Q&A | Insurance and Physical Therapy — Let's Discuss!

If navigating health insurance for physical therapy makes you want to throw your laptop across the room, you’re not alone. Understanding whether insurance covers pelvic floor therapy can feel especially daunting. From deductibles to co-pays, in-network versus out-of-network, and all the specific insurance terms, it can get complicated fast.

Read on as Origin's benefits expert Anusha Sadruddin explains how much pelvic floor therapy costs, whether it’s covered by insurance, and key terms you should know.

Key points to help you navigate pelvic floor therapy insurance coverage

• Verification Process: Many clinics, like Origin, help by checking your insurance benefits before your first pelvic floor therapy visit. This includes verifying in-network or out-of-network status, your deductible, and estimated pelvic floor therapy costs.
• Important Terms: Important insurance terms include deductible, in-network vs. out-of-network, co-pay, co-insurance, prior authorization, and the CPT (procedure) codes.
• Coverage Details: Coverage varies widely. Make sure to find out if you need a referral for pelvic floor physical therapy, if there are limits on visits, and what your out-of-pocket cost will be for pelvic floor therapy.

Is Pelvic Floor Therapy Covered by Insurance?

The good news is: often, yes. Most insurance plans cover pelvic floor therapy under their physical therapy benefits. However, determining whether your specific plan covers pelvic floor physical therapy and at what cost may require:

• Reviewing your plan’s Summary of Benefits
• Calling your insurance company
• Asking your physical therapy clinic if they verify benefits on your behalf

If you’re looking for a pelvic floor therapy clinic, many offices, including ours, verify your insurance coverage before your visit and let you know the cost for pelvic floor therapy based on your plan.

Wondering if Origin Physical Therapy accepts your insurance? Check our coverage page for an up-to-date list of insurers we work with, and visit our prescription page to learn about state referral requirements.

How Clinics Verify Insurance for Pelvic Floor Therapy

When you book a pelvic floor therapy appointment and submit your insurance info, we verify your insurance benefits before your first visit. Origin's team will:

1. Check In-Network Status: Is the clinic in-network or out-of-network for your plan? In-network providers usually cost less.
2. Check Deductibles: Have you met your deductible? What is your deductible for physical therapy or pelvic floor therapy?
3. Procedure Codes: The clinic tells your insurance company what they plan to do (using CPT codes), which helps determine your coverage and out-of-pocket costs.
4. Send an Estimate: You’ll get an email outlining what you can expect to pay for pelvic floor therapy (co-pays, co-insurance, or full session price if deductible hasn’t been met).

Are healthcare providers required to verify patient benefits?

No, it’s not required – and it’s ultimately your responsibility to know what your benefits are — but some clinics like Origin consider it an important part of patient care.

Key insurance terms explained

• In-Network vs. Out-of-Network: In-network providers have agreements with your insurer, which usually makes your therapy much cheaper. Out-of-network pelvic floor therapy costs more and may not be covered at all.
• Deductible: The amount you pay before your insurance covers costs. Plans can vary widely; for example, you might be responsible for a few hundred dollars to a few thousand dollars for services (including pelvic floor therapy) before insurance starts to pay. Some plans that offer both in-network and out-of-network coverage will have separate deductibles for each.
  
• ‍Co-pay: A fixed fee you pay for each visit (such as $20–$50 per session).
• Co-insurance: Rather than a flat fee, this is a percentage (like 20%) you pay once your deductible is met.
• Procedure Codes (CPT codes): CPT or “current procedural terminology” codes are medical codes that healthcare providers have to use to bill insurance. Every medical procedure or service has an associated code that, if covered, is reimbursed at a negotiated rate. Insurance companies may call pelvic floor therapy “physical therapy” or use codes like 97110 (therapeutic exercise) and 97140 (manual therapy).

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What's the difference between an “individual” deductible and a "family" deductible?

Individual deductibles apply to one person. If you’ve on an insurance plan with other family members, you’ll have an individual deductible and a family deductible.

• The family deductible will be much higher.
• When one person meets their individual deductible, then benefits will kick in only for them.
• If you meet your family deductible, then insurance benefits will kick-in for everyone, even if some family members haven’t met their individual deductibles.

Another important detail about deductibles: If your plan offers in-network and out-of-network coverage, you will typically have a separate deductible for each.

What’s the difference between in-network and out-of-network in terms of providers and benefits?

Providers who are in-network with an insurance company have signed a contract with that insurance company, agreeing to certain terms and conditions, including how much they’ll be reimbursed for the covered services they provide. It’s easier and more affordable for your insurance company to work with these providers.

