A little lesson on “Health Insurance”

Being “out-of-network” (OON) myth #1: I can’t get reimbursed if I go to an OON provider. This is FALSE!!!! It is still possible to get reimbursed, but you will have to call your insurance customer service rep (number is on the back of your card) and inquire about your OON benefits/costs for physical therapy as well as all the information you need to submit in order to get reimbursed. After each visit, at Not Your Average Physio, we can provide a “super bill” with all of that information that you can submit to your insurance for reimbursement. We have just begun utilizing an app called “Reimbursify” that helps you submit claims from your phone in less than 1 minute! Inquire about this option when you set up your evaluation!

Read on to learn what “in network” and “out of network” really means!

I get asked a lot “do you accept my insurance?” and my answer is always “I am out-of-network with insurance companies.” Many will nod their head, but few will actually understand what “out-of-network” means. Answer this: What does out of network mean to you?

If you answered (or any form of the following): It means that you don’t take my insurance and that I need to pay for all services out of pocket. You’re NOT wrong, BUT you’re not right, either.

So, then, what does it mean to be “out of network”? Let’s first define what “in network” means. In network providers (MDs, PTs, Chiropractors, Dentists, etc…) have a choice to contract with insurance – this is being “in network”. When you contract with an insurance company, you’re saying that you will follow the insurance company’s outline of providing care. This can include: how many visits a client can be seen, what you can provide as a service, do you need a referral on file for reimbursement etc… all for a pre-determined price per visit. In exchange, the patient pays only their co-pay at the time of visit (think about what you pay to see your primary care for your physical, this is your co-pay amount usually. It CAN vary between services, ex. dentist vs PT). If you haven’t met your deductible (usually $1K+ for most plans), then that means YOU, as the consumer, need to pay out of pocket for ALL expenses until you meet your deductible, then you will still have to pay your co-pay for every visit after your deductible is met. For most plans, in order to end up with a lower deductible, you have to pay a higher premium (what you pay monthly for health insurance)- so most end up with a lower premium, but higher deductible.

Out of Network means that I have chosen to not allow a third party company dictate what I can and cannot provide my clients, or how long I choose to see them for. As a result, the client is responsible for the full cost of each session. However, the client is able to retroactively get reimbursed for these sessions depending on their insurance benefits by submitting a claim (see above).

EX. A 40 y/o male is experiencing low back pain and was recommended to an in-network physical therapy clinic. Because he hadn’t met his deductible, he was responsible for ALL medical expenses. He was charged by the clinic $367 after the first visit. He attends PT 2x/week for 5 visits before meeting his deductible, having spent a total of $1835. He has a $45 co-pay for each of the remaining 7 visits, bringing his total to $2,150! On top of that, he was one of 2-3 patients with the physical therapist during each of his 12 visits and he left with minimal to moderate improvements in his overall symptoms.

At out of network clinics such as Not Your Average Physio: 6 visits would be somewhere between $990-1,200. All sessions would be an hour, 1-on-1 with a Doctor of Physical Therapy. Sessions would include an individualized plan that is designed with the client’s input, accurate testing to pinpoint the root cause of your complaints, direct access to the PT through messaging and email and many more. Visits are 1x/week with plenty of homework throughout the week and after 6 visits, the above client would be well on their way to meeting their goals with significantly decreased symptoms. Most of all, he will learn about how his body works and will have the tools necessary should this ailment return in the future.

Don’t wait till you’re feeling like these guys! Schedule an evaluation today!

In the end, seeing an out of network provider doesn’t mean higher costs. In most cases, the costs are significantly lower and result in superior outcomes. Don’t believe me? Check out what people are saying about Not Your Average Physio here and here

Thanks for reading and learning more about your Health Insurance!

Dr. James Chen PT, DPT, Pn1

Leave a Reply

%d bloggers like this: