Why We Choose To Be Out-Of-Network

Why is Feldman Physical Therapy and Performance an out-of-network clinic, and come to think of it, what is an out-of-network clinic?

The short answer is that we are out-of-network because we wouldn’t be able to offer the level of service that you have come to expect from us, while working in-network; that is, under the insurance model. Why is that? This is where things get complicated.

When a provider signs on with an insurance company, the provider agrees to operate under that insurance company’s rules and regulations, and to do them for a discounted rate. These rules usually involve how many visits a patient can receive in a year, or how frequently the insurance company will authorize visits during a plan of care. That means that the insurance company, and not the patient or provider, decides how many treatments a person receives. It also means the insurance company decides when a patient is “all better” at which point the patient isn’t permitted to continue treatment. The insurance company decides what “all better” means. Usually, the company will determine that if a patent is pain free, has adequate strength, and could possibly continue some exercise on his or her own, the person is “all better”. This unfortunately, doesn’t take into account what the individual’s goals as a patient are. If the person would like to return to running or weight training or even get down onto the floor with his or her kids or grandkids, the insurance company doesn’t care and won’t pay for those services should they fall beyond what the company has already deemed as sufficient care.

This affects patients in many ways. First, treatments may be delayed as a result of the clinic needing to wait for authorization to start treatment. Then there may be a limit on how many sessions the patient can attend prior to needing another authorization, or worse, the determination that no further treatments will be covered. On the other hand, remember that a patient’s provider agreed to a discounted rate with its insurance companies, so what if a person was allowed nine authorized visits, but felt great after three or four? Well, the provider would try to create a reason for that person to finish the nine, because the company would want to get paid for those visits. This is obviously very wrong and, unfortunately, all too common.

Now, what about the situation where a person is training for a 5k or half marathon, or maybe a Spartan race, but an injury sets the individual back in his or her training? Well, according to an insurance company those aims are not, “functional tasks”, or “activities of daily living”, and because of that, the company won’t pay for your treatment to be able to do them. In the company’s eyes, if a person can walk pain free, that is all the firm should have to pay for. Now, if a provider or clinic agrees to the insurance companies contract, the provider also agrees to only provide treatment for its members if the therapy is deemed to be medically necessary. To us at Feldman Physical Therapy and Performance, this simply makes no sense. A patient and his or her therapist are the ones who should be making that decision, and because of that we will never agree to insurance companies’ contract terms.

As a consumer this can all seem crazy and even make your head spin. You pay for health insurance, and feel that you should be able to use it. I like to try and get patients to look at their health insurance like their car insurance. Your car insurance won’t pay for new tires, or brakes, and if you need an oil change, or gas you don’t look for a service station or mechanic that works with your insurance company. Your car insurance is for major accidents, and really unfortunate situations. Your health insurance should be viewed the same way. We make a conscious decision not work with any insurance companies because they are not looking out for your health and wellbeing. They are looking out for their bottom line.

I hope this helps you understand our decision. For more information, watch the video below, or call me, (845) 475-8769.