In some instances, post-rehab professionals are able to obtain insurance reimbursement for post-rehab services, but it's not easy. There is a criteria the client must meet to have a chance for reimbursement:
1. The client must have insurance coverage through either workers' compensation or a motor vehicle accident claim or have a third party insurance carrier such as Blue Cross/Shield. Medicare, Medicaid and government health care plans will not cover post-rehab services.
2. 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 need long-term supervised exercise after the completion of physical therapy and/or chiropractic care.
3. 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 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.
4. The client has a written referral from his or her physician, chiropractor and/or physical therapist indicating the need for a "supervised functional conditioning" program. The referral cannot say "therapeutic exercise" as this modality is specifically covered in the physical therapy practice act in the majority of states and provinces in North America. Fulfilling a referral for "therapeutic exercise" would violate your state or provincial physical therapy practice act. The best medical professional to provide this referral is the licensed physician. Though the support of the physical therapist and chiropractor is important, the referral coming from the physician is essential for insurance reimbursement.
5. The client has received the maximum benefit from physical therapy and chiropractic care. The client has completed a course of physical therapy and/or chiropractic and reached the maximum level of function from these services and now is discharged. The client must be seen by a licensed medical professional prior to referral for post-rehab services. 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.
If the client meets each one of these criteria, there is a strong possibility for insurance reimbursement, but you must contact the insurance claims adjuster directly and explain your conditioning program and outline the goals and benefits of the program. I also recommend sending the insurance carrier of copy of the conditioning program with the physician's approval attached.
Michael Jones, PhD, PT (drmike@postrehab.com) is the founder and president of the American Academy of Health, Fitness and Rehabilitation Professionals (AAHFRP), an organization dedicated to "Bridging the Gap Between Health Care and Fitness" (www.postrehab.com). Dr. Mike has over 23 years experience as an orthopedic and sports physical therapist. For more details on insurance reimbursement, please visit www.postrehabinsurancereimbursement.com.
