How much do you really understand about your plan?

Do you really understand your health insurance? Do you know what your deductible is? Do you know what your copay is? Do you know the difference in going in network versus out of network? Have you been to the doctors office, experienced a hospital stay or have had physical therapy in the past and were shocked by the cost of those services when the bill arrived two or three months after your care? Ill bet you were not expecting the cost of the band-aid, throat lozenge or 30 minute therapy session to cost as much as it did, were you? That is because there is absolutely no transparency in our health care. If you are like me and most of the US, then no, you probably do not truly have a good understanding of your benefits. It is unfortunate but that is the way that insurance companies would like it. They have made it so confusing that most of us do not care to look into the specifics of our benefits. If we are sick or injured we just go to the doctor because we “have” insurance and it will be fine because insurance will cover it. The fact of the matter is that they will cover it, its just a matter of how much is it going to cost you before they cover it and what services will they actually cover? We will be taking some time to discuss some common insurance issues with respect to Physical Therapy services. But first, lets go over some definitions to make sure we all have a basic understanding of some insurance terms.

  1. Premium: the amount of money an individual/business pays in order to obtain an insurance policy.
  2. Deductible: the amount of money an individual pays out of pocket prior to your insurance plan picking up the bill.
  3. Co Pay: A fixed amount of money an individual pays on the spot each time they need to use their insurance.
  4. In Network: healthcare providers or healthcare systems that have contracted with your insurance company in order to receive negotiated (discounted) rates. 5.
  5. Out of Network: healthcare providers or healthcare systems that have chose not to negotiate discounted rates with an insurance provider

Now that we have covered the most common health insurance definitions, we can start to get a more transparent look at how you should go about making your decisions. Again, we are going to focus on where to start when deciding on which PT clinic you are going to go to.

The first thing I would suggest looking into is what your deductible is. In some cases, you may have one deductible that goes toward both in network and out of network and other plans you may have separate deductibles for each. Once you know what your deductible is you can find out if you have paid anything toward that deductible for the year. If you have not met your deductible, any of your visits to the PT will actually be “out of pocket” until that deductible is met. For example, lets say you have a $5000 deductible. Your initial visit may cost $400 and each follow up visit may cost $300 (rough estimate) . So, now it is 2 months and 10 PT visits (1 evaluation and 9 sessions) later and you receive your bill in the mail and you see that you owe $3100. You have not yet met your deductible so that money is coming out of your pocket.

On top of this, you may have an associated copay for each visit to the PT. It is not uncommon now to have a copay for a PT visit of $40 and in some cases way more! Now you have added an extra $400 to your PT bill (10 visits and $40 per visit). The unfortunate thing is that in a lot of cases when people pay their copay they think that is all they are required to pay for their PT session and its not until two months later when they receive their bill in the mail that they see it actually cost them another $3100. Can you now see how not having transparency in health care can be a huge issue? I know I do not like to be surprised by a bigger bill than I was expecting!

Once you have determined deductibles and copays it is now time to make a decision. Do I go with an in network or out of network clinic? Based on your plans deductibles it may not be a huge difference as either way you will be paying “out of pocket” until that deductible is met. Once it is met, your in network plan most likely will cover sessions at a higher percentage than out of network. For example in network may pay 80% of of your session while out of network may pay 60%. Obviously there are going to be differences based on your specific plan but this gives you a general idea.

Often times, out of network clinics can actually keep have lower cost since they are not accepting a discounted price from the insurance company. In network clinics usually have to raise their cost due to the the discounted rate they negotiated in order to remain profitable.

Another thing to remember is that you have a choice! If you are going to PT because your doctor said you should have it, it does not mean that you have to go to the PT clinic affiliated with your doctors office. Do your research, find a location and a PT that you match well with and has experience working with the issues that you are dealing with.

At Paramount we believe in transparency. We understand that people value their money and time. After all, we all work hard to have enough of both. When there is an open understanding on both sides, the provider and the client, we can make sure that we are working towards a common goal with your best interest in mind!