insurance vs cash pay physical therapy: which is right for you?
There is a recent trend in physical therapy moving away from billing insurance and going toward a cash pay model either as a clinic or solo practitioner. I hope to explain the pros and cons of each to help you make the best decision for you and your healthcare.
The gist of it is, based on my experience and observations, is that insurance reimbursement for physical therapy services has been declining over the last handful of years. So basically a physical therapy clinic who is in network with a particular insurance plan has their reimbursement rates determined based on their contractural agreement and it has been doing down and not up over the years. For example, lets say you see a physical therapist for a visit and they bill your insurance for the visit $200 but based on agreement of being an in-network provider they only pay the clinic $90 for this visit. Now there are other factors that determine the rate and that is just an example of how it works. But in order for clinics to keep the lights on and pay their overhead they have had to adapt and one of the ways they do that is by increasing the patient volume because even though reimbursement is going down overhead expenses like employee salaries and benefits and rent go up! So for you that means you likely be treated at the same time as another patient or the therapist will treat you for a little bit before passing you off to a “tech” or an “aide” who will take you through the rest of your treatment. This leaves the therapist feeling rushed, less time to listen and adapt the treatment based on how things are going for you. Also, using insurance for physical therapy sometimes has restrictions: some plans only allow a certain number of visits or billed dollar amounts, or lets say you have shoulder and knee pain but you can’t be seen in the same visit for both areas so you have different appointments for each body part. Also, because they clinic is trying to maximize their reimbursement, not necessarly out of greed, but just to stay afloat, you generally have hour long appointments doing exercises you can someitmes do at home. Also, consider the cost factor: let’s say you have a copay of $25, and you are seen the typical 2x/week for 6-8 weeks, you could still end up paying $300-$400 out of pocket, and then consider what you time is worth - having to go before or after work or during your lunch hour to be seen.
The alternative is a cash based model where you pay the physical therapist directly- like you would a massage therapist, personal trainer, or chiropractor. The upfront cost is clear and no surprise bills. And with this model you don’t have the restrictions of insurance or being over treated with not bad, but unnecessary exercises just to fill an hour, there is more flexibility in creating your plan of care. Plus the goal is to treat you as efficiently as possible, so you are not taking an hour 2x a week to go to therapy, instead you can learn the exercises and do them at home with check ins as needed to modify or adapt your program based on your needs. It’s like if you go to an MD for a prescription for meds, you don’t go multiple times a week for them to watch you take it. With physical therapy, exercise is our medicine, so sometimes all you need is one visit to learn what you have to do and then you go home and do it. Also, at least at my clinic, you not only get one on one care but it is in a private room without having to worry about bumping into other people in a busy treatment room or waiting for a table. Also, if you have a high deductible plan you can use your FSA or HSA for payment.
I understand the feeling that if you have insurance you want to use it and paying out of pocket for physical therapy isn’t for everyone but if you value great care, and want to take a proactive approach to your care and maximize your time, cash based physical therapy may be a great option for you.
Jeff
(737) 334-9310
jeff@physioxpt.com