Is My Physical Therapist “IN” or “OUT” of Network?

Is My Physical Therapist “IN” or “OUT” of Network?

One of the first questions a patient will ask when they are looking for a physical therapist is,”Is this therapist In or Out of network with my insurance?”  To begin, all therapists at Integrative PT of NYC are in network with most major insurance carriers. 

There are many advantages for a patient to choose an in network provider which are listed below:

1. lower deductible amount

2. lower co-pay amount

3. quicker authorizations and approvals for visits are more likely to occur

4. exact contracted rate per visit is known by the clinic in order to properly bill the patient in regards to getting payments at time of service.  So the patient can avoid getting a large bill at the end of their therapy sessions once the explanation of benefits is received by the clinic which can 30-45 days from the date of service.
   

Here are a few examples of some frustrating situations when going to an out of network therapist:

1. higher deductible

2. higher co-pay

3. no specific contracted rate per visit so bills for each individual visit can be costly. The clinic can basically charge what they want because there is no contract between the insurance and the provider.

A patient will call the clinic they are interested in going to and in some cases they will give their insurance information over the phone or by e-mail/fax so the clinic can get specifics regarding the insurance benefits information.  Sometimes this step will be done on the day of the 1st visit.

Most of the time this information is correct but there are some times when the insurance rep. tells the clinic something that is different from the patient’s actual benefits.  These insurance companies do not always have their data correctly entered and that may cause a difference in benefits when the first explanation of benefits is received. The explanation of benefits (EOB) is a break down of your visit at physical therapy for what was performed/charged and for what the insurance company will reimburse the provider. It will show what the patient is responsible for in regards to co-pay or deductible amounts.  To give one example, an insurance rep may tell the clinic that the patient has no deductible and only has a co-pay of 20 dollars per visit.  The first EOB is received and low and behold there is a deductible and the patient is responsible for the cost of the entire visit, which depends on the contracted rate for that specific clinic. This does not happen often but it can and will.

Lets show you a side by side comparison of a patient with Cigna insurance who’s insurance plan offers both in and out of network benefits for the patient.

John’s in-network benefits

• Does the patient require a referral from a doctor for PT: No

• How many visits per year for PT: 30

• Does the patient require authorizations for PT visits: Yes after the 5th visit

• Does the patient have a deductible PT: No

• Does the patient have a co-pay for PT: Yes and the amount is $35/visit

Now lets compare that to the Out of network information

• Does the patient require a referral from a doctor for PT: No

• How many visits per year for PT: 30

• Does the patient require authorizations for PT visits: Yes after the 1st visit

• Does the patient have a deductible PT: Yes and the amount is $2,500, none of that amount has been met to date.

• Does the patient have a copay for PT: Yes and the amount is $60/visit

So let’s say the patient decides to go for the out patient therapy option. They will have to pay for the entire cost of the PT visit, which in some cases can be as high as $250-300 per visit until their entire deductible is met. Once that deductible dollar amount is met they will have to pay $60/visit as opposed to $35/visit and no deductible amount with an in network therapist.

In closing, it is without a doubt better for a patient to use an in network therapist for all the examples noted above. On the other hand, it is clear that the out of network option benefits the provider and there are times when it can for both the patient and the therapist.  It is important for the patients to know their benefits.  That will make your process of finding a therapist much easier.  I hope this blog was helpful in getting you to understand the differences between using an in and out of network provider.

Frank Ruggiero DPT

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