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Cash Based vs Insurance

Do you know what the difference between these two models is? Do you understand the term cash-based? Do you know what your insurance benefits are?

This is by far what I get asked about the most when clients first start looking into working with me. Part of the challenge is that the concept is new to many, and the option of not using insurance is like using an oculus near an open stairwell.

Let's start with what most people know about insurance.

We've always had health insurance, and we get health insurance for our healthcare costs. It's usually a benefit of our jobs and helps us get in to see providers so they can run tests, prescribe medications, and follow up with what's going on. It sounds like an easy decision to get insurance, use insurance, and be happy with insurance.

While traditionally that was the case for a long time, unfortunately, health insurance has changed significantly.

While you may have paid a $20 co-pay for physical therapy a decade ago, that co-pay cost has not only increased but so has your deductible.

Both of these mean that your out-of-pocket cost is now more expensive than what we previously knew.

While having an increase in your co-pay may be annoying, it's usually not too bad since you know about it upfront. You may now have a co-pay as much as $40 or $50, but you're seeing a doctor, so that doesn't seem so bad.

What crushes you is when you get the bill a month later and you find out that you are responsible for everything up until the deductible is met.

If you have a $500 deductible that might seem manageable, but many people now have deductibles at $5000 or more.

I rarely see a plan that stops the out-of-pocket costs below $2500.

All of a sudden your physical therapy session, which you thought costs $50, can now cost upwards of $350 a session. This $350 price is determined by the codes used in your treatment and the rate determined by your insurance.

This is the side that the consumer sees. They see dollars and they evaluate the value of their plan and their care based on the cost they have to spend out of pocket.

Even if you are able to afford those therapy sessions for $350 an hour, the feeling that you've been deceived is where the pain really sinks in.

Now to turn the blade a bit more, you can look back and realize that not only are you paying more out of pocket for your care, but you are also paying more for the insurance plan. Your premium has risen and your deductible has risen, but your wages have not kept up with that rate. Ouch!

I can pull back the curtain a bit on what we see on our side as providers. It's not pretty, but keep reading if you want to know more.

As a provider, I am an expert in determining the best plan for you to recover, make recommendations, provide treatments, and determine a treatment frequency that will get you the best outcome.

I went to school for a long time, spent literal years worth of reading, listening, watching, and doing, (and took on a heap load of debt) to get to this point.

I take your recovery and your care seriously and have committed my brain, body, and passion toward helping others feel great.

However, when we are working with insurance companies, my expert opinion is no longer the deciding factor in your care.

Unfortunately, health insurance is a big business, and big businesses have investors to reward. That means they want to collect the most and pay out the least. By limiting visits, limiting treatments, and reducing the overall care provided, they can keep more of the premiums and turn in a hefty profit sheet.

As a physical therapist in an insurance-based clinic, it is incredibly frustrating when I have a client with me who has a problem I know I can solve for them but red tape gets in the way.

It starts out going well - they have a problem I've seen this problem before, I feel very confident in the outcome and have a good understanding of how long it will take to fix it. They also tend to be motivated to get better, and we are locked in on the long-term goal to get them back to doing what they love.

I write up my evaluation, fill out (excessive) paperwork that is required by insurance, figure out what to code, how to write it, and where to fill it on each paper. I cross all the Ts and dot all the Is. I send it out feeling confident that this client will get better.

Then we get the request returned.

We don't get approved for the sessions we need, we get limited on what kind of treatment we can give, and we have to wait for the payment to keep our lights on.

It has been determined by Debbie in Iowa that this client doesn't need all the visits and treatments that I have recommended, and that it's only worth $70 a session.

My apologies to all Debbies - I know many of you are not insurance agents.

This can't be! I filled out everything completely, I had a bulletproof plan, and I had a client that wants to work with me and absolutely loves the plan. The insurance company says no dice.

This client's care has been determined by someone who knows nothing about injuries, nothing about physical therapy, and most importantly, nothing about the client's affect.

At this point, patients get frustrated with this news.

They call their insurance only to hear the same 'on-hold' song for over an hour and then find out these are their benefit limitations, and there is no changing the approved treatment.

Some clients decide to forget about insurance and decide that they will just pay for the additional sessions they need. However, the physical therapy clinic is in a contract with their insurance company, we have to accept their insurance, and we can't offer them a cash price.

We have to bill them the $350 price that is in the contract. We are not allowed to offer a discount once we are in-contract.

I know it doesn't make sense, but this is very real!

I can go on, but that's why we have more blogs coming every other week.

Here is a quick rundown on the benefits of cash-based services.

First of all, it doesn't mean you have to pay cash.

We just don't accept insurance. You can pay with cash, check, credit card, HSA, or FSA. We will even accept cryptocurrency!

What it does mean though is that you get to pick your provider, you get to find an expert that understands you, and you get to agree to how much care you get and when.

Cash-based doesn't have limited visits, doesn't dictate what treatment you can have, and doesn't refuse your plan because Debbie in Iowa says so (Sorry again to any of those wonderful Debbie's in Iowa).

We didn't even talk about the traditional hoops you have to jump through before getting a referral to an insurance-based physical therapist. Usually, you need to get a referral when you go through insurance. All of a sudden, no insurance means no referral needed.

You want physical therapy, then call your physical therapist and get it.

If you still have questions, reach out and we are happy to share the inside details of insurance compared to cash physical therapy.

Stay tuned for future blog posts because this is something I can just keep ranting about. It's good information, and you deserve accurate information because it's your health. No one should be able to determine what's best for you more than you yourself and a compassionate provider who is on your side. #snowbeastperformance

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