When many people hear the term “Out-of-Network,” they generally assume that this is not the route for them, and that they must find an “In-Network” provider in order to justify all the money they pay for their health-insurance, and belief me I have also found myself stuck in that mindset at times, BUT…
In many instances, specifically with high deductible plans, people don’t read the benefits of their plan that they have elected for. All these confusing words… Deductible, Co-pays, Coinsurance, Premiums…what does all this mean? Many times we assume insurance will cover “____.” Hardly is this the case though.
In our present state of healthcare, there are significant disadvantages and expensive measures that insurances put in place to avoid paying for services. YES, Insurance will come in handy to save you from paying an exuberant $200,000 Hospital Bill following an unexpected health crisis, but with more an more emphasis being placed on company “profit margins” there is significant drive to avoid paying for the smaller things. The system is failing due to many issues.
In this day and age, where it pays to be proactive and not reactive in regards to your health, the focus should be on quality of care over quantity and convenience.
So, how can seeing that out-of-network physical therapist save time and money?
This is often a question I receive and educate many of my patients on. You see… how much time do you really get to spend with the physical therapist in a traditional outpatient physical therapy setting? Well the surveys are in, and it is generally around 15-20 minutes (yes, this is because of insurance coding and reimbursement). The rest of the session is generally spent with support staff or with your physical therapist shouting out your next exercise while he or she is working on another patient (for their 15 minutes). The cycle continues like this. Let’s now look at the average co-pay which is anywhere from $25-$75 for a specialist (we’ll go with $50 for this example), and your script requests 2-3 visits a week for 4-6 weeks (we’ll pick 14 visits for this example). So 14 visits x $50 = $700 just in co-pays. We can then look at the ever rising High Deductible ceiling which is now anywhere from $1000-$7500 (or more). So if your deductible has not been met, you will also be responsible for the visit cost (billed amount-adjusted amount) which varies based on insurance and clinic, but typically runs between $100-$200 (or more depending on your coverage). Based on these numbers you will be looking at a minimum of $1700-$3500 in direct costs for a typical out-patient course of care for 14 visits on a high deductible plan. Side-note There are clinics in the in-network insurance model that still perform 1 on 1 care but are few and far between, likely in Hospital settings with extremely high single visit charges (due to another myriad of reasons that we won’t get in to).
Next, lets now add up (the indirect costs) the time spent driving to therapy, at the session, and then drive home. We can average this to about 1 hours per session times 3 and you are looking at 3 hours per week. Is spending more time in the car driving to physical therapy what you want to be doing?? What is your time worth to you?
How does this compare to a typical out-of-network clinic?
Most clinics that operate in this space have the time to focus on quality of the visit over quantity of visits because they do not have to rely on insurance reimbursement or account for high overhead costs in their budget. The therapist has much more time to spend with the patient, typically 1 on 1 for an hour session, focusing on manual therapy treatments and working on specific exercises that may simulate the hobbies or recreational activities you are trying to get back to. I’m not saying this doesn’t happen in traditional OP clinics, it’s just the time and attention to detail is significantly less. With this in mind, the OON physical therapist can accomplish as much in 1-60 minute session as sometimes gets accomplished in 3 in-network sessions. The therapist not only has more time with hands on treatments and 1 on 1 focus for form and exercise correction, but they can also spend the whole time educating the patient on what typical progression looks like, pain neuroscience, return to running etc.. Also, due to having a smaller overall patient caseload, their is generally more time for between session follow-up (keeping you accountable for your programming). The average plan of care in this model is 6-8 visits vs 14-16 in the traditional in- network model.
So, if we do the same math as above (at say a per visit rate of $175) we would be looking at $1000-$1400 per episode of care. So, the direct cost upfront is less due to frequency of visits, and another benefit is that you know exactly what you are paying up front (no mystery bill 3-6 months later ). Plus, there is the added benefit of gaining back nearly 2 hours in your week. How valuable could those 2-3 hours be to you at work or spent with your family?
The math is there to show the value of the Out-of-Network therapist if you are generally healthy and looking for quality of quantity.
I know when it comes to health, we all want the best…and at the lowest cost…because after all, we paid for our “health” insurance. But remember cheaper is not synonymous with better or a better experience. You just need to ask yourself, what are your priorities and values when it comes to your health.