Why we are out of network with insurance

The out of network model is becoming more popular among medical providers for several reasons. When I first started Absolute Kinetics, I chose the out of network model because it aligned with my goals and vision for the business. In this post I want to explain more about this model and clear up some myths around out of network care.

Why I chose OON

I spent years working at in network clinics and saw that insurance reimbursement rates were continuing to plummet, I was required to see more and more patients each day and for shorter treatment sessions, and a lot of my patients who needed care were being denied. I also saw that patients with higher level goals were stuck. Insurance only wanted to cover the patient’s ability to be able to complete “activities of daily living”, but for some patients being able to exercise, run, and do more physically demanding tasks were necessary for their health and quality of life.

I knew that in order to provide true individualized one-on-one care, I needed to cut out the middle man. Being OON, I can spend more time with patients each session and provide any type of treatment I think will be beneficial. By being able to spend a full uninterrupted hour with patients, we can accomplish so much more. This means most of my patients only come to see me once a week/once every other week during their plan of care. I am able to give them techniques and exercises to do on their own so that they have time to progress between sessions.

Is out of network care more expensive?

There is a big misconception that out of network care is always more expensive, which I think really stems from how confusing our insurance system is.

The short answer: it depends.

The total cost of care, whether in or out of network, depends on your plan, diagnosis, and goals. Let’s break down what we need to consider when determining total cost.

1. Total number of visits – how many visits will it take for you to reach your goals? MOST in network clinics recommend 8-12 visits. Most of my patients come in for 4-7 visits.

2. How long is the plan of care – Healing and strengthening takes time. I typically try to span visits out over 3-4 months so we can be confident that symptoms are managed or resolved, vs only working together for 4-6 weeks. So overall it is less visits, but over a long period of time so we can ensure long term results.

3. Price transparency – As a patient, this is one of the things that grinds my gears the most. Medical treatments are the only thing we agree to pay for without having any idea what the total cost will be. I love that I can tell my patients up front exactly what they will owe for their care, and they know that they won’t receive a surprise bill from me weeks or months after a session.

4. What does your insurance cover, and what is your co-pay and co-insurance? – will your insurance cover dry needling? Are there certain codes they don’t cover? Do you have a co-pay each visit or co-insurance? It’s important to consider how much per visit/week you may owe for a co-pay + your co-insurance when comparing overall cost.

5. What is your deductible and have you met it? – Many folks now have high deductible plans. This means outside of having major medical costs for one reason or another, many of us never hit our deductible before it resets. This means you may be paying all or most of your medical costs out of pocket regardless of whether you go to an in network or out of network facility.

Can I get reimbursed for out of network care? And does it go towards my deductible?

The answers to these questions will vary from plan to plan. I always recommend that you contact your insurance company and ask questions so that you fully understand what your benefits are and how your plan works. Here is a list of questions I recommend asking your insurance company.

1. What is your deductible?

2. Will out of network care count towards your deductible? Do you have a separate deductible for OON care?

3. Have you met any of your deductible?

4. What percentage of reimbursement is offered?

5. How do you submit superbills for reimbursement? (mail, fax, email, etc).

6. Do you require any other documentation (referral, letter of medical necessity, etc)?

Are out of network therapists “better”?

The answer to this one is simple: absolutely not.

Now in general, the therapists who I know that have gone out of network and started their own practice are committed to their specialty and lifelong education. They are leaders in both their business and the field of PT, so they are very good at what they do.

But that doesn’t mean that all the therapists working at in network clinics aren’t just as talented. Just like any other field, there are good and bad providers everywhere. There can be a lot of reasons why a provider chooses to work at an in network facility, but that doesn’t mean they aren’t a great clinician or that they can’t help you.

My best recommendation for finding the right facility and therapist for you is to ask questions and find what best fits your needs. Understand your insurance plan and find a provider you are comfortable with who has experience and expertise in helping people like you.

I hope after reading this you have a better understanding of why some businesses choose to be out of network and what to consider when choosing a provider and facility. If you have questions, please reach out to us any time at info@absolutekineticspt.com. You can also set up a free 10 minute phone consult with Dr. Alexis by sending us your information here.