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  • Writer's pictureJason Burtchell, PT, Cred. MDT

The Insurance Game, and what you give up by playing it

One of the most common questions that I've been asked is whether or not I take insurance. When I answer that I am using a private pay model, there is a palpable pause in the conversation and look that generally conveys "why on earth would you do that?"

Being private pay means I get to work for you, the patient and not the insurance company. What patients and providers often don't realize is that "private pay" does not mean "expensive" or "not cost effective." In fact, in many situations private pay is a more economical way to buy your care. Below I'll explain what private pay can mean for you, the patient, and how it may save you money and will most certainly get you more value for your dollar.

Insurances will generally have "in network" and "out of network" benefits. An "in network" provider will contract with the insurance company to take a certain (usually reduced) rate for services provided. An "out of network" provider does not contract with the insurance company and therefore does not need to negotiate a reduced reimbursement rate. How does that affect you, the consumer? Let's take a look at "in network" models first.

In Network Physical Therapy Models

When a physical therapy clinic negotiates to be considered "in network," they are generally accepting a reduced rate of reimbursement in order to have greater accessibility to a larger patient population, meaning they can provide increased numbers of visits and offset the reduced reimbursement by simply seeing more patients. So how do you do that? There's only so much therapist to go around! There are a few models:

  1. Shorter Treatment sessions: one way to increase the number of patients you see in a day or week is to keep treatment sessions short. Often sessions are 25 to 30 minutes. This will often necessitate a patient attending therapy more frequently as there is only so much you can get done in that amount of time. This is usually a one on one model (a plus for quality) but may result in increased visits per week or over the total duration of care. Most insurances will require a co-payment each visit. If you have a $50 co-pay every visit, this can add up over the course of a week or over the total duration of care.

  2. Multi-tasking Physical Therapy: In my opinion a poor care model, as this requires the therapist to manage more than one patient at the same time. In other words your appointment may be double booked with another patient at the same time. This is a common model in some private and most if not all corporate therapy models as it will most effectively drive a positive bottom line. Theoretically your physical therapist will "monitor you" from across the room while providing care to his other patient and then eventually switch. Bear in mind that for this to be billed ethically there would need to be a clear line of sight from the therapist to the patient. The reality is that this often doesn't happen. What it always results in is: less effective instruction from your physical therapist while you are exercising, with patients often being left on their own (begging the question: why come in to the clinic at all if you could just have done it at home?) to do exercises; a constantly distracted therapist who is trying to perhaps do manual work on one person while somewhat paying attention to another patient and generally doing a poor job with both. It may lead to increased time in the clinic (and therefore even more overlap with the next set of double booked patients). I've never seen it done well, and I cringe for the poor patients who could be getting so much more for their time and effort. Mind you, you're still paying that same co-pay. There's no discount for sharing your appointment time with someone else. So that same $50 dollar co-pay from scenario 1 is now buying you perhaps 10-15 minutes of "one on one" time with your therapist for each session- a 50-60% reduction, and with the added disadvantage of knowing that your physical therapist is not 100% focused on what your needs are. How could they be when there is another patient who also needs their attention?

Out of Network, or Why I decided to try the Private Pay Model

An "out of network" physical therapist has elected not to negotiate with insurance and instead work more directly with the patient. Let's restate this for what it is: In-network providers work for insurance companies. Out of network providers work for patients. Here's what that means for the patient who comes to Resilience Physical Therapy and Wellness, LLC:

  1. One-on-one treatment every time for as much time as you may need. If you are coming in for your first visit or a follow up you can plan on spending 45 to 60 minutes in a one on one setting with your physical therapist who is focused on your problem and your needs only. This allows for a more in depth and meaningful therapy experience that is catered to your individual needs. Your back pain is going to impact you differently than another person's back pain, and should therefore be treated according to those needs. A shorter treatment session means "starting over" more often as the session stops almost as soon as it begins; I find that some of the most meaningful discoveries and achievements happen for my patients in the back 1/2 of a 45+ minute session. It also allows for improving your understanding as to how to do exercises and movements well, which simply won't happen if your physical therapist is paying attention to someone else.

  2. Achieve your goals more efficiently as you learn how to self treat. The private pay/out of network model tends to push the physical therapist and you, the patient, to be more efficient with the care delivered. In order to remain cost effective and competitive, and as a direct result of the one-on-one model, you should have to see your physical therapist less than you would in the more traditional models. Remember: the goal of most in-network models is to get you to come in as often as possible. More visits = more money. If you are paying out of pocket (which you may be able to get some reimbursement for, more on that later) you are likely to see your physical therapist less over time. This is why the model in #1 above is so critical: if you're seen less over time, you should make sure you're getting everything out of every visit that you can.

  3. It's usually not as expensive as you think- it may actually save you money. Say what? But seriously, in many cases this is the truth. Let's spell out some scenarios, purely financial, where private pay may actually cost you less:

    1. You have a High Deductible Health Care Plan: These plans are more and more common and involve you, the consumer, to be responsible for a significant deductible prior to your insurance helping pay for care. This varies significantly from plan to plan, so it's important to check with your insurance provider for details. Let's say your plan has an $8,000 deductible and your physical therapy won't be covered until your deductible is met. Go to your "in network" provider and your visits may cost you north of $300 per session. Why? That's generally the cost of a visit billed to your insurance, you just don't see it if you only have a copay. If you see your private pay physical therapist, cost is going to be reduced by over 40% for a visit! By the way, most of the time these will both count against your deductible.

    2. You have Out of Network benefits. Most insurances will have an "out of network" benefit (again, check with your provider) meaning that you would pay up front, then turn in your receipt to your insurance and get reimbursement. Each insurance plan is different, so it's important to call ahead and find out how much you may get back for each visit. Often times the reimbursement is very comparable to what a more common "co-pay" would reimburse.

TLDR: Like most things in life, you get what you pay for. If you want high quality, individualized care with one on one attention then seeing an out of network (or private pay) physical therapist such as myself is something to strongly consider. I have worked in nearly every setting (home health, skilled nursing, hospital, private and corporate practice) over my 20+ year career, and have come to the conclusion that the best care model for my patients is the one in which I can focus on the patient in front of me. I invite you to experience the difference.

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