The Healthcare Consumer

Understanding Your Insurance Benefits

Four years ago, when I started Feldman Physical Therapy and Performance, I wrote a blog post about how I thought Obamacare was going to affect the healthcare industry, specifically physical therapy. My thought was that potential patients were going to need to realize that they had to treat their health care like anything else they spend their hard-earned money on, including that they needed to be an educated consumer of their health care, and not just a patient. Over the last four years the first part of that has proven to be very true, however I am not sure that most patients are aware of the second part — that they need to be an educated consumer, or even about what they need to be educated. Most people are still used to being a patient, where they simply go where their doctor tells them, or where they went the last time they had a similar problem.

Since the inception of the Health Care Reform Act, people have had to deal with issues with which they may or may not have been familiar, such as deductibles, in-network versus out-of-network issues, copays, coinsurances, out-of-pocket maximums, and many other terms that may seem foreign to some. To understand what all this means, an important place to start is with a working definition of each term.

A deductible is the amount of money a patient must pay before his or her insurance kicks in.  Some insurance plans have an in-network and an out-of-network deductible, and others combine the two. In-network refers to providers who are contracted with a patient’s insurance company, while out-of-network refers to a provider who does not have a contracted rate with the insurance company. A copay is a set dollar amount that the patient will need to pay for each service he receives. This is often a different dollar amount for a primary care visit, a specialist visit, an urgent care visit or an emergency room visit. There may be yet a different copay for a hospital admission. Then there is coinsurance, where, instead of a set dollar amount for a procedure, patients see a percent amount on their insurance card. This means they are responsible for that percent of the charges accepted by the insurance company. This is an important difference for consumers to realize because different offices can have different agreed-upon rates with the same insurance company, and knowing that could save or cost a patient a significant amount of money. Both a coinsurance and a copay only come into effect when a person has met his deductible. Last, the out-of-pocket maximum is just as it sounds, it’s the maximum amount a person will have to pay out-of-pocket in a given year.

Becoming an educated consumer of your health care starts with knowing how each of the above applies to your insurance. The next step is knowing what a given service is going to cost, before it’s received, which is where things get tricky. If you think about health care like milk at the grocery store, you would never go to the store, leave with the milk and tell the owner to bill you later for whatever that milk costs. No, you pay (or charge) the price for the milk that the store has posted and then bring the milk home. Often, getting the cost of a service from a provider can be harder than it should be, but it is important to be sure that you, as a consumer, know what you are going to have to pay before getting a service or treatment. At Feldman Physical Therapy & Performance we make this easy because every visit is the same price, with all prices posted on our website, www.feldmanphysicaltherapy.com. This is the luxury of being an out-of-network provider. That still leaves you, the consumer, to determine how that applies to your specific case.  Do you have out-of-network benefits, if so what is your deductible?  If not how does that cost compare to your in-network co-pay.

To write this post, I called four different local physical therapy offices in Dutchess County and asked what the price of an initial evaluation would cost with my insurance. I have a high deductible plan, and since the year has just started, I knew I wouldn’t be close to meeting it, which would make me responsible for the entire, out-of-pocket cost of the treatment. I got different answers on the cost of an initial evaluation from each of the four practices. One office couldn’t give me an answer until after I came in, another told me the cost was $75, another said it was $60, and another  said it would be between $50 and $120. One office also offered me a flat rate of $90 if I agreed to not use my insurance, which would work to that practice’s advantage but not mine since the payments would not count against my deductible.  As an in-network provider with my insurance that clinic is bound by their contract with my insurance company, by offering to treat me for a different rate, they are going against that contract, and therefore cannot tell my insurance what I paid, and told me that i would not be able send anything to my insurance to get the amount applied to my deductible.

I also want to point out that I got the information because I knew the right questions to ask. Clearly, this can get very confusing, especially for the average consumer inexperienced in asking these questions.

As a consumer, the next step is to make sure apples are being compared against apples, and not with milk. Ask specific questions about what your visit will include and how long will it be, including how much time you will spend with the therapist and with aides/office staff as well as the amount of time that will be dedicated to passive treatments like heat, ice or ultrasound.  Then be sure to ask the same questions about your follow-up visits. I believe that the clinics that gave me a price range or couldn’t give me any price at all, did so because the amount depended on what their therapist chose to bill for it  Some modalities like ultrasound, e-stimulation, or heat or ice therapy, are often used for billing purposes not necessity, with very little research to support their efficacy. As a consumer, you have a right to know these things, and what you are paying for.

At Feldman Physical Therapy & Performance we spend a full hour with each patient at each visit, while in-network clinics usually average 15 minutes of one-on-one time with each patient, following, perhaps, a half-hour an initial visit. At first, our $100 per-visit fee may seem more expensive than a copay of $50 per visit at an in-network clinic (which is average for a specialist in New York State), however, when figured per-minute spent with a therapist, our fee breaks down to $0.60, while the clinic that bills your insurance costs you $3.33 per minute.

Because we work one-on-one with our patients, weekly follow-ups are all that’s needed, while visits to insurance-based practices might require follow-up visits two or three times a week. All of a sudden using insurance costs much more money, which an uneducated consumer might not think could be possible. Moreover, this example only counts for a person’s co-pay. Imagine how much more that hourly rate increases for those paying more than just a copay because of a deductible. As well, most of our patients can submit our bills to their insurance company to for reimbursement, further lowering the cost for service, or opt to use their health savings accounts.
Complicated or not, it is very important for you to understand exactly how health costs and payments affect your individual situation, because when it comes to health care, you are no longer just a patient. You are a consumer spending more and more of your hard-earned money. So, like everything else you do, make sure you are informed and spend it wisely.