3 Questions To Ask Before Deciding To Use Your Insurance

Here’s the situation many people get in at the beginning of the year.

You’re a fairly active person and manage to stay healthy throughout most of the year. You like to work out, go on hikes, and play rec league sports with your friends. You end up getting a nagging injury that doesn’t affect your ability to function during your daily life, but sidelines you from doing your favorite things for a little while. You wait a couple of weeks and it just seems to be hanging on and not getting better. You find your way to a PT that takes your insurance and is close to home and go to your first visit. (This is if you’re lucky…many people start with an MD, medication, and imaging and find themselves 4-5 additional weeks down the road before getting to this point!)

You go for your first PT visit and they diagnose the issue and prescribe that you return 2-3x/week for 4-6 weeks. You go to the front desk to check out and you’re given a bill for $250-350. This catches you off guard because you thought you had a $40 copay. Unfortunately for you, it is then explained that you must first hit your deductible. Even with great insurance this can be well over $1,000-2,000. So once you’ve met the out of pocket deductible expense (which will be quickly if you come 3x/week) then you pay $40. You pay the bill and leave somewhat annoyed and not looking forward to paying out of pocket 3x/week to get what seem like cookie cutter exercises.

What’s wrong with this scenario? The issue is that people who stay relatively healthy rarely use up their deductibles unless something catastrophic occurs and there is a major change of health in the family. In the case of an incident like this, you’re glad you have coverage. For bangs and nicks that you get with regularly pushing your body, if you’re in generally good health, you can expect that insurance won’t pay for much. Especially with deductibles on the rise.

To be clear, the $250-350 that your PT may charge you is an estimate. The physical therapy practice has a negotiated contract with your insurance company, and they have to charge you the rate they charge the insurance company in order for that amount to go towards your deductible.

Let’s say you have a $2,000 deductible and they’re charging you $250. You’ve been prescribed 12 PT sessions.
What’s the time cost? 5 hours plus that 30 minute round trip puts us at 7.5 hours of time.
Total cost $825 plus 7.5 hours of your time. Less than half of the cash cost of in-network and less than half the time cost as well.

So it may be true that it costs you less money and less time to go out of network to patch up the occasional injury. This doesn’t mean that your insurance is useless, you still need that in the case of catastrophic events or if you need surgery, then it really comes in handy. There are a couple of scenarios in which you should use your insurance when it comes to PT.

The main scenario is post-surgically. Usually you’ve already met your deductible through getting surgery meaning that you’ll be paying your $40 copay from the jump. During the first 4-6 weeks after surgery you may need regular consistent treatments during which it is likely that the PT will be following a protocol to help the surgery heal. We always advise that in the early stages someone go to an in-network PT over DPT because it’s simply more cost effective. Once someone is ready for higher level back to sport activity, they switch over to us for advanced movement retraining and strengthening.

Here are the 3 questions you should ask yourself when deciding to use your insurance for PT.
Do you need someone to count your reps?

  • If you’re a self motivated individual and you can do your PT homework without supervision then you don’t need to go to PT 3x/week. The out of network model is better for you because we spend the time teaching you exactly what to do at home to keep getting yourself better between visits.

Do you value your time?

  • With the time cost laid out above it’s easy to see that out of network PT is much more cost effective in the long run. If you want to keep your vacation time for vacation and time with your family, it makes sense to go out of network.
  • There’s a common misconception that only wealthy people choose out of network PT and that’s simply not the case. We see people of all statuses who value their time and want to get the most bang for their buck.

Have you met your deductible?

  • If you’re a generally healthy person and your deductible is >$1500 you’re better off going out of network for your PT. Chances are that you’re not going to hit that deductible in the process of getting your knee or shoulder patched up.
  • Do you anticipate someone in your family will have major medical expenses that year? If you do, then you may be better off going in-network so that you can hit that deductible.

Hopefully this helps clear some of the confusion as to why you may choose to go in network vs out of network for your physical therapy. If you’re in Scottsdale, AZ and in need of a PT so that you can get back to doing what you love, give us a call. We can set up a 10 minute phone consultation to determine if you’re the right fit for our clinic and vice versa.
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