That’s a great question! I’m sure many have asked this question when running across physical therapists who decide to set up their practice as an out-of-network provider. When establishing our physical therapy practices we must decide: Will we take insurance or not?  It is becoming more common in many specialties in the medical field to bypass the red tape of insurance and have our patient’s pay us directly. But I promise you, it is not a decision made purely on money. When we decide to set up our businesses as out-of-network providers we are doing this fueled by our desire to help our patients in the way that feels clinically best. 

You may be asking yourself now: why wouldn’t you take insurance? Isn’t that why so many people have insurance – to use it at places like physical therapy? Sure! But not everyone has insurance and having to follow the strict (and often arbitrary) guidelines of insurance is more of a headache than it’s worth. As a consumer (or patient in this case) we always look to see what is the value? Do we get enough value from the service to be worth the money? 

The big answer as to why we don’t take insurance for payment comes down to three things: 

1. skilled one-on-one time with your therapist
2. Medical care decided on by your medical provider, NOT your insurance, and 
3. transparent billing 

One-on-one time with your therapist

As a provider, I have worked for a private practice as well as some big-name box PT companies - all who took insurance and all with similar underlying issues. In these models I was given 45-60 minutes to work with a patient for a new evaluation and 30-45 minutes to work with a patient for follow up treatment sessions. I also was required to double book patients and hit certain productivity (billing) requirements. In both of these scenarios - double booking and productivity requirements - the patient is not the primary focus for the company, it was about money. 

When a therapist is double booked they are splitting their time and attention between two different patients. This means while they may be doing some hands-on manual therapy with one patient the other doing exercises. But are they doing them correctly? Are the right muscles engaging? Is it painful? Is it too easy? Can’t they be doing this at home without a therapist? Then from the money side, double booking allows providers to appropriately bill for two patients at the same time thus making more money than seeing one patient. As for the productivity requirements, providers are encouraged to hit those productivity numbers by adding on billable modalities (think electrical stimulation, ice, heat, etc) which do not require their attention to administer but will make the company money while the therapist is working with another patient. 

With a fee-for-service or cash pay model, we are able to schedule our patients for longer sessions and devote all of our time and attention to the patient in front of us. At Pelvic Pride, we schedule our initial evaluation appointment for 75 minutes and our follow up appointments for 60 minutes. This means plenty of time to tell your story, work through all concerns, thoroughly evaluate, treat, educate, and guide you through the therapy process. We never double book and productivity requirements don’t exist. 

Medical care decided on by your medical provider, NOT your insurance

Did you know that your insurance company may be involved in dictating if, when, and how long you can receive medical care. Most insurance plans have a visit limit for physical therapy services - sometimes per calendar year, other times per incident (diagnosis). Either way, this visit limitation can restrict a patient’s ability to receive care or receive care covered by insurance. For example, many Blue Cross plans come with 35 visits per calendar year, which is not enough to help someone recover from an ACL surgery, a total knee replacement, or chronic low back pain. In this case, a patient may stop therapy just shy of completion or at a crucial moment - like getting ready to return to sport. On the pelvic floor side of things, many diagnoses are not covered by insurance at all. So even though you have insurance coverage for physical therapy visits, your specific issue may be denied coverage, regardless of if the research supports pelvic floor therapy as a gold standard of care or not.

Your care should not be dictated by your insurance company - EVER. Your care should be a conversation between you and your medical providers, and that is it! Your providers are the ones sitting in the room, listening to your story, assessing your symptoms, and we are the ones who have the medical training to be able to decide what the best care is. 

But what happens when your insurance company decides not to pay? 

Do you realize that on Day 1 you sign a paper that states you agree to pay for any dates of service not covered by your insurance?