Navigating Out-of-Network Pelvic Floor PT Providers
Prefer to print it and write on it? Download the full guide and worksheet as a PDF to keep and fill out.
Download the worksheet (PDF)Many pelvic floor physical therapy practices choose to be out of network (OON) with insurance. Practices may do this because of low insurance reimbursement, the need for specialized one-on-one care, or simply to reduce the administrative burden of billing. Pelvic floor PT may be medically necessary as part of your endometriosis care, and there are often options for insurance coverage for this essential care.
Your three main options
Cash pay
Paying out of pocket is the simplest option. But PT is an essential part of endometriosis care — would you expect to pay cash if you tore your ACL and needed PT?
Out-of-network benefits
Depending on your plan, you may have OON coverage and be able to use it for your care. Your cost sharing will likely be higher than for in-network care.
Network deficiency claim
A network deficiency claim lets you pay in-network rates at an OON provider because the insurance network lacks in-network providers for your care.
Why file a network deficiency claim?
- Pelvic floor PT is often medically necessary for pelvic floor dysfunction and pain management. It makes sense to have your medical insurance cover medically necessary care.
- The in-network providers may not be experienced in endometriosis care. This is a more challenging claim, but still worth trying so you get the best quality care.
- There are long waits for in-network providers. You should not be penalized because the network cannot provide timely care — especially after surgery.
- None of the in-network providers are in your local area. Traveling for one specialist appointment or surgery may be feasible, but PT requires several sessions.
Out-of-network provider FAQ
Will any pelvic floor therapist be a good fit?
Pelvic floor therapists are often experienced in a variety of pelvic floor conditions. Because endometriosis — especially after surgery — can come with unique challenges, it is recommended to specifically ask about experience with endometriosis patients or other conditions where you need support.
If the network deficiency is approved, will the clinic bill my insurance directly?
Most providers will likely ask you to pay upfront and file for reimbursement on your own.
My PT provider offers a package for discounted care. Should I purchase the package?
It depends. If you are confident in the provider and your ability to complete the sessions, a package could reduce the cost. It may not be the best choice when first starting with a new provider, or if outside commitments may prevent you from completing the sessions.
Pelvic Floor PT Coverage Worksheet
Work through these steps with your insurance and providers. Download the printable PDF to fill it out by hand.
1. Contact your insurance to understand your in- and out-of-network benefits.
In-network benefits
Deductible:Coverage & patient responsibility:Additional limits for PT:Out-of-network benefits
Additional OON deductible:Coverage & patient responsibility:Additional limits for PT:2. Confirm in-network pelvic floor PT providers.
Ask your insurance for in-network pelvic floor PT providers, then contact those providers to confirm experience with endometriosis and appointment availability.
In-network provider Experience with endometriosis Appointment availability 3. If no in-network provider fits, look out of network.
Look for providers with endometriosis experience. Patient advocacy groups, online patient groups, and your gyn provider may have local recommendations.
OON provider:Phone number:Address:NPI:Tax ID:4. Gather what you need for a network deficiency claim.
- From your doctor: a prescription for PT including a diagnosis code.
- From your OON PT: cost per session, and the CPT codes that will be billed with the total billed for each code (several CPT codes are usually billed per session).
- From your insurance: the allowable cost for each CPT code.
Cost per session:CPT code Amount to be billed (PT provider) Insurance allowable cost 5. Request the network deficiency claim before starting care.
Your insurance will need the provider's information, your diagnosis code, and the CPT codes that will be billed. They may also contact the PT provider to verify care. Approval can take several weeks — it is your choice whether to begin care at your own risk while you wait.
6. Estimate your cost with an approved claim.
Responsibility for the difference between the amount billed and the allowable cost may vary based on balance billing laws.
In-network patient responsibility (copay, coinsurance)+difference between billed and allowable cost=total patient cost
+=Example 1: Network deficiency approved for an OON provider who bills $297 per session. In-network PT has a $50 copay, and the provider bills under the allowable cost for every CPT code. Total cost: $50 + $0 = $50.
Example 2: Network deficiency approved for an OON provider who bills $385 per session. In-network PT has a $50 copay, and the total allowable cost for the five CPT codes billed is $310. Total cost: $50 + $75 = $125.
7. Track your reimbursements.
Once approved, you will likely need to submit a "superbill" from your PT provider to your insurance after each session.
Date of service Amount paid Date submitted Date reimbursed
Note: This resource is for educational purposes only and does not constitute medical, insurance, or legal advice. Coverage rules vary by plan and by state. Always confirm details with your insurance company and consult a qualified healthcare provider about decisions affecting your health.