Do You Take My Insurance? - The Most Common #CashPT Question

"Do You Take My Insurance?"

Do you know what your own insurance benefits are? Do you know your in-network co-pay and deductible? How about your out-of-network co-pay/co-insurance and deductible? What are your physical therapy or rehabilitation benefits? This is a vital concept to grasp and understand so you can answer this question and help your patients make an informed choice, especially when they are looking for the best value.

Health Insurance coverage is drastically different than what it was just 10, even 5, years ago. More and more people are choosing high deductible health plans and "insurance" is becoming more of a catastrophic save your ass plan, rather than a "pay it all for me: plan similar. It is more similar to automobile insurance, which does not cover "wear and tear" items like new tires, an oil change, or even a new head gasket at 210,000 miles! When was the last time your automobile insurance paid you to get a 90,000 mile service?

 I once owned a 1993 Jeep Cherokee which got broken into in when I moved to San Francisco. I paid the $250 deductible to get the broken window repaired and received a check from my auto insurance company to cover the stolen items inside.

A dozen years later my 1993 SAAB 900, after 5 trips across country and countless miles driving to bike races, blew a head gasket at 214,000 miles and change. It needed major surgery, more than just a "routine" reverse total shoulder replacement and double it's street value, so I called up my local NPR station and donated it.

That's easy enough to understand. Right?

Health Insurance is Not Auto Insurance

When it comes to health insurance, it's not so black & white or easy for most people to understand, even those of us who are in the "game." When is the last time you had to get an authorization from Geico to get your 90,000 mile check up? or if you have a SAAB, to get your water pump replaced, again!

Most of the times when my patients report to me that their insurance "wouldn't pay" or that their visits are "not covered." What they mean is that they have not reached their deductible. Unfortunately even the insurance representative or the patients' human resources insurance representative do not understand and tell or convey to patients that physical therapy in our clinic is "not covered" or that they "will not pay." What they should do is educate the beneficiary about the meaning of their benefits. It is my guess that they just don't know either.

A vast majority of my patients do not reach even their in-network deductible in my practice as my average patient is seen for 5-8 visits. That's about $600 - $1000 for a patients care. I am out-of-network and so they usually do not even get close, however some do and when they file a claim, they do get reimbursed.

Just last week I went to see a Sports Medicine D.O. for a check-up and my co-pay was $80 since he is listed as a specialist (a visit to a family medicine physician is a $50 co-pay). For my co-pay and $1,247/month for my family of 4 premium I received about 20 minutes of his time, and that's stretching it.

I get 30 PT or Rehab visits per year, and have an $80 co-pay in-network and a $5,000 deductible. So in essence, if I needed Physical Therapy, Occupational Therapy or Chiropractic treatment, I would pay for my therapy out of pocket anyway. Why wouldn't I look for the best value?

I've been doing a soft survey of therapists during my presentations in the last few years. A majority of people have seen co-pays over $50 and a significant portion have seen co-pays of $80, $90 and even $100. Where is the physical therapy benefit in that?

$1,100 Physical Therapy Treatment!

Recently a client of mine reported that since January 1st about 10 of his patients have stopped their physical therapy treatment because the bills they have received so big, they can't afford physical therapy. I'm not talking about people who can't afford their $20 co-pay, I'm talking about a bill for $1,100, 1 unit of manual therapy and 1 unit of therapeutic exercise. With a co-pay of 20%, that's $220 a visit for 2 units and about 30 minutes. He reported that almost all of these patients had high deductibles of $5,000 and some have to pay the whole $1,100 bill for just 1 visit!

In a cash-base practice, we usually compete on value and time, now in this case, and with rising deductibles, it is also easy to also compete on price!

Understanding Your Physical Therapy Benefits

Determine Your Insurance Benefits Worksheet

To help my patients understand their benefits I've created an Insurance Benefits Worksheet that I've made available on my clinical website. I can direct patients to use it when calling their insurance provider to inquire about and educate themselves about their insurance benefits.

Do you know your insurance benefits? Pull out your insurance card, pick up your phone and use this Insurance Benefits Worksheet to find out for yourself. This worksheet and 30 other documents, such as the receipt or superbill I provide to patients, are available for you to customize & use in your own practice in the CashPT Toolkit.

What Are Your Benefits?

After you make the call to your insurance company, post your deductible, co-pay and physical therapy or rehabilitation benefits in the comments section below. Let's see who has the highest deductible!

Via Dr. Aaron LeBauer of lebauerconsulting.com

Photo by Stuart Miles and courtesy of freedigitalphotos.net

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

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