**DISCLAIMER** This is a long post, but hang in there and read it through to the end. There is a ton of important information packed into this blog post. (If you don’t want to read the entire post, just click “WHY GAME CHANGER IS DIFFERENT”)
Many times the first question I get when potential patients contact me is “do you take my insurance?” I understand why this is often the first question people want answered because people want to know how much something is going to cost. I also understand that the answer of, “no, I do not accept insurance,” is often a deal breaker because it is unconscionable to pay for something that is already “covered” by insurance (I used quotes on purpose and I will unpack that later). This post will explain why going with the cheaper option isn’t always the best option and the phrase, “you get what you pay for” is something to keep in mind while reading this post.
UNDERSTANDING YOUR INSURANCE
Before we get too far along, lets explain a few things about insurance. Among other terms, I will define deductible, percentage of reimbursement, and co-pay.
– Deductible: what you are required to meet before insurance will pay a percentage of any bills.
– Percentage of reimbursement: how much you are responsible for AFTER your deductible has been met. Once your deductible is met, then your insurance will pay a percentage and you are responsible for the remaining balance.
– Co-pay: Set dollar amount determined by your insurance company that is due each visit and the co-pay does not go towards your deductible.
– Out-of-pocket: A maximum amount that you are required to pay prior to insurance paying for 100% of the remaining medical costs.
– In-network provider: the provider is contracted with the insurance company at pre-negotiated rates.
– Out-of-network provider: the provider is not contracted with the insurance company, but a “Superbill” (or medical receipt) can be submitted for reimbursement – or at least the amount of the bill applied to your out-of-network deductible.
– PT visit limit: A set number of physical therapy visits that will be covered by insurance. Once you pass that limit you will need to pay out of pocket.
Click here for an insurance worksheet you can use to find out what your physical therapy benefits are. It’s good information to have for your records and really easy to do; just be prepared to be on hold for a while to speak with a representative. I suggest that you download the worksheet and call your insurance so you know your physical therapy benefits.
INSURANCE REIMBURSEMENT RATES
Over the years, health insurance reimbursement rates to medical providers have steadily declined. Practitioners are providing the same services, but are getting paid less for those services. With increased cost of operating business combined with decreased insurance reimbursement rates, physical therapy clinics (and other health care providers) are struggling to keep their doors open. Many privately owned clinics have been sold to big health care corporations in order to make ends meet, which means clinic owners have given up their dream and position of “Owner/Boss/Founder” and are now working for someone else.
DECREASED PATIENT-THERAPIST INTERACTION
To avoid going out of business, some clinics have increased their daily patient load in order to bring in enough revenue. A not-so-great solution to this problem is double or triple booking patients in a single time slot. With this set up, the quality of care the patients receive significantly decreases because the patient-therapist face-to-face time diminishes. At the average insurance-based PT clinic, physical therapists are only allowed 15 minutes with each patient before the patient is handed off to a physical therapy aide for the remaining 45 minutes of the appointment. Some physical therapy aides (or technicians or trainers – whatever the clinic prefers to call them) are awesome and know how to properly teach therapeutic exercises and correct movement faults; they are the exception. Unfortunately, most aides are individuals who may or may not be interested in the field of physical therapy, aren’t particularly self-driven, and are not extensively trained in the biomechanics and kinesiology of human movement which typically makes for ineffective teaching and lack of correction of therapeutic exercises. This is a problem because if patients are not closely monitored while completing therapeutic exercise, further injury can occur…which increases health care costs. So, in this model you get 15 minutes with your physical therapist (who most likely has a doctoral degree in physical therapy) and 45 minutes with an aide. Don’t you think that spending MORE time with a Doctor of Physical Therapy should be the standard?
SO YOU HAD YOUR TREATMENT SESSION, WHAT’S NEXT?
After each session, your physical therapist will document the visit and the front office will bill the treatments that were performed. At the end of the day, those bills are sent to the insurance company for review. Most of the time, insurance companies do whatever their process is to pay the PT clinic and everyone is happy. But…..sometimes insurance companies will deny payment (remember, “covered”?). Payments can be denied because the insurance company determined the treatment was unnecessary, not enough progress is being made, pain levels aren’t disabling enough, strength and range is “functional enough”, etc. and will joyfully reject the claim—yes, I have had an insurance company tell me that one of my patients was “functional enough” and denied reimbursement. Now, that bill is then passed on to you (the patient) and you are responsible for payment in full. It might happen quickly or it could take months for this process to happen. And it may not be only one visit but multiple visits that you will suddenly be financially responsible for. I know of at least one case that a clinic didn’t receive insurance payment until 2 years after the initial claim was submitted. You read that right, they waited 2 years to be paid for legitimate service they provided. That doesn’t sound fair, does it?
WHY GAME CHANGER IS DIFFERENT
In order to maintain my ethical and moral standards, I am avoiding insurance altogether.
GCPT is a direct pay (out-of-network) practice that is able to provide the high-quality care that you deserve. Since GCPT is not contracted with insurance companies, I am able to spend 1 hour with you providing individualized treatments that will be far more beneficial than a 15 minute visit with your physical therapist. With this set up, you will most likely only require about 6 visits (1 visit per week) to get back to your prior level of function compared to the 12-18 visit standard of 2-3 visits per week for a 6-week prescription.
Will coming to GCPT save you money? I emphatically argue, “Yes!” How so, you ask? Let’s walk through the process: You either need to go in to work late, leave early, or take an extended lunch; that costs you in hourly wages or paid time off. You then spend 15-or-so minutes driving to the clinic where you’ll spend the next hour (likely longer). Only approximately 15 minutes of that hour will be with a licensed physical therapist. Once the appointment is done, you’ll either have to pay your approximate $65 copay or you’ll eventually get a bill for, probably, north of $100 if you haven’t already met your deductible or out of pocket max. Finally you’ll have to drive for another 15-or-so minutes to get [back] to the office or home. That really takes a chunk out of your day, and your bank account. Now do that 2-3 times per week for 6 weeks.
OR do it only once per week for the same 6-week period except you’ll get the high-quality, individualized treatment you deserve for a little more coin per visit (remember, fewer visits…quality over quantity). Oh, you’ll also get to reap the benefits of getting better faster and having more time with your family and friends, doing the things you enjoy doing.
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