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3 Questions to Decide If You Should Use Your Insurance

dr. danny healthcare & insurance May 03, 2016

Here’s a scenario I see all too often in my clinic:

You’re a middle-aged, ex-athlete but you still like to workout and are a weekend warrior. You bang your knee up a little doing a CrossFit workout or a long trail run so you go to see a physical therapist. You have a good job and you have health insurance through your company. You pick a clinic that you find that takes your insurance that’s near your home or office and go in for your first visit.

You get your diagnosis, they do some work on you and then you leave with some homework and a plan going forward. This plan is typically to come back 2-3x/week for 4 weeks. As you head to the front desk to check out, they present you with a bill. The bill is for $250 and is due today for the cost of your treatment session.

You’re completely caught off guard. You are almost positive that you had read you have a $40 co-pay for physical therapy. The front desk staff explains to you that is correct but it’s only a $40 co-pay after you’ve met your deductible. Your deductible is $2,000. She explains that once you’ve met that out of pocket expense which should be after the 8th visit, then you will have a $40 co-pay.
You pay the bill and leave aggravated. You wonder why the hell you’re paying $400 a month for insurance. Why didn’t anyone tell you before that you had to meet the deductible first before your insurance started kicking in?

My opinion on insurance is that you only win if you lose. What I mean by this is that you really only get a return on what you’ve been paying for if you get hurt badly or get very sick. We all need insurance for these catastrophic events but most people can expect their insurance to pay for very little if they are healthy.

It used to be that deductibles were as low as $200 and maybe $1,000 on the high side. I know individuals that have a $3,000 deductible on a single person policy. I’ve seen family deductibles in the $10,000 range. They are trending higher and the emphasis on the consumer (you) to pay more out of pocket is expected.

First, let’s clear up some confusion. In the scenario I laid out above, the $250 is an estimate. If the physical therapy practice that you go to is in network with your insurance, that means they have a contract and will charge set amounts. If you want that money to go toward your deductible, that clinic has to charge you the same amount they would bill your insurance company.

Let’s do a little bit of math here and show the true cost to you assuming you want to use your insurance and apply your physical therapy towards your deductible.
$250 a visit x 8 visits to meet the deductible= $2,000
4 more visits to meet the 12 visits recommended by the physical therapist at the co-pay amount of $40= $160.
Total cost for physical therapy= $2,160

Last thing is to factor in the the cost of your time. You have now gone to the clinic 12 visits, each for 1 hour. Let’s assume that round trip you drive 30 minutes to each visit, that would come out to 6  hours of driving back and forth from the physical therapist. Add in 1 hour for each of the 12 visits you spend there and that equals 18 total hours.

Total cost $2,160 and 18 hours of your time.
Let’s compare this to an out-of-network model like the one we use at Athletes’ Potential.

Because we have no contracts with insurance companies, we can charge whatever we want. Our office visit is $175 for an hour visit. This exclusion of being in network with an insurance company allows us to make decisions based on patient needs, instead of when you may or may not meet your deductible.

Our clinic average is currently between 3 and 4 visits. Let’s say we see this patient once a week for 4 weeks for a total of 4 visits.
$175 a visit x 4 visits= $700

We also need to factor in the time cost. Let’s say we have the same 30 minute round trip commute to our clinic. This patient makes a trip 4 times for a total of 2 hours driving. Total time commitment 4 hours of physical therapy plus 2 hours of driving= 6 hours.
Total cost $700 and 6 hours of your time.

So if it’s less expensive and costs less time to not use your insurance, why would you want to use it? That’s a tough question to answer. I think most people don’t actually know what their health plan covers or doesn’t cover. It’s also very confusing to look at your benefits sheet and try to figure out what it all means. You have a deductible, a copay, co-insurance, family vs individual and max out of pocket expenses. No wonder people show up at a clinic thinking they have a $40 copay and get slapped with a $250 bill.

So should you just dump your insurance? Well, no, you legally need it and hopefully you never have a catastrophic event but if you do, that insurance will come in handy. I also think there are a few scenarios where you should use your insurance.

The main physical therapy scenario in which you should use your insurance is if you need surgery. Surgery in most cases will be expensive enough to meet your deductible. Once that deductible is satisfied you owe that $40 co-pay for your insurance. Early on in the post surgery physical therapy plan it’s important that you get consistent treatment. It’s also not rocket science. They know why you’re there and for the first 6 weeks in many cases they are following a standard post surgery protocol laid out by the doctor.

We actually turn people away almost every week that just had surgery. Not because we don’t think we can help them but because it will be more cost-effective for them to go to an in-network clinic since they’ve met their deductible.  Once they get out of the early stages of rehab and can get more into return to sport/activities, they will switch over to us for home-based programming and advanced movement retraining.

Here’s the litmus test I usually give people to see if it’s worth it to use their insurance or seek out a provider outside of their insurance contract.

Have you met your deductible?

  • If your deductible is $2,000 and you’re a healthy person, you would be better off going outside of your insurance contract. It’s highly unlikely that your shoulder or knee injury will require you to see a physical therapist enough to meet that deductible.
  • Also, do you think you or one of your family members will have any expensive medical costs the rest of the year. Let's say you have a child that needs a minor surgery then you would be better off going in network so you can reach that deductible. 

Do you value your time?

  • In the scenario above going the in network clinic route cost this person 18 hours in a month. Going the cash clinic direction cost 6 hours in a month. What’s your time worth?
  • Many people have the perception that only the very wealthy go to a cash based physical therapists. In my experience that is not the case at all. The trend I have seen is busy people. I see people who value their time and don’t have much time to waste. Think school teacher, physician, chef, business owner, mid level managers and anyone who has a very time restrictive schedule.

Do you need someone to count your reps?

  • What I’m really asking is are you self motivated? Do you need someone to watch you do your physical therapy exercises or will you actually do them on your own? If you’ll do them on your own go the cash-based clinic route. If you’re not self motivated, go in network and have someone keep you consistent with your exercises.
  • Do you have access to a gym where you can do your exercises? You may not and in that case you may be better off going to an in network physical therapy clinic because they will have all the equipment you need.
  • One other option I have people do is get a short term gym membership at a place like 24 hour fitness. It’s cheap and they can go do their PT exercises on their own time once we teach them what to do.
  • If you’re a fairly fit person that has access to a gym and are self motivated you are better off going the out of network route. You’ll save time and be able to rehab yourself with guidance from a physical therapist you might see once a week.

I hope this helps navigate some of the difficult to understand territory that is our current health system. Before you decide to go see someone for physical therapy, ask yourself the questions I posed in this article.

If you’re in the Atlanta area and you want some help dealing with an injury or getting back to an activity you’ve been avoiding, give us a call. We can set up a 10 minute phone consultation with one of our Doctors of Physical Therapy to see if you’re a good fit for what we do.

Thanks guys,
​Dr. Danny, PT, DPT, OCS, CSCS


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