"Using Insurance": What's the Deal?

Author: Dr. Blair Green PT, DPT, OCS, PHC

If I had a nickel for every time someone asked if Catalyst “takes their insurance,” I’d never have to treat another patient in my lifetime. If only that question were as simple to answer as it was to ask. In today’s healthcare climate, choosing a provider is not as simple as scrolling and picking someone you found on a list of “in-network providers.” 

I get it - everything seems to cost more these days. You are paying thousands of dollars in health insurance premiums. You want to be able to put this benefit to good use and not come out of pocket more than you have to. However, I urge you to examine what it really means to “use insurance” and to educate yourself as to why choosing a physical therapist based on insurance may not always be in your best interest (or necessarily less expensive).

First, let’s do some basic education around health insurance:

1. In Network v Out of Network - what does this mean?

Insurance companies contract with providers, which means the providers are in-network. Patients who see these “preferred” providers will pay lower copays and coinsurance, thus seemingly less out of pocket expenses per visit. In many cases, patients can also see providers who are out of network (not contracted) and insurance will still pay a portion of the fee. There are a few things to know about in v out of network. First, the copay amount or coinsurance percent is usually lower for in-network, giving the illusion that the total cost is lower. This incentivizes patients to stay in-network. However, in-network does not mean the cost of care is free, and many times there are restrictions on the number of visits, and types of treatments covered. Secondly, by accepting insurance contracts, the PT center may be agreeing to a lower fee from the insurance company. They are paid less! So they have to see more patients just to keep the lights on and keep people employed. More on this below.

2. How deductibles work

A deductible is a dollar amount that your insurance contract says you must pay out of pocket before a coinsurance or copay will apply. Every plan has a different deductible. Typically, the higher the premium the lower the deductible (you are paying one way or another). These days, it is typical to see deductibles of over $2000 even for a good plan. Depending on the PT center’s contract with the insurance company, you may need to pay the full price of the visit until your deductible is met. If there is a contracted lower rate, you will still have to pay this amount until the deductible is met. In other words, if your in-network deductible is $2500, you must pay that full amount until the $2500 is reached, whether in PT or through other medical services. (It’s amazing how confusing this can be).

Some plans have different in-network and out of network deductibles. Depending on your plan, you could be paying more initially for the in-network PT because their actual rate may be higher and you have not met your deductible. 

3. Coinsurance v Copay

Physical Therapy visits come with either a copay or coinsurance fee, once the deductible has been met. Sometimes, there is a copay and you are not required to pay the deductible first. All of this depends on your individual plan (so if you weren’t confused before you surely are now). The difference between a copay and a coinsurance is that a copay is a set dollar amount while coinsurance is a percentage of the cost of the visit. An in-network copay or coinsurance is lower than an out of network amount. This is another perceived benefit of staying in-network. 

Again, it is necessary to consider the cost of the service. For example, let’s say your in-network coinsurance is 20% and your out of network coinsurance is 30%.  If an in-network PT charges $500 for an evaluation, you will pay $100 (if your deductible has been met). An out of network provider may charge $250 for the same service, but you will only be required to pay $75. In this case, the out of network provider may save you money.

In summary, DO THE MATH. Know your in v out of network deductible and coinsurance / copay amounts. Find out if you have visit restrictions, or if there are uncovered services (such as dry needling). Don’t assume that in-network care will save you money.

Next, consider what you hope to achieve in physical therapy:

Are you in pain? Are you struggling to get through your day because of it? Do you struggle with pelvic organ prolapse or leaking that keeps you from being active, or leaving the house? Have you recently gone through cancer treatment and are you trying to feel like yourself again? How important is it for you to achieve your goals not only quickly, but in a way that feels good to you? To have someone to ask questions to and help you problem solve? To receive care that is curated specifically for you? If it were as simple as “come in and do these exercises on your own, or while an unlicensed office aide watches over you,” then you would probably be able to help yourself by looking it up on Google or YouTube.

There is a reason that in-network physical therapy clinics often are crowded, and patients receive little, if any, personalized attention (and it’s not because the PTs don’t know what they are doing). As a result, your care is compromised. Many in-network PT clinics have patients come in 2-3 times a week, compared to 1-2 (or less) which is what we typically recommend at Catalyst. That means more time away from work or your family, in addition to scattered care. Additionally, if you attend 2 or 3 sessions a week, and you are required to pay your copay or coinsurance each time, the cost may start to add up. In the end, you may be saving little, if any, money to “use your insurance” and stay in-network but also missing out on the results you want.

When the time comes to choose a physical therapist, I recommend you do the following to help you choose the person who is best for you:

1. What is bothering you? There may be a specialists that can help better than a generalists PT clinic
2. How important is it for you to get the results you want?
3. Is personalized care important to you?
4. Check your in-network AND out of network insurance benefits - this is simple to do online or through a quick customer service call 
5. Do the math! Is there a significant financial benefit to stay in network? Is the person you have chosen as your best fit in or out of network? Is the potential cost savings worth potentially not getting the best result?

Only you can make the decision that is best for you. With the knowledge and information you need to make that decision, you can manage expectations and choose the provider that best fits your needs and goals.

Want to read our FAQs on the ins and outs of health insurance and physical therapy? Click here and we will send it your way!