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When a medical provider is out-of-network with your medical insurance it does not mean that you are unable to be treated by that provider, nor does it mean that you will not receive reimbursement from your insurance company. It simply means the provider does not have a relationship with that insurance company and will not be able to file a claim on your behalf. The provider will provide you with a special invoice called a “super-bill” which you can submit to your insurance to receive reimbursement.
There are many reason that you may seek the care of an out-of-network provider:
Providers with expertise in a particular area
To receive a level of care which is not possible for in-network providers
Uninterrupted and dedicated time with your provider
Always work with your provider directly, not an assistant or a tech
Easy access to your provider for questions, concerns.
Knowing your total costs upfront and never receiving surprise bills
Etc…
It is generally understood that going to an out-of-network or cash-based medical provider yields a better experience and ultimately a better result of your treatment. However, a common misconception is that the increased quality of care comes with an increased cost. You are probably thinking to yourself, “How is it possible that an out-of-network provider could cost less than an in-network provider?”
High Deductibles- Over the past decade health insurance deductibles have increased by more than 150%, leading to fewer Americans meeting their deductible or meeting it later and later in the year. If you are relatively young and otherwise healthy there is a very good chance you will not meet your healthcare deductible this year. Most health insurance plans will cover 0% of your physical therapy treatments until after your deductible is met. Leaving you with 100% of the bill.
Decreasing reimbursement- Year after year the amount that insurance companies reimburse providers for their services decreases. Just this year alone a bill passed to decrease medicare reimbursement for physical therapy by 8%. Decreasing reimbursement means that the therapist will need to see more patients just to break even. Leading to you splitting your 60 minutes treatment with up to 3 other patients and spending, at most, 15 minutes with your provider directly.
Increased amount of visits- Less time spent with your therapist and increased pressure on your therapist to hit quotas leads to an increased amount of overall visits for the patient. There is a fairly good chance that if you are evaluated by an in-network provider your treatment plan will consist of 3 hour long treatments per week.
Let’s break this down into some scenarios.
Scenario 1- You show up to an in-network provider for an evaluation. The provider has many other patients present so they quickly take your medical history and give you a short amount of time to explain why you are coming to see them. They then begin their examination of you with the remaining time they have before they need to get to another patient. They examine the bare minimum to start treatment that day due to a lack of time and they turn you over to an assistant or a tech to have you complete some therapeutic exercises. At the end of your treatment session the therapist recommends that you be seen 3x per week for 4-6 weeks and sends you to the front to check out with reception. While you are checking out the receptionist explains your health insurance benefits and explains that you have to meet your deductible of $1500 before anything will be covered and that after you meet this you will only have a co-pay for each visit. You are charged $160 for the evaluation and the treatment you received that day. You schedule your following appointments starting at 3 visits per week. Each visit cost about $100 and in total you required 12 visits. At each appointment you spend on average 15 of your 60 minutes with your therapist as they frantically run between patients. At some point your insurance deems that you are good enough and you are discharged. Your total cost comes to $1260 for 12 hours of treatment, of which you spent 3.25 hours with your therapist. Making the cost of the time spent with your therapist $388 per hour.
Scenario 2- You show up to an in-network provider for an evaluation. The provider has many other patients present so they quickly take your medical history and give you a short amount of time to explain why you are coming to see them. They then begin their examination of you with the remaining time they have before they need to get to another patient. They examine the bare minimum to start treatment that day due to a lack of time and turn you over to an assistant or a tech to have you complete some therapeutic exercises. At the end of your treatment session the therapist recommends that you be seen 3x per week for 4-6 weeks and sends you to the front to check out with reception. While you are checking out the receptionist explains your health insurance benefits and explains that you have great healthcare coverage and that are only responsible for a copay at each visit. You are charged a copay of $80 for the evaluation and the treatment you received that day. You schedule your following appointments starting at 3 visits per week. Each visit cost $50 and in total you required 12 visits. At each appointment you spend on average 15 of your 60 minutes with your therapist as they frantically run between patients. At some point your insurance deems that you are good enough and you are discharged. Your total cost comes to $630 for 12 hours of treatment, of which you spent 3.25 hours with your therapist. Making the cost of the time spent with your therapist $194 per hour.
Scenario 3- You schedule an appointment to have an out of network therapist come to your house to evaluate your condition and begin treatment. The therapist utilizes the time to perform a thorough and in depth evaluation and makes note of all impairment they believe may be contributing to your pain. They have plenty of time to perform any needed manual therapy before beginning therapeutic exercises. While you perform therapeutic exercise the therapist is observing every repetition and making adjustments to insure you are getting the most out of your exercise. You are given a home exercise program consisting of the exercises you just performed and instructed on how often to complete the exercises daily and weekly. At the end of the visit the therapist recommends that you be treated once per week for 4-6 weeks while performing your exercise independently between visits. You are charged $150 for today’s evaluation and $150 for each subsequent treatment. In total you required 5 treatments. At each appointment you spend the full hour with your therapist receiving one-on-one individualized manual therapy and therapeutic exercise. At some point you decide that you are rehabilitated and are discharged. At each treatment you are provided with a “super bill” which you submit to your insurance company for out of network reimbursement. On average you receive $50 reimbursement from your insurance company. Your upfront cost comes to $750 for 5 hours of treatment, of which you spent all 5 hours with your therapist. You receive $250 from your insurance company. Your total cost comes to $500, making the cost of the time spent with your therapist $100 per hour. While simultaneously reducing the burden of travel and the amount of time associated with attending 3 visits per week.
We hope that this helps to clarify what going to an “out-of-network” provider entails and removes the notion that premium service comes at a premium cost. As always we encourage you to reach out to us directly by email at info@chaseptwellness.com or call us at 512-650-8528. You can also visit our website at www.chaseptwellness.com to learn more about our services.
**The above scenarios are common examples of what you may experience while going to physical therapy. However it is impossible to know exactly what your specific scenario will look like. It is always recommended that you contact your insurance provider directly to understand what your in network and your out of network benefits are.
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