One of the biggest challenges in the healthcare industry, as well as in your own personal finance, is navigating health insurance. It’s a headache, and it’s confusing. We understand that. We’ve been on the consumer side ourselves, so we know all the frustration that can come with using health insurance. Let’s talk about some of the bigger issues, and why we choose to be an out of network practice.
First, let’s define out of network practice. This means, that we are healthcare providers that are not contracted with any insurance agencies. You may think this is a mistake by us, but we are going to go over whey we don’t contract with insurance.
As healthcare providers, we have worked very hard for a long time on developing skills and systems that help you get rid of pain, overcome obstacles, and reach your goals. Everyone agrees that we want this for you. No dispute there.
However, when we are contracted with an insurance agency, we are limited as to how we use those skills and systems to help you. What you may not see on your side, is that insurance limits you to how many visits we get to see you, what procedures we can do with you, and for what reasons we get to work with you.
The good news is, by being out of network, we don’t have those limitations. We can see you as often as needed, for as long as needed, and for whatever issue we want to work on. No need for physician appointments, referrals, imaging, injections, or pre-approval. If you’ve got a problem we can solve, then come on in and let’s get solving it.
A study I read a few years back reported that the average time from an injury to treatment was 15 days. That happens when you get injured, you go see your primary care doctor, they refer you to a specialist, you get imaging done, go back to the specialist, and then finally get sent to physical therapy. You’ve waited over two weeks, drove to, waited for, and sat in four appointments, not to mention paid four co-pays, only to end up where you should have gone within the first day or two. At day 15, you still have had no relief, and you likely have made it worse by compensating how you move. You may have needed medication for relief, but that hasn’t fixed anything, and it’s only masked the problem.
That’s a frustrating two weeks that could have been avoided if you just went right to physical therapy. Most times, we can help you feel better immediately, and help you understand what is going on. We are movement experts. We are injury experts. We are specialized in helping you move and function pain free and efficiently.
In every state, physical therapy has some form of direct access. That means, you don’t need to see your primary care physician to have physical therapy. In Vermont, we are able to see you without any need for a physician referral. It is our job to diagnosis your needs, and that includes if you need to be sent to your primary care physician, see a specialist, or even have imaging done. While most injuries we can treat without expensive testing, we are also trained to identify when you do need more testing, and when you need to see another healthcare provider.
If you’ve been told that you need to see your physician and have a referral for physical therapy, then that’s a rule your insurance company has. That is not a rule in Vermont, and it is not a rule for physical therapy.
If you’ve previously been to physical therapy, you know that at some point the conversation happens that we are only approved for so many sessions, or we can only bill for this skill this many times. Or even more frustrating, sometimes you need to go back to your primary care physician before we can continue the progress you’ve already been making.
Also, if you’ve previously been to physical therapy, you likely had the experience that your therapist was working with you and another person, or two, or three, all at the same time. This is allowed by insurance, and for high volume clinics, this can be a real financial boost.
By being out of network, and working individually with you, we are leaving money on the table. We are comfortable with that though. We would rather have individual time with you, and have a great relationship with you knowing that you got what you wanted out of working with us.
Here is what I think is the biggest kicker to healthcare insurance. Over the last decade, health insurance premiums have gone up. Not a big surprise as everything gets more expensive overtime. What has also happened though, is that healthcare deductibles have also gone up., much more than premiums or earnings. This means, you have more out of pocket expense before your benefits kick in.
Even if you go to an in-network provider, you still may have to meet your deductible. Unfortunately, you may not find this out until you’ve already been to several sessions. This is the scenario where you get a bill months after you started therapy. In network clinics can charge $100-$350 per session. That’s tough to accept after your 10 sessions in, and you’ve only worked with your physical therapist for 15-20 minutes per session.
While everything we talked about has being a patient in network can be challenging, we have plenty of difficulties as providers too.
As a physical therapist, it is exhausting to have a day full of 2-4 clients at a time. It’s frustrating to have clients that are doing well and have their care stopped or paused due to rules about what services we can offer, how often we can provide them, and the need for physician follow ups.
Also, insurance companies have lots of back end hassle including paperwork, submitting bills, and documentation. So many forms! And waiting on hold for so long!
All that work takes us away from focusing on you.
This blog post could go on and on, but here is a summary to wrap it all up. Check out this graphic about two paths. Out of network private pay vs in-network insurance based. Less visits, less cost, and more time with the expert you’re working with. #snowbeastperformance
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