Out-of-Network Provider Notice for UHC Patients

This clinic is not an in-network provider with UnitedHealthcare. UHC’s reimbursement rates are too low for a single-practitioner clinic to sustain high-quality, one-on-one care. Many large clinics accept these lower rates because they treat multiple patients at the same time, often leading to less individualized attention and lower-quality care.

I choose not to follow this model because I believe personalized, focused treatment produces the best results for my patients.

What This Means for You

• Higher Co-Pay: Since I am out-of-network, your co-pay for each session will likely be around $60 per visit.

• Partial Reimbursement: Some UHC plans allow you to submit claims for partial reimbursement of out-of-network therapy costs.

• Verify Your Coverage: I encourage you to contact UHC to confirm your out-of-network benefits before starting therapy.

If you value personalized care and one-on-one therapy, I believe the quality of treatment provided here makes the higher co-pay worthwhile.

Non-Covered UHC PT Services

Non-Skilled or Custodial Care

UHC does not cover therapy that does not require a skilled therapist's expertise. This includes exercises that can be learned and performed independently, general movement programs that do not need therapist adjustments, and therapy that is provided only for monitoring rather than hands-on intervention.

For example, if a patient is doing a basic home stretching routine that does not require therapist input, UHC will not cover ongoing sessions.

Maintenance Therapy

UHC does not cover therapy aimed at maintaining function rather than improving it. This includes general fitness programs, conditioning exercises, and long-term therapy for maintenance when a home exercise program could be used instead.

If a therapist establishes a home program to maintain strength, ongoing therapy sessions may not be covered unless the patient requires ongoing skilled intervention.

Duplicative Therapy Services

UHC will not pay for overlapping therapy services provided by different therapy disciplines. If a patient is receiving PT and OT for the same condition, UHC may deny one of the services. Similarly, if speech therapy is addressing swallowing difficulties, UHC will not cover PT for the same issue.

Work Hardening & Conditioning

Therapy programs that are designed to prepare an individual for returning to work rather than restoring medical function are not covered. UHC considers ergonomic training, workplace injury prevention, and vocational rehabilitation to be outside the scope of physical therapy benefits.

For example, a PT session focused on improving lifting mechanics for work would not be covered unless it is part of an injury-related rehabilitation program.

Experimental, Investigational, or Unproven Treatments

UHC does not cover treatments that lack strong clinical evidence or are considered experimental. This may include certain electrical stimulation techniques, alternative manual therapies, and interventions that are not supported by research.

For example, if a clinic offers an unproven biofeedback device for pain management, UHC may deny coverage due to lack of validated research.

Recreational or Non-Medical Activities

Therapy focused on recreation, leisure, or sports performance is not covered by UHC. This includes therapy sessions incorporating dance, music, or drama therapy, as well as swimming programs that are not billed as aquatic therapy with an approved CPT code.

For example, if a PT session is designed to improve an athlete’s running speed, it will not be covered since it is considered performance training rather than medical rehabilitation.

Educational Therapy

UHC does not cover therapy that is primarily educational rather than medically necessary. This includes services provided in schools that should be covered by an Individualized Education Plan (IEP), as well as sessions focused solely on patient education without hands-on skilled treatment.

For example, if a therapist spends a session teaching a patient about posture correction without providing direct intervention, the session may not be covered.

Durable Medical Equipment (DME) & Assistive Devices

Physical therapy benefits under UHC do not cover medical devices or equipment. Braces, orthotics, mobility aids, and wheelchair seating assessments are typically covered under DME benefits instead of PT benefits.

If a patient needs a custom wheelchair fitting, this service may not be billable under PT and should be processed through a DME provider.

Therapy Solely for Convenience

PT services requested for convenience rather than medical necessity are not covered by UHC. This includes therapy that is requested by a patient "just in case" after an injury, as well as services provided for legal, insurance, or administrative purposes rather than direct medical treatment.

For example, therapy requested for a workers' compensation claim evaluation without an active treatment plan may not be reimbursable.

Services That Do Not Follow Medical Necessity Guidelines

UHC requires that all therapy services demonstrate functional progress. If a patient is not improving and the treatment plan is not adjusted accordingly, further sessions may be denied.

Similarly, if a patient fails to follow home exercise recommendations and does not progress, UHC may deny further sessions due to lack of compliance.

Key Considerations for UHC Coverage

• All PT services must be medically necessary, skilled, and goal-directed.

• Pre-authorization may be required for certain treatments.

• State-specific Medicaid/UHC Community Plan policies may have additional exclusions.

• Out-of-network providers (such as this clinic) typically have higher co-pays, around $60 per session.

If you have questions about UHC coverage, I recommend reviewing your specific policy details or contacting UnitedHealthcare directly.

Why Choose This Clinic for Your PT Care?

Even though I am out-of-network with UHC, my clinic prioritizes one-on-one, patient-centered care, ensuring you receive the highest level of treatment.

Unlike large chain clinics that double-book patients, I offer:
✅ One-on-one therapy sessions without interruptions.
✅ Customized treatment plans designed for your unique needs.
✅ Hands-on, skilled therapy instead of generic exercise programs.

Many patients find that the quality of care here is worth the slightly higher co-pay. If you value personalized, effective therapy, I encourage you to reach out and discuss how we can work within your insurance plan.