Some plans will also offer a separate set of benefits for out-of-network providers. For example, if you see an in-network provider, they might pay for 70% of your care after you meet your in-network deductible, whereas if you see an out-of-network provider, they might pay 30–50% of your care after you’ve met your out-of-network deductible. Actual numbers will vary depending on your plan.

Many plans do not offer any out-of-network benefits. That means that if you see a provider who is outside of your plan’s network, you’ll have to pay for 100% of your bill.

What is co-insurance and how is it different from a co-pay?

Co-insurance is the percentage of the cost of your care that you pay yourself (or that you pay “out-of-pocket” to use another insurance term).

If your plan has a deductible, you’ll pay 100% of the cost of your care until you meet that deductible. After you meet your deductible, you’ll pay a co-insurance that can vary but is often 10%, 20%, or 30% of the cost of your care. The exact percentage will depend on the provider or facility or type of service you receive (check your benefits summary for details).

To make things more complicated, some medical bills that you pay will count toward your deductible and others won’t (again, your benefits summary will have the details).

Co-pays, on the other hand, are a fixed amount that you pay for a covered medical service, regardless of how much that service costs your insurance. For example, you may have a $25 co-pay when you see your primary care provider for an annual wellness visit, or a $50 co-pay when you see a specialist like a physical therapist or when you go to an urgent care clinic.

Most plans use co-pays for some things and co-insurance for others.

How much does pelvic floor therapy cost?

Pelvic floor therapy cost depends on your plan and network status:

• In-Network: Most people will owe a co-pay ($20–$75) or co-insurance amount per visit, before or after your deductible has been met.
• Out-of-Network: If your plan allows it, you may have a higher co-insurance or must pay the full cash rate amount.
• No Insurance: Expect to pay the full session cash rate set by the clinic. Depending on your location, this is typically around $125–$175 per visit at Origin, but other clinics can charge more.

Always ask your provider:

• Is pelvic floor therapy covered by my insurance?
• Do I need a referral?
• How much will each visit cost?
• How many visits are covered each year?

Referrals, prior authorization, and visit limits

• Referrals and prescriptions: Some insurance plans require a referral from your physician before they will cover pelvic floor physical therapy.
• Prior authorization: Prior authorization is an extra layer of approval. Sometimes insurance plans (especially HMO plans) want to double-check that the visit or procedure you want to schedule is a medical necessity, so they require that you get their authorization or approval. In this case, your provider will need to submit your prescription/referral to both the physical therapy company and your insurance.
• Visit limits: Many plans limit the number of physical therapy or pelvic floor therapy visits per year (for example, 20 sessions), regardless of how many visits you need.
• Always ask during verification: Do I need a referral or pre-authorization? Is there a limit on visits for pelvic floor therapy?

Origin will help find out if you need a referral/prescription or prior authorization in order to get covered care.

Bottom line: Is physical therapy, including pelvic floor therapy, covered by insurance?

• Is pelvic floor physical therapy covered by insurance? Often, yes, under your plan’s physical therapy benefits.
• Coverage and costs vary by plan; always verify upfront.
• Ask your clinic for a coverage check and estimate.
• Know key insurance terms so you’re prepared.

FAQs

Q: What information does Origin pass on to the patient after verifying their benefits?

A: We send a comprehensive email explaining what you can expect to pay “out-of-pocket” and why. So we’ll let you know if Origin is an in-network or out-of-network provider for you. Then we’ll tell you if you’ve met your deductible yet and what you can expect to pay.

Q: How often are the estimated costs that we send patients off-base?

A: Not often, but it can happen because insurance is tricky even for people that work in insurance. Whether we’re calling an insurance rep and asking them to interpret the data that’s available to them or our team at Origin is interpreting the data ourselves, it’s not cut and dry.

No one can 100% guarantee what you're going to pay for healthcare ahead of time. Even if you call your insurance company, they're going to give you the same warning. You’ll hear words like “any information that we provide you is an estimate” and “patient responsibility is subject to claims finalization.”

But I can assure you that our team is well trained and doing our absolute best to give you a solid estimate. We want you to feel comfortable coming to Origin, knowing that you can afford it. To me, that’s another, equally important way of providing care to people.

Q: How can I verify my insurance coverage before my first visit?

A: Ask your provider or clinic for a personalized insurance verification and cost estimate before you start pelvic floor therapy. That way, there are no surprises, just the care you need, at a price you expect!