Understanding Out-of-Network Billing: What You Need to Know About Balance Bills and Allowed Amounts

At MovementX, we’re committed to providing high-quality, personalized care. Our physical therapists often work outside of traditional insurance networks so they can spend more time with each patient, offer one-on-one care, and tailor treatment plans to meet individual needs.

That said, we understand that dealing with insurance can be confusing – especially when you hear terms like “allowed amount,” “limiting charge,” or “balance bill.” This guide is here to explain what those mean and how they affect your out-of-pocket costs when working with an out-of-network provider like MovementX.

What is an “Allowed Amount” or “Limiting Charge”?

Insurance companies decide what they believe a physical therapy session should cost. This number is called the “allowed amount” or “limiting charge.” It’s not based on the actual cost of delivering high-quality care, but rather on what the insurer is willing to reimburse.

When a provider is in-network, they agree to accept this amount as full payment, even if it doesn’t fully cover the cost of care. This can force providers to shorten visits or double-book patients just to stay financially afloat.

Since MovementX therapists are out-of-network, they aren’t bound by these rates. Instead, they’re able to set fair, sustainable prices that reflect the level of time, attention, and expertise they offer. This allows them to focus entirely on your care without compromising quality.

How Reimbursement Works with Out-of-Network Care

When you see an out-of-network provider, your insurance may still cover a portion of the visit. However, it’s important to understand that your insurance will base this reimbursement on the allowed amount, not the actual price you paid.

Let’s look at an example. Suppose:

• Your MovementX therapist charges $185 for a one-hour session
  
• Your insurance sets the allowed amount at $120
  
• Your plan covers a 70% coinsurance for out-of-network care

In this case, your insurance would reimburse 70% of $120, which is $84. That means you would be responsible for paying the full $185 upfront and could expect an $84 reimbursement. The remaining $101 would not be reimbursed. 

The difference between the allowed amount and the therapist’s rate is known as a balance bill. In-network providers aren’t allowed to charge this, but out-of-network providers can. That’s why it’s important to understand how your plan works and what you might owe.

Why We Can’t Predict Your Reimbursement or Balance Bill

One of the most frustrating parts of navigating out-of-network care is the lack of transparency from insurance companies. Unfortunately, insurers do not disclose their allowed amounts to out-of-network providers ahead of time. These rates can vary significantly depending on your insurance plan, the company, and even the specific policy you have. Because of this, MovementX cannot accurately predict how much your insurance will reimburse until after the claim is processed.

That said, if you’re interested in finding out what reimbursement you may receive, we’re happy to provide a list of the billing codes we commonly use. You can share these directly with your insurance company, and they may be able to disclose the specific allowed amounts for your plan. This can give you a clearer picture of what your out-of-pocket costs might look like before starting care.

Is This Considered Surprise Billing?

Not at MovementX. We believe in full transparency, and we align with the protections laid out in the No Surprises Act, which ensures patients know exactly what they’re being charged for before receiving care.

When you book with us, you’ll see your therapist’s rate clearly listed on their profile. You’ll also receive a breakdown of the expected cost for your session before your visit. There are no hidden fees and no unexpected bills after the fact.

Why MovementX Operates Out-of-Network

Our model gives us the flexibility to put patients first. By staying out-of-network, we can:

• Spend a full hour with each patient
• Avoid overlapping or double-booked appointments
  
• Build truly personalized treatment plans
  
• Recruit and retain expert therapists who prioritize quality over quantity

What to Keep in Mind

The key takeaway is that reimbursement is based on your insurance company’s allowed amount, not the rate you pay your provider. Since allowed amounts are usually lower than the cost of care, you may be responsible for the difference. This is known as a balance bill.

At MovementX, we believe that transparent pricing, honest communication, and exceptional care go hand in hand. We’ll always make sure you know what to expect, and we’ll continue to advocate for a better, more sustainable model of care that puts people first.

Need Help Navigating Your Insurance?

We understand that benefits and claims can be overwhelming, and we don’t expect you to figure it all out on your own. Our insurance support team is available to answer your questions and help you better understand your out-of-network coverage.

You’re always welcome to reach out to us by phone or email, and we’ll do our best to respond within 24 hours.