Monday, April 8, 2019

Why Don’t You Take My Insurance?

Cash-based Physical Therapy is gaining a lot of interest from both clinicians and patients due to the emphasis on quality of care over the quantity of patients. This setting allows for one-on-one appointments with a doctor of physical therapy, a full 60 minutes to address all of the patients needs, and a faster and more thorough rehabilitative process.

Unfortunately insurance creates multiple challenges for health care providers that negatively impacts patient care. First, many insurance companies require what is called pre-authorization. This means that your initial evaluation will be provided to the company and they decide whether or not care is medically necessary. Remember an insurance agent, not a health care provider, is making this decision. Next, if it is found to be medically necessary, the patient will be awarded approximately 6-8 treatments. In the insurance-based setting, this is often not enough time, there is a lapse in care, and patient regression. It’s a nasty cycle.

After care, insurance reimburses the provider. This reimbursement is not the amount that is charged; it is often much less. Poor reimbursement leads to minimal time with the PT and increased time with the physical therapy assistant or a rehab aide. PTA’s can vary in education/experience (some are very good!), but rehab aide’s often have no education in exercise or physical therapy. This leads to poor technique with exercises or excessive use of passive modalities. That’s low quality PT, which is not worth your time or money.



One final consideration when it comes to insurance-based physical therapy is the pressure on doctor’s to refer “in house.” How do hospitals make money? Outpatient services. When a doctor refers within his or her own network, it brings even more money in to said network. Referring “in house” isn’t necessarily a bad thing, but not everyone specializes in your specific condition or population. If you are a CrossFitter and get stuck with someone that specializes in geriatrics, it’s probably not going to pan out well. This can often result in low quality PT, which again, is not worth your time or money.

Insurance companies are not all bad. They provide a lot of services that are of vital importance and may not be possible without their financial support. I find that it’s largely life or death situations; unfortunately, wellness does not fall into that category. Healthcare is making a huge shift from a “sickness” to a “wellness” paradigm. This is an exciting time as a clinician. Following is an outline of the top 5 reasons that a cash-based PT practice benefit the patients.

1) Cost-effective Care

Therapists have the extensive education and training to be neuromuscular primary care providers. For the majority of patients’ with movement deficiencies or pain, PT’s are the provider of choice. For people with high deductibles, it makes much more financial sense to seek treatment from a cash-based physical therapist.

Insurance-based models require the PT clinic to charge very high rates in order to be reimbursed a profitable margin. Thus, those that are private pay (or are still working to meet their deductible) are required to pay these elevated rates.

2) You’ll See The Doctor

By the year 2020, all PT’s will have earned their doctorate in order to provide treatment. In the insurance-based world, it is common for you to be pawned off on one of the physical therapy assistants (PTA’s). Although many PTA’s are very knowledgeable, they do not have nearly the same educational requirements as a PT.

In a cash-based practice, you are paying for a specific service, which is evaluation and treatment by a Doctor of Physical Therapy. In this setting your provider has significantly more time to focus on you and your healthcare.

3) Accessibility

In the state of Indiana, we have direct access for evaluation and treatment of 24 calendar days. Patient’s have a significantly shorter wait time (we can typically provide an evaluation within 48 hours) in a cash practice. Most research shows that earlier treatment correlates with improved outcomes.

Let’s face it, there’s nothing more frustrating than going to a doctor’s appointment to just be told you need to go somewhere else. In the cash practice, we cut out the middle-man.

4) Transparent Affordable Pricing

Prices are right up front. Cash based practices cut out “playing the insurance game” and extra administrative costs. Often, it shocks people to hear prices of treatment because we have become accustomed to physical therapy being covered by insurance. Unfortunately, they often later find out that each visit actually had a $40 co-pay, insurance only covers 80%, or that their deductible hasn’t been met.

When working in an insurance-based practice, I far too often saw someone end up with a $4000.00 bill after 2 months of treatment. $150 an hour no longer seems so expensive.

5) All Patients are Welcome

All patients, insured or uninsured, in network or out-of-network are welcome. Payment is by cash, check or charge. Patients aren’t treated in a way that satisfies their insurance company – even better: no more silly outcome forms. Patient’s are provided the care that is needed and that will lead to desired results. We are about and for the patient.

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