Why Be Out of Network?
We have noticed an unfortunate trend in physical therapy. A patient's care is often dictated by their insurance company, down to what treatments can be provided and for what reason.
Some real world examples
-"We don't see patients without a referral. The patient needs to go to a physician first for insurance to cover PT."
-"We only have 6 visits. Insurance denied anything further"
-"No dry needling for this patient. Their insurance does not cover it."
-"Don't provide any treatment on the first visit. We are waiting for insurance to approve treatment."
-"We can't provide sport performance rehabilitation. It's considered 'not medically necessary' by insurance."
Adding to the strained system, insurance companies continue to cut reimbursement to physical therapists. Most clinics now see 2 to 3 patients at a time in order to stay open. Quality is traded for volume. As you can imagine, patient care suffers. The result is more visits needed, higher cost to the patient, and a poor healthcare experience.
Being out of network allows us to provide care that is higher quality, more accessible, and often at a lower cost.
Let's Explore Cost Effectiveness
The out of network PT model provides a framework to make healthcare more cost effective than insurance based models. It is natural to be concerned with cost. We believe that our model is actually more cost effective for the patient. Let's explore some scenarios that occur in insurance based PT clinics.
Scenario 1: You Have Not Met Your Deductible
-You are responsible for 100% of costs (usually thousands of dollars out of pocket) before insurance begins to pay for any services.
-You may have a copay (usually $20-$50) per session- 2-3x per week.
-Once the deductible is met, you usually are then responsible for a percentage of costs (Coinsurance) until your annual "Out of Pocket Max" is met. Most "out of pocket maximums" are around $7000-$8000 annually.
-When insurance companies are being billed, charges are generally higher than out of network rates. Sometimes, patients end up being billed $200/visit.
- Due to being seen concurrently with 1 or 2 other patients, you require more visits(and more copays) and still may not get the outcome you want.
Scenario 2: You Have Met Your Deductible
-You likely are still responsible for coinsurance until the annual "out of pocket max" is met.
-You may still have a copay
-You likely will still be seen concurrently with 1-2 other patients and will receive lower quality of care.
The craziest part is that in both scenarios, you don't know the true cost until you have already received the service! Imagine you are trying to buy coffee at a coffee shop. You ask the cost, and the person behind the counter says "I'll tell you after you drink the coffee." You would find another coffee shop! This is the unfortunate reality of insurance based clinics.
Finally, we provide a superbill to patients with each visit that patients can submit to their insurance company for reimbursement. The amount depends on your plan, but often patients can recieve reimbursement for a portion of costs via "out of network benefits."