Insurance: The Patient and Provider Perspective

As you may have noticed, a lot of providers are no longer accepting insurance and going the “cash pay” route. I think it is vital to address why this is in fact happening and happening rapidly. Believe me, I have been in the “patient shoes” and had the same questions and concerns regarding insurance. However, you will be surprised that in some instances, you may pay the same or even less and get better in less visits if you choose out of network services! Now, this blog is not a knock on in-network providers because they are honestly doing the best they can with what they have. I have been there. My intention is to provide you with my point of view as both the patient and provider in this industry in hopes of helping you make more informed decisions about your care.

For as long as I have been a working adult in the physical therapy world, health insurance has been on my radar. Always under the impression that “you need to have a good plan or you’ll have to pay a lot of money for services.” I could not be more wrong. Over time, I became less and less surprised when I would get billed $30 for a literal 3 minute telehealth appointment or a $700 emergency room bill because I hadn’t met my deductible. (…but I am still paying a premium every month so shouldn’t that count toward something?) It is confusing and designed to be just that.

I spent 10+ years with symptoms that went misdiagnosed or were brushed off because providers did not have enough time to truly troubleshoot or insurance would not pay for a scan or service. All of my symptoms eventually pointed to the fact that I needed pelvic floor physical therapy. Unfortunately for me, my insurance would not cover my services with one of the only providers in my area because I was “capitated.” Low and behold, I still went and paid out of pocket because I truly needed the services. Each session was $80 for 35 minute appointments. Eventually, I got “phased out” because there were so many people that needed the services too so I was not able to get another appointment for weeks.

If you think that is frustrating, the provider side of insurance is even uglier...

A patient can come for their appointments and receive all of the services they need but the insurance company can turn around on the back end and not pay the provider for the ambiguous reasons of “the sessions were not medically necessary” or “we do not support that code.” Or even worse, the patient gets stuck with a hefty, unexpected bill a few months later.

I used to waste HOURS of patient time and lunch on the phone fighting with insurance companies and come out with a victory maybe 50% of the time. The sad truth is that many companies try to have therapists see anywhere from 2-4 patients an hour to make up the difference, which brings down the quality of the services. This is leading to burn out in not only physical therapy but medicine, mental health services, chiropractic, and more. Honestly, I was teetering on the thought of leaving the healthcare industry altogether because I was in a constant state of stress, exhaustion, and fear that I was not doing enough. More and more providers are choosing to start out of network practices for these reasons.

It may seem like a sticker shock when you first hear the prices of out of network services. It is helpful to look at your time and investment as a whole because it may end up costing you the same amount or less than in-network services. Here are some things to keep in mind to make an informed decision:

• How many times am I asked to go each week and how much is the co-pay each time? How many visits will I need in total? Typically, at insurance based clinics you are asked to come 2-3x per week for 2-3 months (multiply that by your co-pay). I generally see patients 1x per week or 1x every other week for a total of 6-8 visits depending on the complexity of the symptoms

• Am I seeing the therapist the whole time or am I working with an aide or by myself half of the session?

• Is the therapist working with me in a holistic view or just zoned in on one specific area? (surprise, this is due to insurance too)

In the end, I ask kindly, please do not get upset with your providers who choose to go cash pay. We are working in a broken system and honestly just want the best for you without ramming ourselves into the ground.