Why IN-Network Is Not Always IN Your Best Interest!

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It seems impossible these days to turn on the news or even have a conversation with a friend, without the topic of healthcare costs coming up. According to the health insurance index report from eHealth, the nation’s largest private online health insurance exchange, the average family premium (without subsidies) is $1,021 which is 23 percent higher than the average in 2016 and the average annual deductible for families was $8,352 in 2017 up 5% from 2016. Now, take into consideration that a large number of healthy families will never meet these high deductibles. We are then, receiving care based on the terms negotiated by the insurance companies and still paying out of pocket trying to reach that high deductible.

These numbers are a painful reality for many Americans and the level of care is often less than impressive. As we all come to terms with this new reality, we are forced to take a more focused approach to our healthcare needs. With that, comes truly understanding our benefits and when they are actually working for us. Today I want to talk about the questions we should be asking to make sure we are really benefiting from using our benefits!

When choosing a doctor to be a part of our healthcare team, we typically consider the 4 pillars below

• ​Quality of care,
• Convenience,
• Reputation in the marketplace
• Price

The two that create the most confusion, especially when comparing in-network vs out-of-network are price and quality of care.

Price is often the trickiest of the four to determine. Have you ever had a spouse on a different healthcare plan? If so, you have probably experienced something along the lines of going to the same optometrist for the exact same eye exam and receiving significantly different bills. What you pay is dictated by how well your insurance company has negotiated that particular service with that particular provider. So, what questions do we ask and where do we direct those questions, to prevent this from happening?

If it has been recommended that you see a Physical Therapist, we suggest you contact your insurance company and walk through your benefits with them and then call the PT’s you are considering and ask the below questions:

Ask your insurance provider:

• What is your deductible and how close are you to meeting it?
• What percentage of the bill if any, will they be paying prior to you meeting your deductible?

Ask potential Physical Therapists

• what rate will be charged prior to your deductible being met? (It is almost always much more than the negotiated rate available once your deductible is met)
• If you are considering an out-of network provider, ask for their pricing schedule and compare it to what you will be paying in-network.
• How many treatments on average they recommend for their patients.

When comparing pricing, one thing you cannot forget to consider is quality of care. For example will you be receiving a one-hour session where 100% of your time is spent with a Doctor of Physical Therapy? This level of service allows for faster healing times and less visits. Progressively worsening reimbursement rates and pressure from insurance companies are creating incomplete and insufficient care. In-Network providers have to see at least 2 patients per hour, leaving technicians and assistance to provide most of the patient care. This creates the need for more treatments, sometimes up to 3 per week. A focused treatment plan with dedicated time with your PT is almost always the most effective treatment option. 

After considering these factors as well as answering the above questions, most patients find it is in their best interest to choose a provider based on quality of care and the providers reputation in the marketplace, not whether or not the provider is in-network.

In-Network does not always mean IN YOUR best interest. Quality of care should be the number one priority when it comes to your health. Coverage and pricing should not be so confusing, but unfortunately, it is the nature of our healthcare system today. If you have any questions as you determine the best avenue for care, please do not hesitate to reach out.

In Health,
Julie Henderson

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