Why Going “Out-Of-Network Could Save You Big Bucks

The healthcare industry as a whole is changing, somethings are changing for the better, some for the worse, and some are simply changing but won’t be any better or worse in the end.  The major change that we are all going to see is that patients are going to be required to pay for more of their care themselves.  This can happen in a variety of ways, but they all lead to more out-of-pocket expenses for patients.

Increased out-of-pocket expenses means that patients are going to be required to be smarter consumers,  they are going to start to have to factor in cost to their health care decisions.  This is new for many Americans and will require a little out of the box thinking, for many people it may actually be less expensive to either go outside their insurance network, or simply pay out-of-pocket for their care.  

The first thing that patients will see is their co-pay or co-insurance for services will increase.  This will be especially true for services that are considered a specialty by their carrier (in New York State physical therapy is under this umbrella).  By taking this approach the insurance company isn’t directly telling you that they won’t cover the service, but they are making you foot more of the bill.  Since you will be paying more of the bill, it is important you know what you are getting for your hard earned dollars.  A clinic within your network will be required to charge you the rates they have negotiated with your insurance plan, while a clinic that does not have any contract with your insurance plan will be able to set their own rates and therefore be less expensive.

The next thing that you will see is an increase in the deductible on your insurance plan.  We are already seeing this a lot, as deductibles can range from a few hundred dollars to over $5,000.  This means that you will be required to pay all of your medical bills up until a specified dollar amount before the insurance company will pick up any of the expenses, and then you could still be subject to a co-pay as we discussed above.  Again in this situation if you are going to a clinic within your insurance network they will be required by their contract with your carrier to bill you at their contracted rate.  A clinic that is out-of-network will again be able to determine their own price structure, and ideally help you save money.

As consumers patients are also going to need to think about what they are getting for their money and how efficient it is being spent.  I have said many times before that physical therapy is not spending 15 minutes with a hot pack, 15 minutes with your therapist, 15-20 min doing exercises while an aid watches you, and 15 minutes with an ice pack.  Unfortunately that is the model that most insurance based clinics are forced to work in because they are 100% volume driven, they need to get as many people in the door each hour as possible.  An out-of-network or self-pay clinic can allow each therapist the necessary time to give each patient the attention they need and deserve.  This will allow each patient to get more out of each visit, and see results faster.  They will get rid of their pain, and back to what the love to do faster and in far fewer visits.

Why are fewer visits so important?  Remember as a patient who is dealing with an increasing deductible and/or co-pay you are paying for each visit, the fewer visits you need the less money you will have to pay.  For example lets say Jason has a pretty good insurance plan with a $35 co-pay for physical therapy.  He is a healthcare consumer so he has the option to go wherever he chooses for his physical therapy.  He can pick a clinic within his network, where he will only need to pay $35/visit, but will only get to see his therapist for about 15 minutes per session because they will be treating other patients at the same time.  Because of this the therapist recommends that he attend PT 3x/week for 8 weeks.  That means he will spend $105/week for 8 weeks meaning his rehab will cost him $840.  Let’s say he chooses to use Feldman Physical Therapy instead, he will be seeing his therapist for a full hour of hands on treatment each visit, so he will only need 1 visit/week, and even though it will usually take fewer weeks to get better with this approach let’s say he comes for the full 8 weeks.  His care will cost him $800, a savings of $40/visit, plus the additional savings of his time since he didn’t need to go as many days/week.  It should be easy to see how these savings will be magnified if Jason’s co-pay goes up, he has a higher deductible, or needs to attend PT for a longer time.  The other way that Jason can increase his savings is if his insurance network offers out-of-network benefits.  In this case he can take receipts given to him by his therapist and submit them to his insurance plan and they will issue him a check, further decreasing his out of pocket expense.

I hope this has helped to take away some of the fear that people may have about going out of their insurance network, and helped make everyone aware of how it can actually save you money.  If you found it helpful please share it with your friends and family.  In my next post I will cover how you as a patient should know when to call your favorite physical therapist, and sticking with the money saving theme how calling at PT first came save you big!