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Why out-of-network?

It’s no secret- insurance is not as helpful as it was in the 90s and early 2000s. How it works is less than clear and it only continues to cloud as deductibles and premiums skyrocket. Does it confuse you? You are not alone. Many people blindly go to the doctor that is closest to them and is in-network with their insurance simply because they think they HAVE TO or are just plain confused by the system.



So why go out-of-network for healthcare? First, a quick insurance lesson:


Many times one of the first questions that people ask is “Do you take my insurance?” What they mean is “Can I pay a co-pay for your services?” For in-network healthcare, the companies have agreements with the insurance companies that they will be paid a certain amount per visit. So if you pay a $30 copay for a physical therapy visit, the PT is not only making $30. Your insurance company is paying them more.


For most plans, you may have to pay 100% out of pocket until your deductible is reached then you would pay the co-pay for services. A deductible is a set amount that you must pay out of pocket before your insurance will cover any services; it usually restarts in January. Over the past decade, plans have seen an increase of deductibles by 200% or more! This means more out-of-pocket spending but also ever increasing premiums. The premium is that you pay monthly for your insurance policy.


If you work for a larger company, or pay a higher premium, you may have a lower deductible than most. However, being self-employed or working for a smaller company nearly always means you will have a high deductible plan. Folks who are looking to spend less monthly (lower premium) will also opt for the high deductible option.

Real life example: Woman going to PT at an in-network clinic, deductible not yet met. For each visit, she was charged $387. This is out of pocket, no insurance help (because remember, her deductible isn’t met). She attends PT 2x/week for 2 weeks before reaching her deductible, thus paying $1548. After that she has a $30 copay for the remaining 8 visits they want to see her which is another $240. During her visits, she is one of three patients that the PT is helping. It is not until the 5th visit that hands are even laid on her to check the joint or provide manual therapy. She has made minimal progress in her pain.


Another option: out-of-network clinics like Spectrum Performance. Her total for 4 visits would be somewhere between $660 and $720. These 4 visits would be one-on-one with her PT, include an individualized and flexible plan, plenty of manual work, direct access to the PT through email or messaging. The visits would probably be spaced out 1-2 weeks. She will likely already be feeling much better and well on her way to getting back to activity following 4 visits.



On first glance, it may seem “more expensive” but when you do the math it may surprise you! Regardless, do you want to choose who will take care of your body based on “cheapness”?


Quicker track to your goals


Many of the patients at Spectrum Performance decide to self-pay rather than slowly tick away at a $5000 deductible with providers that don’t get them or aren’t able to fit their schedule. Because of this, we have the ability to flow seamlessly from rehab to strength and conditioning to return to fitness then to injury prevention. Visits are full of education, investigating and planning accordingly and establishing your goals. These patients are dedicated to feeling better, so they have little trouble performing a few exercises on their own through the week. Then we are able to check in, progress the rehab and spend time addressing their needs hands-on. The outcomes are incomparable! These opportunities would not be possible had they paid Kaiser $30/visit for upwards of 12 visits. Nobody has time for that.


What can you do?


That co-pay of $30 sounds really nice,” but what value does that bring? Read the fine print and know your plan- you might be paying MORE money for LESS care.


Frustrated? Yea, we all are. My suggestion to you-- call your insurance company (number on the back of your insurance card). Ask for these things:

In-network deductible, copay and out of pocket costs

Out-of-network deductible, copay and out of pocket costs

If you have a high deductible plan, ask if you can set up an HSA (health savings account) -- more on these later.


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TLDR

Seeing an out-of-network provider allows individual plans with better outcomes, less time spent, greater flexibility, and less total cost.

Learn about your insurance plan. Call the number on the back of your insurance card and ask them what your deductibles are- both in and out of network.

Have questions about out-of-network care at Spectrum Performance? Send an email to info@SpectrumPerformance.fit and let’s schedule some time to chat about your goals!

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Thanks for reading!

Dr. Jackie, DPT



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