impair the client’s functional status. These deficits include functional limits in ROM/flexibility, strength, power, endurance, balance, proprioception, joint stability, muscle recruitment and coordination. The post rehab conditioning program addresses these deficits after discharge from physical therapy or chiropractic care.
4. Maximum Benefit from PT or DC Services – The client has received the maximum benefit from physical therapy and chiropractic care, having reached the maximum level of function from these services and now is discharged. This ensures the proper care and treatment are delivered during the acute and sub-acute stages following injury. Once physical therapy and/or chiropractic care are over and the client still has residual functional deficits, there is a need for a supervised functional conditioning program under the supervision of a Medical Exercise Specialist or Post Rehab Conditioning Specialist to improve the client’s level of function.
5. Written Referral from Physician – The client has a written referral from his or her physician or physical therapist indicating the need for a “supervised functional conditioning” program. The referral should not request ‘therapeutic exercise’ as this modality is specifically covered in the Physical Therapy Practice Act in most states and provinces in North America. Any attempt to fulfill a referral for ‘therapeutic exercise’ is a violation of the act. If the client meets each these criteria, there is a strong possibility for insurance reimbursement.