What are the most common Physical Therapy billing surprises?

The most common: (1) an out-of-network provider at an in-network facility, (2) multiple bills from different providers for one procedure, (3) prior authorization issues, and (4) facility fee differences between hospital and freestanding settings.

What is the No Surprises Act and how does it protect me?

The No Surprises Act (effective Jan 1, 2022) bans balance billing from out-of-network providers at in-network facilities and from out-of-network emergency providers. Your cost sharing is capped at what you'd owe in-network. You cannot be sent a balance bill - dispute any attempt immediately.

What should I do if I get a bill I didn't expect?

First, request an itemized bill. Then compare the CPT codes to what your physician ordered. Check your Explanation of Benefits (EOB) to see how your insurer processed each line. If there's a discrepancy, dispute with your insurer (not the provider) in writing.

How do I read my EOB to find billing errors?

Check: (1) CPT codes match the procedure ordered, (2) the provider is processed as in-network if they should be, (3) the allowed amount matches what you were quoted, (4) deductible and coinsurance applied correctly, (5) Member Responsibility column equals only what you should owe.

Rehabilitation

John Caruso, FSA, MAAA • June 26, 2026 • 7 min read

The biggest Physical Therapy billing surprises involve separate bills from multiple providers, prior authorization gaps, and out-of-network providers at in-network facilities.

Not sure if it’s worth disputing your bill? Run it through our quick, free bill screener first.

Physical Therapy Billing Surprises: What Patients Don't Expect (2026)

Physical therapy billing surprises most often involve hitting the annual visit cap unexpectedly, being denied coverage because therapy is classified as "maintenance" rather than restorative, or discovering that re-authorization is needed before your next block of visits. Here's what to watch for.

Common Physical Therapy Billing Surprises

Surprise	Why it happens	What to do
Visit cap hit mid-treatment	Plan's annual PT visit limit reached	Track your remaining visits; request re-authorization before running out
Claim denied as "maintenance therapy"	Insurer says you've plateaued - therapy is maintaining, not improving	Appeal with PT progress notes showing measurable functional improvement
Re-authorization lapsed	Treatment continued past authorized block without new approval	Get re-authorization before the previous block expires
Initial evaluation billed at higher rate	CPT 97161/97162/97163 is priced differently than treatment sessions	Expected; first visit is always higher
Modality not covered	Plan excludes certain therapy types (electrical stim, ultrasound therapy)	Review plan benefits before starting specific modalities
OON physical therapist	Patient chose a PT outside their network	Out-of-network PT is typically reimbursed at lower rates or not covered

The Maintenance vs. Restorative Distinction

The biggest ongoing battle in PT billing: your insurer claiming therapy has become "maintenance" and stopping payment.

What maintenance means: You've reached the highest level of function you're expected to achieve, and PT is now just preventing decline - not improving function.

How to fight a maintenance denial:

PT progress notes must show measurable, objective improvement at each reassessment - functional scores (e.g., DASH, Oswestry), strength measurements, range-of-motion degrees
Goals must be time-bound and achievable - not "maintain current function"
If denied: request the specific insurer criteria for "maintenance" and have your PT document why each session meets the restorative standard
Appeal with progress notes comparing baseline to current functional status

Red Flags on Your PT Bill

Red flag	What it means	What to do
Per-visit cost suddenly higher	Crossed into a new authorized block with different terms	Confirm re-authorization was obtained; review new allowed amounts
Claim denied for "not medically necessary"	Plan of care documentation gap	Ensure referring physician's plan of care is current and on file with insurer
Modality charge denied	Plan excludes certain PT modalities	Review benefit summary; ask PT to substitute covered modalities
Visit count higher than expected	Each day = one visit; some practices bill evaluations separately	Confirm visit count with PT practice

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About the Author

John Caruso, FSA, MAAA

Healthcare actuary with 20+ years of experience in insurance pricing, medical billing systems, and healthcare cost analytics.

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