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Understanding IN vs. OUT of Network Health Insurance

If you’re confused about IN vs. OUT of network in regards to your health insurance, you are not alone. I graduated with a Doctor of Physical Therapy degree and passed my national licensure exam, and I still didn’t fully understand health insurance until several months into working my first job. And things have continued to change at a rapid speed ever since then.


Over the years, more and more financial responsibility has been placed on the member – higher premiums, deductibles, and co-pays. Meanwhile, reimbursement for health care providers continues to go down. This mis-match leads to providers seeing more and more patients to make up the difference.


From the patient’s perspective, the PT is only spending 10-15 (oftentimes distracted) minutes with them while the PT hops between the handful of other patients also scheduled at the same time. The rest of the therapy appointment is spent with an aide/tech or completely independent using a handout. (**As a side note – billing an insurance company for skilled therapy when skilled therapy was not provided is insurance fraud.)


From the therapist’s perspective, they are running (sometimes literally) for 8-11 hours/day oftentimes through lunch, working before and after clinic hours, and often without time for a bathroom break.


Very quickly, the environment and stress can become overwhelming for well-meaning therapists, leading to burnout. Many talented and caring physical therapists have left the profession altogether because of this burnout, while others have been motivated to start their own out-of-network practice to provide the excellent level of care they’re capable of providing and that patients deserve, without the oversight of an insurance company. Some of the differences between an in-network and out-of-network physical therapy experience are listed below:


In-Network PT

Out-of-Network PT

Payment

​If deductible hasn’t been met, you pay the entire bill – I’ve seen up to $500/PT visit; if the deductible has been met, you may still owe money due to the co-insurance

You pay the provider directly at time of service (or pre-pay) with possibility of reimbursement from the insurance company

Pricing transparency

Provider is not required to disclose cost of services

A Good Faith Estimate is provided

One-on-one with PT?

NO - often seen alongside 1-3 other patients

YES

Amount of time spent with PT

Often limited to 10-15 minutes with remainder of time with an aide/tech or independent

​Working with the PT the entire session, usually 1 hour

PT expertise

Often a generalist – they are expected to treat all types of people/diagnoses, even ones they're not well-trained in – or, they don't have time to use their specialized training

Often a specialist – they have dedicated their post-grad training to learning how to help specific types of people who engage in specific activities

Appointment frequency

Expected to schedule 3x/week – some insurances consider 1x/wk as “maintenance,” which they do not pay for

​Determined by functional diagnosis, progress, goal timeline, independence and commitment to working on things outside appointments, and overall life schedule

Insurance company dictates...

1. How many sessions it should take you to “get better” – to an insurance company, this typically means back to everyday function, NOT back to dance

2. What type of treatment is covered (certain codes will not be covered at all or will not be covered if provided on the same day as another code) – you will foot the bill if a code is not covered

**This is based on your medical diagnosis and algorithm

NOTHING – number of sessions, type of treatment, and “better” is determined by you and guided by your PT’s expertise and recommendations

In short, out-of-network PT simply removes the ability of your insurance company to make decisions about your dancer’s health and wellness. And at Charlotte Dance Medicine, you (and your dancer) get a PT who has dedicated their time and training to continual learning about dance AND medicine as they both continue to evolve.


We, as a society, have been conditioned (by insurance companies) to view in-network as more "affordable” without considering other options that may be a better overall choice. In some cases, an in-network provider may be less of a financial investment. In others, it will not. But rather than asking yourself how much you want to pay for physical therapy or what’s the cheapest option… I encourage you to look at the whole picture.


What type of expertise are you searching for?


What type of experience will make you and your dancer feel supported throughout the recovery process?


How confident do you want your dancer to feel returning to what they love?


Find a provider who meets you on that level of care.


If you're ready for that level of care for your dancer, Charlotte Dance Medicine is here to help. Click the button below to schedule a call so we can chat through your current situation, goals, and any questions you may have – insurance-related or otherwise.


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