While at first glance it can seem like an out-of-network provider will come at an additional cost, that turns out not to be the case for most patients. Here are some of the main points to consider when selecting your Physical Therapist.

The Basics of Using Your Insurance Coverage for “In-Network Physical Therapy”

• In order to use your health insurance, you’ll first need to be seen by a physician and be referred to physical therapy. For many plans, the referral will then need to be submitted to the insurance company so that they can review your diagnosis and determine if they agree that physical therapy is indicated. If the insurance company (NOT your doctor) decides that PT is indicated, they will then determine the number of visits that you will be allowed to have. The number of insurance-approved visits is not always in alignment with what is prescribed by your doctor or what is needed for your condition, many people find the number of visits they are approved for is significantly less than the number that was requested and needed.

• Even if a pre-authorization is not required, many health insurance companies require that you have a PT referral from a physician for the service to be covered. This often leads to long wait times to get in to see your primary care provider to get a PT referral and delaying the start of care.

• Once you are finally able to get in to see an in-network physical therapist, your cost will be dictated by the specifics of your health insurance plan, namely your deductible, copay, and co-insurance responsibilities. Here’s a basic rundown of how deductibles, copays, and co-insurances work:
• Your plan’s deductible is the amount of money you’ll pay out of pocket in exchange for covered services from in-network providers before your insurance company pays anything. You are responsible for paying 100% of the cost of your treatment with an in-network provider until you have met your deductible.
• USA Today reports that average deductibles for health insurance plans in 2023 are roughly $2,000, but deductibles can be as high as $7,500 for an individual and $15,000 for a family. In other words, if your deductible is $2,000 and each session costs $100 with your in-network provider, you will pay $100/session for the first 20 sessions in full before your insurance kicks in to help cover the cost.
• Once you have hit your deductible, your insurance company will begin to pay for a portion of your care. A copayment is a flat dollar amount, while co-insurance is a percentage of the cost of the service. Depending on your plan you can owe one or both once your deductible is met.

• Perhaps the most important component to understand when using in-network providers is the limited amount of time you spend with your physical therapist in this model. Since in-network providers are contracted with insurance providers, they are guaranteed increased access to that insurance company’s patients. In exchange for this access, the provider agrees to accept a low reimbursement rate for their services. Here’s an example to better describe how this affects patient care: let’s say a provider needs to make $300 per hour to cover their overhead costs (rent for their location, paying themselves, their support staff, billing department, front office employees, etc). To get those guaranteed patients, the clinic agrees to a rate with insurance providers that is typically around $60-$75 per visit. This means that for the clinic to make enough money to cover its expenses, PTs need to pack 4 or 5 patients into each treating hour. As a result, patients are often booked every 15 minutes. Does this sound familiar? Patients often spend 10-12 minutes with their physical therapist, and then are left to complete their treatment with little or no supervision. This is the recipe for the typical experience patients have with an in-network provider – where a 60-minute treatment entails 10 minutes on a hot pack, 10 minutes of ultrasound from an assistant, 10 minutes with a physical therapist who is simultaneously managing other patients’ treatments, 20 minutes of mostly independent exercises with little direction on form or performance, and 10 minutes on an ice pack.

How it Works to Go “Out-of-Network” for Physical Therapy

An out-of-network provider is defined as a provider that does not have a contract with an insurance provider and is therefore not covered in the insurance company’s network. Since the provider is not a part of the insurance provider’s network, many of the restrictions listed above do not apply. Here are some important benefits to using an out-of-network provider:

• There is no pre-authorization process that must occur before starting with an out-of-network provider. No determination will be made as to whether physical therapy is considered necessary for your injury, and no one will restrict how many times you can see your physical therapist.
• No referral from a physician is needed to start physical therapy. State laws vary as to how long treatment can continue without a referral, but no referral is needed to begin PT. This is so important for patients seeking physical therapy to understand, since delays in access to PT negatively impact patient outcomes.
• There are no deductible, copayment, or co-insurance issues to wade through. When dealing with an out-of-network provider, patients can seek out and discuss rates that make sense in exchange for the service they are receiving.
• The most important benefit when making the decision to work with an out-of-network provider is the one-on-one time you get to spend with your physical therapist. Out-of-network providers are not limited by contracts with insurance providers, and as a result, do not need to pack multiple patients into each treating hour to cover their costs. By setting their hourly rate at a price that allows them to see one patient at a time, these providers are ensuring increased one-on-one time with their patients, which inevitably leads to improved outcomes for those patients in fewer visits.

Deciding between In-Network and Out-of-Network

While on the surface, it appears that going out-of-network can be a more costly decision for physical therapy, but taking a closer look at a total course of care and what you are getting as a patient reveals a different story. Let’s take the following as an example: A patient is prescribed physical therapy 3x per week for 6 weeks, here are two routes they may take.

In-Network PT Provider

• Submit PT referral to insurance company for pre-authorization (7-10 days)

• Make appointment for initial evaluation at a clinic (10-14 day waitlist)

• Spend 10 minutes of 1-on-1 time with physical therapist at each appointment

• Pay $75 for each appointment

• All 18 prescribed visits will be required and utilized due to limited time with physical therapist during each visit

• Duration of course of care from referral to completion: 59-66 days

• 3 visits per week for 6 weeks equates to $1,350 in cost and 180 total minutes with a physical therapist ($7.50 per minute)

• Upon discharge, patient no longer has access to physical therapist and must get another prescription to return to PT for refresher visits or updates on exercises

Out-of-Network PT Provider

• No pre-authorization required

• Contact provider, schedule evaluation (often within 48 hours of contact)

• Spend 60 minutes of 1-on-1 time with physical therapist at each appointment

• Pay $200 for each appointment

• After evaluation, physical therapist determines 2x per week for 2 weeks, then 1x per week for 2 weeks will be sufficient for current case as more work can be completed with increased 1-on-1 time

• Duration of course of care from referral to completion: 30 days

• 2 visits per week for 2 weeks, then 1 visit per week for 2 weeks equates to $1200 in cost and 360 total minutes with a physical therapist ($3.33 per minute)

• Upon discharge, patient can contact physical therapist with questions or concerns, and resume occasional visits to review exercise performance or progress/adjust home program

In Summary

Many factors go into deciding which provider to choose for physical therapy. While one of the most common questions patients have is “do you take my insurance,” a provider that takes your insurance may end up being more expensive and being unable to provide you with the same one-on-one care that you will find with an out-of-network provider. The time, dedication, and individual focus you will receive from an out-of-network provider is well worth the investment to ensure you’re getting the best care that’s available when you’re in need of PT.