How to Win at the Insurance Game –
Get AMAZING RESULTS and SAVE $$$ by going Out-of-Network for your Physical Therapy!
What do Baseball, Pac-Man, Monopoly and Insurance all have in common??
Think about it… wait for it… yup, you guessed it. They’re all games!!
The difference is some are more fun than others and I’m thinking even if you feel Baseball is too boring it still won’t end up on the bottom of anyone’s list.
In all games there are rules/objectives to get to a desired destination. Whether it be a high score, a victory, ‘owning the board’ or to get to a state of better health.
We are going to touch on the last destination on that list, better health. Which will specifically bring us to (the game of) insurance and how to win at this game by GOING OUT OF NETWORK for your Physical Therapy…
Rule # 1/The Golden Rule:
The Game of insurance, as a business, boils down to one simple concept: Take in more money (premiums) than paying out (paying for treatments/procedures).
As a patient, the game comes into effect as to how you can use your insurance coverage once you have paid to play. And if you haven’t noticed at all (or greatly noticed!) the rules have changed A LOT in the past 10 years.
Statistics published in 2016 in Time Magazine show that while in 2006, only 10% of workers had high deductible plans (paying at least $1,000 out of pocket before insurance kicks in), today that percentage is a striking 51-65% of all workers currently!
If this trend continues as it has, more people will be moving to $5,000 -10,000 deductible range (which we are finding to be more and more common).
So with high deductibles like that it makes even more sense to stay in network, right?? Not quite… Since the game has changed, your approach may also need some tweaking if you plan on *winning*
Let’s do some quick stats on Physical Therapy for a High Deductible Plan:
Here is an average fee system for a standard PPO insurance plan on an in-network visit: $45 co-pay each therapy visit (limit 20-25 visits per year) and being in network, you are responsible for 20% of the bill each visit.
An average therapy plan of care includes attending therapy 2-3 times per week for 4–6 weeks for (of course this can vary by extent of current and past medical history for each individual).
Each therapy session lasts about 45-60 min, however most clinics have you work with your Physical Therapist for a small amount of this time and then hand you off to an aide or to do exercises on your own the rest of your session (while your therapist juggles several other patients at the same time). However, you are being billed for the entire time you are there, with an average price of $300-$700 per session.
For our calculations, let’s pick the midrange and say you’re billed $350/session. For most high deductible plans, you are required to cover the full cost of those sessions until you have met your deductible, then beyond that you still have to pay 20% of the session price plus a possible co-pay!
“Congrats!! You have met your 2017 $5,000 deductible!!” Is not the best Title Screen message at the end of this game, especially when you have only been playing for hardly a few months!
It’s like going to an arcade as a kid and popping in $20 of quarters into one machine and only making it through the second level but you have 3 more levels to go. You still want to play more and you wished your money went further in this game! It stunk then and stinks even more now!!
And now for Physical Therapy with a PPO Plan:
These plans often require copays which more commonly are $40-$45 these days. And/Or they will often require you to pay 20% of your bill. So with the same PT plan of care:
15 visits x $45 co-pays each session = $675
20% patient responsibility for the $5250 bill = $1050
If you’re responsible for both the copays and the 20%, yikes.
Every Plan is Different.
Each insurance plan is different. We highly recommend calling your insurance to know your PT benefits before you check out a clinic!
- Each plan has a different contracted amount of with they will ‘pay’ for PT (despite what the clinic may bill out).
- Some plans may approve 20 visits per year TOTAL no matter whether you have new injuries or surgeries.
- Some plans require “authorization” or “pre-approval” where your PT has to send in their evaluation notes for your insurance to determine how many visits they will agree to covering. The down side with this is that more and more plans are requiring PT’s to spend a large portion of your treatment session every 2-3 visits to re-measure everything just to justify you’re making progress. Taking away precious time from treating you!
Speaking of authorization/pre-approval requirements from insurance companies…
Here is another ‘Rule’ to be aware of in play at this time in the insurance game: Tiering
Tiering is when an insurance company or outside review company places different providers in different levels.
They decide they will pay more and require less paperwork for a PT clinic if they:
- See their patients for less visits on average (it doesn’t matter whether you actually complete your therapy or never return after one visit, your insurance just wants to pay for less visits!)
- The results of the care doesn’t matter for Tiering (whether you’re actually better or not)
- They are definitely not giving incentives for good patient care with these rules are they?!
- If you go to a poor-quality provider for even 3-4 sessions and they send you home with exercises but you feel no better, you probably have wasted possibly around $1,000.
But What if There Was a Better Way??? YES!!! There Is!!!!!!
Now before I go on, one thing I would like to clarify is this… Just because you go to a place that accepts insurance, does by no means, conclude you are getting inadequate care. Many in-network providers give great one-on-one care! And if you have met your deductible or plan to, in-network care can be a great option. As with any self- monitored healing journey you must always test (trying some treatment) and re-test/assess (asking, most importantly, yourself, and then your therapist ‘is this benefiting me’?)
We just want to make sure if you are not getting the results you want, we can help you navigate the system to a better place… To give you a boost, like giving you $200 for passing “Go”!
So here is your Power Pellet, Pac-Man (gobble some ghosts!). Your Monopoly Hotels, your ‘Check Mate’ Bobby Fisher… Get greater specialized one-on-one care at an out of network Physical Therapy provider. Why??
- Full one-on-one time with a therapist (Balance Within has 1 hour sessions)
- Your Therapist is not under the mercy of the insurance company, performing extra time consuming measurements and paperwork that take away from your care and progress
- That means greater hands-on specialized care (such as John Barnes’ Myofascial Release) while treating holistically! (“Yes, insurance company, that twisted pelvis and rotated spine is affecting this patient’s neck!”)
- Sessions are billed at a reasonable flat fee per session (you can still submit this to your insurance to get applied to your deductible, for whole/partial reimbursement, or pay with your HSA!!)
- LESS SESSIONS are needed – also saving you valuable time and $$$! Our average patient sees us 6-8 sessions TOTAL with a frequency of once/week (more required for more chronic/complicated cases).
- Small, private clinics don’t have to deal with all the red tape and CAN SEE YOU WITHOUT A DOCTOR’S PRESCRIPTION in Wisconsin! Saving you $$$ to avoid that MD or Urgent Care visit and imaging that may not be necessary. As Doctors of Physical Therapy, we are licensed in WI to see you without a prescription. With our extensive training, we can evaluate you, let you know what might be causing your symptoms and let you know whether there are any red flags that mean you should see an MD or get imaging (Xray, MRI, etc).
- Small, out-of-network clinics often offer specialized niches, ours is chronic pain/John Barnes’ Myofascial Release and Women’s Health (many of our patients have tried other clinics with limited results then come to us and we’re able to help them feel better, no matter how chronic their condition is!)
- You’re always seeing the same therapist, not jumping around!
- BOTTOM LINE: You can get better FASTER!
- …And can save yourself THOUSANDS of dollars!!!
And so with that power-packed info, for your physical ailments there is plenty to gain… So take control of your health and win the game!!
All our Best Wishes,
Drs. Jereme and Sarah Trunk, PT, DPT
P.S. Whew! This is a complicated topic and this was only the tip of the iceberg! As always, please know we are here to answer your questions, just give us a call!