Out-of-Network May Not Be More Expensive!

by | Aug 7, 2016

Out-of-Network ≠ Expensive! 

Oftentimes when people hear that I am an ‘out-of-network’ PT, they assume this means that it must cost a lot of money to see me. This is simply not true! There are many reasons why I have chosen to be out of network, but the most important reason is that it sets me free to provide excellent patient care without the insurance company acting as a middle-man, influencing how I practice. The PhysioWorks business model is very simple, and our pricing is set up so that the out-of-pocket cost for a course of treatment should be very similar to, if not less than, what you would pay at a traditional insurance-based clinic. Let me explain.

Simple Pricing

My pricing structure is very simple: $225 for a video running assessment appointment, $135/hour for everything else. This hourly fee is the same regardless of which or how many treatments we do during your appointment. My only incentive is to do  those treatments that you really need to get better – I’m not worried about which ones have the biggest insurance payout. There is no incentive to do treatments that research shows do little or nothing to progress healing, or spend time doing things that you can easily do yourself at home – like heat, ice, or exercise repetitions (unless that’s what you really want to do!) Plus, at PhysioWorks, all of your treatment will be with a licensed, experienced physical therapist (that would be me!) – no being handed off to aides, assistants, or having to explain yourself again and again to different therapists.

Now, I agree that on the surface, $135/hour does sound a bit expensive, especially when compared with a $25 or $50 per visit co-pay or co-insurance. But in order to do a true cost comparison, we need to look a little deeper: we need to consider how many appointments are required over the whole course of treatment in my clinic vs. a traditional insurance-based clinic, and we need to know how much each of those appointments will ultimately cost the patient in each case.

Tailored Schedule

In the US, it is standard to go to PT 2-3 times per week over 4-8 weeks. Today’s PT business models and insurance reimbursement rates are all built around this assumption. So, many people who go to PT will have 8-24 visits over 4-8 weeks. There really isn’t any research supporting this frequency of treatment – it’s simply what we’ve come to accept as normal in the US. In the UK, where I earned my degree and started practice, once a week is a more common appointment frequency. I know from having worked in both places that neither model is ‘right’ – they are just different. Both systems work ‘ok’ for most patients, but both also have drawbacks and fail a certain percentage of patients.

Do you need to be going to therapy as often, should we be working off a different schedule?

Do you need to be going to therapy as often, should we be working off a different schedule?

At PhysioWorks, because I am not beholden to insurance company reimbursements, I am free to tailor treatment and appointment frequency to fit each patient’s individual needs. In my experience, very few patients need to come in more than once a week. Also, as treatment progresses, we can usually stretch appointments out even further. This approach can provide a longer term solution to your problem; we have blogged about this previously. The table below shows a typical out-of-network treatment schedule compared with an in-network schedule. If we follow this schedule, I would see this patient for a total of six visits over 10 weeks. I may see some patients five times over six months! The schedule is tailored to the patient, including the length of time they have had their issue.

In-network vs out-of-network cost

In-network vs out-of-network cost. (Hypothetical example; individual patient schedules will vary depending on needs.)

Predictable Cost

Now consider that at an insurance-based clinic, many patients will have to meet their insurance deductible before they start paying co-pay or co-insurance. This is when you find out what the ‘sticker price’ is at the traditional clinic –and it’s almost always going to be at least, or maybe much more than, my hourly rate. But, because an insurance-based clinic charges per treatment unit, they won’t be able to tell you exactly how much your visit will cost until after your appointment, because it will depend on which treatments your PT chooses. If you see different clinicians each time, then each appointment cost will often vary.

In addition, many insurance plans do have some out-of-network coverage. This means that you as the patient can submit your receipt from PhysioWorks to your insurance company for reimbursement. How much they cover will depend on your specific policy.

How we compare with in-network clinics

So how can you figure out which option is more cost-effective? Based on our example schedule above and several typical insurance profiles you can see in the chart below that we can often be less costly.

Graph showing the out-of-pocket cost in attending therapy using different physical therapy models. Does not account for travel costs or the value of time lost for appointments.

Total estimated cost for an entire course of PT treatment for several common health insurance plans. Does not account for travel costs or the value of time lost for appointments.

The spreadsheet below has a detailed breakdown of the numbers summarized above. You may argue that we cost a little more per minute than in-network therapy, but when you account for all the travel time, appointment time, and time lost from work for a typical therapy schedule I would argue that we are at the very least an even cost, and perhaps maybe less costly.

Chart showing the cost of in and out of network physical therapy hypothetical example

Chart showing the cost of in and out of network physical therapy hypothetical example

Is this for you?

I realize that everyone’s insurance coverage is different, so for some, it might cost a little more to choose PhysioWorks for PT over a traditional clinic. But I believe that practicing this way provides many benefits and value to the patient that would be very difficult or impossible to achieve in an insurance-based clinic. I’ve already mentioned that being out-of-network frees me up to provide individualized care without worrying about which treatments are and aren’t reimbursed. I am not time-pressured to achieve high-volume patient throughput in order to make enough profit in an era of ever-falling insurance reimbursements.  I have time to focus on each patient, to really listen to their story and their goals. Time to educate my patients about biomechanics and pain science (something insurance won’t reimburse for!) and to answer all their questions. Time to stay up-to-date on the very latest research. Time to respond to phone calls and emails from patients in-between appointments – I’ve even had patients email me pictures or videos to show me their concerns, and I’ve been able to send the pictures back annotated and sometimes video to answer their questions. I believe all of this provides tremendous value to my patients.

Believe me when I tell you that I did not leave a good-paying job, go out on a limb, and invest my time and savings into starting my own PT practice, just to overcharge patients for services they could get elsewhere for much less cost. No. I did this to help patients that I could see falling through the cracks in the traditional PT setting. Those for whom 2x/week for 4 weeks isn’t enough to correct months or years of chronic pain. Those who want to do more than go about ‘daily life’ pain-free – they want to get back to running marathons or playing 18 holes of golf pain-free. Those who want to learn how to prevent re-injury and wind up stronger than ever. Those who want to avoid costly, risky, and disruptive surgery. And those who just don’t have time in their schedule for PT 2-3 times a week for 4-8 weeks! (Who does?!)

If this sounds like you, I’ve love to hear from you and discuss how I can help you overcome pain and injury and meet or even exceed your goals!


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