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Insurance. Reform. Why providers are moving from in-network to out-of-network, fee for service model

Updated: Feb 17, 2020

Cash based, fee-for service, physical therapy

Most frequently asked question: Do you take insurance?

Answer: No, I do not take insurance.

Second most frequent question: Why?

Answer: Im glad you asked.

I understand you pay for insurance so you'd rather go somewhere you can use it vs. spend more money. What if I told you an out of network provider would save you time and money in the long run? I've worked at insurance based clinics for 10 years and its time to throw a truth bomb, dispel some myths, and share my WHY.

First and most important, patients, clients, athletes, you my priority. I work for you. I do not work for insurance companies. I want to save you time. I want to save you money. I want to get you back to doing what you love, and living your best life. You think the insurance associate has the same goal in mind?

Did you know that you can see a Physical Therapist without a MD prescription? Don't wait 3 weeks to see your MD only to pay a $40-60 copay for them to tell you to see a specialist which means waiting another 3 weeks to get in, and pay another $40-60 copay for them to tell you to go see a PT.

6 Weeks and over $100 later you're working with a PT. Did you know that most injuries when managed properly, sooner vs later, are resolved within 6 weeks. You could've been better by now.

Still not convinced?

Did you know that medical providers have to submit their findings to insurance, and wait for the insurance company to "approve" treatment? Insurance companies tell the provider how many visits are allowed, and what interventions can be performed. A very small number of insurance associates have medical training. That's like walking into a coffee shop and asking the barista to fix your hip pain so you can return to running.

Thanks, but no thanks.

Wait theres more....

How many of you have you ever asked your provider to estimate the cost of a procedure? If you have, then you've likely realized they can't. The truth is, everyone pays a different amount based on the insurance companies negotiated rate with hospital and provider that is providing your care. This means that Sally and Samantha might have the same exact injury, receive the same exact care from the same exact provider, but pay very different rates only because their insurance companies are different.

Thanks but no thanks.

We all anxiously await that EOB, and we're all shocked at the cost of 1 therapy session. The average cost of a therapy session ranges from $200-400/hour. Thats a large range! That hour is often shared with 1-2 other patients which means you see the PT 1v1 at most, for a very rushed,15-20 minutes.

Are you putting 2 and 2 together? For those that haven't keep reading...

There's been a shift to high deductible insurance plans. The average deductible is about $2000, and after that theres usually a 20% coinsurance until a $5000-7000 out of pocket max. This means your paying that $200 to 400 therapy bill you shared with 2 other people. Because of the constraints the therapist is working under you schedule 1-2x a week for 4-6 weeks. Thats about 10 visits, totaling $2000-4000. There goes your $2000 deductible, and your still paying 20%, $40-80, every visit until you reach your out of pocket max.

If thats not enough, have you ever thought about how you were "assigned" to your PT?

Maybe they were the first available, maybe their schedule matched up with your needs, but are they really the best for your injury? If you need lasik eye surgery are you going to go to a podiatrist (foot doctor) because they can get you in faster? Thanks, but no thanks. Start shopping for your PT just like you shop for a doctor to perform a surgery. You want the best, right? I digress, let's keep that for another blog post....

When you cut insurance out of the mix, and allow the provider to make the rules, you get timely, quality care at excellent value.

Providers that are out of network with insurance companies get to make the rules. They treat patients when and how they determine is best, which in most circumstances is one on one care. This means we cover a lot of ground in very few visits. Patients are seen 2-4 times over the course of months. Much different from the traditional, insurance based therapists that see patients 2x a week, every week, for months. The price is a flat fee, always the same no matter who, or what walks in the door, and a fraction of the cost you pay at insurance based clinics.

Final word

Don't be quick to dismiss out of network providers. It is scary to think of paying out of pocket while also paying to maintain insurance. Consultations with these providers are usually offered for free. Ask questions. Educate yourself. Find the provider that will serve you best. We are talking about an investment in your health, wellness, and happiness after all. In most cases you're going to save money. You can use an HSA or FSA to pay. If you don't have an HSA or FSA, then the monies you do spend can be applied towards tax write off, and your out of network deductible. If your out of network deductible has been met, then you are eligible for out of network reimbursement.

Author Bio:

Dr. Erika Patterson, PT, DPT, OCS

Dr. Patterson is a Doctor of Physical Therapy, APTA board certified Orthopedic Clinical Specialist,

with advanced certifications in manual therapy, dry needling, RPR, and specializes in Endurance & Multi-Sport Athletes.

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