Why is my provider out-of-network?


When you call to make an appointment with a doctor, dentist, physical therapist, or any other medical professional, the chances are high that you are asked for your insurance information before scheduling an appointment.  This is so that the office can verify your benefits before your appointment and so that you know what you are responsible for paying before your treatment (co-pay, co-deductible, etc).  This usually means that your provider is “in-network.”  They have a contract with your insurance company to provide services at an agreed-upon rate.  Unfortunately, physical therapy reimbursement in Colorado usually ranges from 25-40% of what we charge for our services, and every year the rates go lower despite the provider’s expenses getting higher.  The other thing that most patients do not realize is that some insurance companies limit what we are able to do and do not reimburse for certain procedures.  This means that providers are constantly reviewing insurance policies to make sure that they are treating in a way that will help the patient, but also allow them to get paid.  Insurance companies also limit the amount of physical therapy visits that a patient can utilize in 1 year; often this number is very low at around 20 visits per year.

So what is “out-of-network” and how come some providers aren’t contracted with insurance companies?  Out-of-network means that the provider does not have a contract with the patient’s insurance company.  Depending on what their out-of-network benefits are, patients can submit for reimbursement from their insurance company.

I cannot speak for all providers, but I will list my personal reasons for being an “out-of-network provider.”  I am very passionate about improving my patient’s quality of life and eliminating their pain and I feel that everyone deserves the best care that they can possibly receive.  Being regulated by insurance company requirements causes us to adapt our treatment to fit within the imposed limitations, by what treatments they will cover and how many visits they will allow.  Insurance companies also require us to complete so much documentation that we find ourselves typing on the computer during part of the treatment just so we can keep up with the mounting paperwork.  When I complete private physical therapy treatments, I utilize whatever technique I feel is optimal for the patient and because it is one-on-one care, I am not dividing my attention between other patients and keeping up with demanding paperwork.  My patients tend to improve faster and are more comfortable with their customized exercise program because I teach it to them in their home; it’s often difficult to complete exercises in a clinic and then transfer them confidently to the home setting.  I can also utilize dry needling techniques without having to charge extra fees (insurance companies do not reimburse for cost of dry needling supplies).  There are also no costs associated with billing and being on the phone with insurance companies for hours, which allows me to keep my rates lower.

Being “out-of-network” gives me and my patients much more flexibility with treatments – I can treat them in their home or office, which is very convenient for the patient and allows me to observe them in their daily environment and advise beneficial changes.  I can utilize any technique that I see fit, I can treat one-on-one for as long as the patient requests (most appointments are 1 hour), and my time is dedicated to the patient, not the paperwork.

Utilizing out-of-network providers does take some effort on the patient’s part if they want to submit for reimbursement.  In my case, payment is always taken at the time of the appointment and then a “superbill” is given to the patient in order to submit to the insurance company.  Most out-of-network providers accept credit cards, cash, check and HSA plans as well.  Paying at the time of service is advantageous for the patient, as more than likely the fee is drastically reduced from the normal charges.  In my practice, I come to the patient’s home and I still charge a similar amount or sometimes less than it would cost for the patient to go to a clinic and pay out-of-network costs.

Before you decide if you are going to go for an in-network provider, check your co-pay or co-deductible payments.  Often you will find that your out-of-pocket payment to an IN-network provider is not much less that the OUT-of-network charges.  If you are looking to get the most bang for your buck, out-of-network providers do not have limitations based on what the insurance company feels is adequate and are able to focus solely on YOU!  They will spend more time with you, are able to listen to your needs and customize a program based on their expertise and your feedback.

If you have any questions or would like to look into private physical therapy in the Denver Metro area, please visit my website at http://www.SolsticePhysicalTherapy.com  or fill out the contact form below.

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