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  • Writer's pictureKirsten DesMarais

In-Network vs. Out-of-Network Physical Therapy: Deductible Math

By now I am sure you've noticed that healthcare costs are rising exponentially. And, your insurance premiums, copays, coinsurance, and deductibles are now reflecting that. In an effort to contain the rising healthcare costs and shift more risk to the insured, employer provided insurance options often include high-deductible plans with a lower premium and option for an HSA, "lower deductible" plans with higher up front cost, and finally PPO plans that determine your in-network provider options.

Keep reading if you want to learn my tips for assessing your own, unique insurance situation to make an informed decision about your most cost-effective care options.

Tip #1 - Determine your relative risk vs. your deductible.

Are you LIKELY to meet your deductible this insurance year?

Here are some things to consider when attempting to answer the above question:

What is your individual/family deductible (both in-network and out-of-network)?

Do you have any planned surgeries, procedures, or tests this insurance year?

Do you have things like medications, consistent appts., or other medical expenses that typically go towards your deductible?

For the above answers, are these expenses with in-network providers or out-of-network providers?

Find the sum of your planned expenses (or, use previous years if things are fairly consistent with you and your family's health)

How far are you from your deductible(s)?

Tip #2 - Determine other related insurance expenses and limitations.

Most insurance plans also include copays for office visits, co-insurance, visit limits for therapy services, covered and non-covered services, and required prior authorization to utilize specific services, to name a few.

Here are some things to consider when assessing the other related expenses and limitations of your plan:

What are the visit limits for physical therapy services per year?

Do you have a lifetime limit on therapy sessions for a specific diagnosis? (YES, this is a thing)

What are the covered/non-covered diagnoses or services? Are you seeking care for non-covered services?

What is the copay for a physical therapy visit?

Is there co-insurance for therapy visits?

Find the sum of the respective copay amounts, co-insurance, and/or note the office visit cost your insurance plan offers.

Tip #3 - Is the Math Mathing?

Now is the time to break out your calculator.

Below is a case example to guide you. This is based on a very simplified mock insurance scenario.

In-network physical therapy using a high deductible plan:

  • Initial evaluation: $430

  • Follow up visits: $230 x 6 = $1,380

  • Copay $20 x7 = $140

Total billed to insurance = $1,810 ** client responsibility, goes towards deductible. Bill recieved 4-6 weeks after sessions (or longer)**

Total client pays up front = $140 ** $20 collected at the time of each PT session **

Total financial investment = $1,950 for a PT evaluation and 6 follow up visits

** Financial investment NOT including any childcare, PTO, travel, or wait time to be seen **

Each insurance plan varies based on their respective benefits. However, you can see how significant of an investment physical therapy could be, depending on your plan.

Next, let's look at the same case example for an out-of-network option.

  • Initial evaluation: $175

  • Follow up visits: $150 x6 = $900

Total financial investment = $1,075

** Financial investment NOT including any childcare, PTO, travel, or wait time to be seen **

Comparison: $1,950 vs. $1,075

If you have an $8,000 deductible and only go on to utililze a total of $5,600 in medical services that year, you left almost $1,000 on the table for that one physical therapy episode of care.

Many insurance compaies allow you to apply your out-of-network expenses to the out-of-network deductible which allows for you to account for the out-of-pocket expenses you accrue.

AND, FSA/HSA funds can be used for out-of-network physical therapy services too!

Making the out-of-pocket option potentially even more reasonable.

Tip #4 - Assess the non-financial pros/cons of your in-network vs. out-of-network options

Specifics to consider when assessing your options:

- The provider - Do you connect with the provider? Are they a good fit for what you are looking for? Will you be able to see the same provider for all of your appointments?

- The wait time - How long is the wait to get in to see them and how soon will you be able to follow up? Waiting isn't always a negative thing! But, could be considered a cost if your function is significantly limited due to your current symptoms.

-Is it a welcoming environment?

- Does their schedule availability fit with your available time for appts? Do they offer evening or weekend appts.? Do they offer online scheduling?

- Can you bring your children to the appt.?

- Do they require a referral from your doctor?

Tip #5 - What do YOU want?

If you are going to extend financial resources, time, emotional energy, and physical effort on physical therapy, make sure it is what you want it to be. If you have specific things you value in a provider, in an environment, in scheduling needs, in a specific approach, then prioritize those in your decision making.

The age of out-of-network care is here.

Options for out-of-network care will continue to increase as patients and providers experience the benefits. Through my tips aove, I hope you see that out-of-network care may be more cost effective than you thought. And, in the least, gave you some things to consider next time you choose to seek care.

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