By Dr. Jessica Warnecke PT, DPT, OCS
There are so many different healthcare plans out there today that it can be hard to keep them (and their rules) straight. In fact, most of the general public have no idea what the difference between a deductible plan or a co-pay really is. Do you have a health savings account? Is your out-of-network deductible different than your in-network deductible?
All coverage considered, did you know that your plan may actually be costing you more money on the services they are "supposed" to include?! Not ok... but you are not alone in this thinking.
There are multiple answers to how a private PT can actually be more cost and time effective depending on what type of PT benefits your plan offers. Let’s go through a few common scenarios…
Scenario A: You’re On A Deductible Plan And The Deductible Has NOT Been Met
In this case, you will pay more to see an in-network provider. Austin area clinics easily charge $200-$300 per visit. You will pay this until you meet your deductible or until you’re done with PT, whichever comes first. The majority of cash PTs I know of in the area charge anywhere from $100-200 a session and get their clients better in half the amount of time as those therapists juggling 2-4 patients every treatment session. Plus, these PTs can provide you with a Superbill after each session so you can still apply the funds towards your deductible and potentially get reimbursed. Win Win.
Scenario B: Insurer Requires A Co-Pay For In-Network Care
Depends on the specific plan but I’ve seen insurers require the patient pay $40 - $80 per visit for in-network care. If you take the average and say $60 out of your pocket per visit and 2 visits per week, that’s $120. Multiply that by 6-8 weeks of treatment and you’re out about $840. If you only had to see your cash PT 3-4 times, you’d pay $800 (let’s assume they charge on the high end at $200/session), but you’d also gain a full month of your time! Plus, with co-pays the number you pay is assuming that all treatments are being covered. Very often you will still see bills for additional charges for a number of reasons because that’s how insurance companies make money.
Scenario C: Non-Covered Treatment
If you see your in-network therapist and they perform a treatment that isn’t covered, see you an additional visit that wasn’t approved, or treat you on a date outside of the permitted time frame, then you are stuck with the full bill! In the clinicians’ defense, many times we are not aware of what won’t be covered because the insurance company will look back on it after the fact and decide it doesn’t want to pay x, y, or z for whatever reason. Also, because the billing process through insurance occurs so slowly, you may not find out for 1-2 months after you’re done with PT and then get a shocking notice in the mail. With a cash service, you know how much you’re paying upfront and that includes everything that the therapist deems beneficial for your care.
Scenario D: Health Savings Account Or Flexible Spending Account
If your insurance plan has a HSA or a FSA with it, you get the benefits of seeing a cash-pay therapist without spending a dollar out of your wallet. Use your health savings or flexible spending account money and receive high-quality care.
These are four examples of common situations that I deal with or get asked about on a weekly basis. You may even have more than one that applies to you. So make sure you fully understand your plan and don't place full trust in your insurance to make all your healthcare costs a simple, upfront experience.
Knowledge is Power!
If you have other questions regarding your benefits or if private PT may be best for you, feel free to contact us today with any inquiries.
Meet Your Therapist
Jessica has been in Austin, TX for the past four years. She grew up in Idaho and attended PT school at Idaho State University. She completed an Orthopaedic Residency and became a Board Certified Orthopaedic Clinical Specialist in 2016.