• Dr Jess Klain

Health Insurance --> The Good, The Bad & The Ugly

How do you feel about your health insurance coverage?

For many of us, that question can bring up a variety of emotions and responses. As both a consumer and a provider, I have had a variety of frustrations dealing with health insurance companies. As a consumer I deal with high deductibles, confusing coverage, and poor communication with billing departments. As a provider, my experience involves copious amounts of paperwork, phone calls, and frustration. I've had days that I have spent more time and energy on dealing with insurance than on actual physical therapy care.

I became a physical therapist for many reasons, but the main one was to help people feel better. I was exposed to the PT profession in high school due multiple injuries related to soccer and track. My high school physical therapist heard all about who I was dating, my prom dress, and my college goals. He also kicked my butt and told me to stop whining when things got hard or frustrating. His guidance after my ACL reconstruction surgery is a huge reason why I can hike, mountain bike, and run marathons today. I briefly considered going to medical school but decided that physical therapy was a more enjoyable profession because I could get to know people and socialize as I helped them achieve their goals.

12 years into my PT career, I still love the profession. Each year I gain more knowledge and experience that allows me to help people in a more efficient and complete way. But I don’t love the insurance part of my profession and I don't anticipate the insurance world improving significantly anytime soon.

As much as I dislike insurance, it isn't all bad. Some good things include:

  • It's a safety net. There is a set max out of pocket you can spend in a year. Depending on your plan, this can range anywhere from $2000 - $18,000.

  • Basic preventative care services are covered for free. Prevention is always better!

The bad part of insurance consumers may experience include:

  • It is expensive. Monthly premiums, high co-pays, and co-insurances add up quick.

  • It is hard to understand. The most common confusion is related to figuring out what is in network vs. out of network, vision/dental vs. medial coverage, pre-authorizations, ICD-10 diagnosis codes, CPT codes, etc..

  • Transparency is lacking. Depending on what codes a provider uses, the cost and coverage can vary substantially. This information can be hard to get from both your provider and your insurance company.

The ugly part of insurance (from a providers perspective) includes:

  • Insurance companies are a for-profit businesses. The goal is to make more money.

  • Insurance companies are frequently dictating what type of care and at what rate. Many insurance companies use a third-party "gate keeper" to dictate how many PT visits you can use and at what frequency.

  • The people at the insurance companies making decisions on what services are covered and when (i.e. MRI, injections, PT, procedures, etc.) are typically not practicing healthcare providers.

  • Navigating the health insurance world causes the administrative cost to rise. This contributes to the need to increase the amount charged and ultimately increases your overall cost.

  • In Colorado, insurance reimbursement rates for PT are so low it forces PT businesses to assign multiple patients to a provider at the same time and/or increases the need to utilize techs and aides for care. This reduces the ability of the provider to provide their full attention to you and your goals.

There is no simple fix to the complicated world of health insurance. But an alternative healthcare model emerging is "concierge medicine". There are several models of concierge care, but it generally involves paying cash for services received with no insurance involvement. Concierge care often requires monthly or annual fee that gives you 24/7 access to the provider via email, text, or phone. Another model is a "private pay" or "self-pay" model. This involves paying the provider directly for their services and does not include a monthly/annual fee. Deals and discounts are common for multiple visit packages. At first, it may seem counterintuitive - you've paid all this money for health insurance premiums, why would you pay for an appointment with your doctor or physical therapist out of pocket?

Reason 1:

  • You will receive better care. The provider will have more time, more energy, and more attention dedicated to you.

Reason 2:

  • You and your provider will be able to determine the best plan of care based on your needs. The insurance company/third party company will not be dictating your care.

Reason 3:

  • Paying out of pocket for services may be cheaper depending on your healthcare plan. If you have a high deductible plan, going through your insurance is usually more expensive. This is because providers charge a higher rate to insurance companies; if you haven't met your deductible you will pay the full amount billed to your insurance company.

  • You can submit a Superbill (receipt) for reimbursement at an out-of-network rate. Insurance companies typically reimburse 40-60% for out-of-network services.

Health insurance resources:

https://health.usnews.com/wellness/articles/what-is-concierge-medicine

https://www.nashvillephysicaltherapy.com/post/why-choose-an-out-of-network-or-cash-based-pt-practice

https://www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/Downloads/uniform-glossary-final.pdf


Health insurance is complicated and confusing, but it should not interfere with your health! If you have questions about concierge/self-pay physical therapy reach out directly: Jessica@physioyogaandwellness.com