Insurance blues

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So you’ve just finished your twelfth Physical Therapy visit for your low back pain. You did your research and chose to go to a clinic that accepted your insurance and only charged you a $25 dollar co-pay. The PT says you are close to discharge and then the other shoe drops. You get a letter from the PT billing office saying you owe over $1800 dollars for those 12 visits because you hadn’t met your deductible.

I can’t tell you how many times when I work for outpatient clinics we had this happen. a patient chose us because we were in-network and the copay was only $25 $30 $40. so they thought they were coming out cheap. The thing was, a lot of times people choose insurance based on how the copay looks or how much the in-network fees look and they fail to pay attention to how much their deductible is. If your deductible is $5,000, $6,000, or worse unless you go to the doctor a lot of times throughout the year or you have some type of serious medical issue it’s hard to bring that deductible down. and so you usually end up with a bill later on because the insurance is only paid partially the amount that they said they were going to pay initially or they didn’t pay anything and of course, the clinic has to recoup that cost somehow. Let me tell you, when somebody sees a bill for over $1,000 that they need to hurry up and pay, that PT session is not a fun one.

 It’s not like we as physical therapists are informed of what billables are exactly. I can tell you as a staff clinician or even the clinic manager we didn’t know how much each patient’s deductible was and we didn’t know how much each of our charges is billed for in the system. so we may be with a patient for our hour, hour and 20 minutes including the modalities and that patient bill for that day is almost $300 or more. Because we are not told how much every charge is so working in a clinic I didn’t know how much therapeutic exercise was. I didn’t know how much 8 minutes of the ultrasound came to, didn’t know that you got $25 for electronic stimulation something that the patient can do at home. The clinician at most places is pushed to build five to seven units because we’re told that’s the only way the clinic is making money not knowing that okay The company is paying me $40 Maybe 45 if I’m lucky per hour treatment but I’m seeing two to three patients and that one hour and the company is billing each patient due to what I’m doing with the patient close to $300 an hour. now see for the insurance companies usually with each Clinic they work with they set up okay here’s the greatest upon the percentage that we’re going to pay and they paid that but if the patient has a high deductible and the insurance company is not going to cover that cost until the deductible is met then boom the patient is forced to pay that full amount and not what the percentage markdown is that the insurance company was given because the insurance company basically negotiated we are either going to pay you this or we’re not going to pay you anything

  Back in Carolina after a patient got their bill I would get asked, how are you driving that car when you’re making $250 or $300 every time I see a patient I used to laugh because I was making $38 -$40 an hour maybe a little bit more with incentives and I’m like this money that that you had to pay out I’m only seeing my little $38 per hour my little $40 per hour and so at the end of the day I’m only receiving hey what the cost of your visit might have been pretty for a full 8 hours when I have seen 16 people in that 8-hour day so now I’m a little ticked off because somebody getting paid off of my back and I’m taking conciliatory crumbs.  Shoot I should be driving a Mercedes or something for the amount I’m billing out and I’m going home in a Hyundai.  That used to get me very mad.

Now coming from a world where I own my own clinic and have to deal with the insurance companies a little bit more I understand the process a little bit better. I had someone question me here about a year or so ago if you know the insurance company is only going to pay $25 for you doing this activity why don’t you just build $25 for this activity then I have to explain to the person well if I only build 25 dollars for this activity when the insurance company gets it they’re not going to pay me $25 for this activity they’re going to pay me less I might get $12.50 I might get $15 but even though they said that okay we’re going to pay this all that $25 as soon as I send it in and the bill is only 25 dollars they’re going to chop that up to whatever the do whatever the percentage rate is. Unfortunately for being such a small company it’s not something I can really argue about. I had to accept whatever reductions they place to place on the bill.

Sometimes when I get that remittance letter they also tell me that “Hey this patient has not met deductible yet and so this bill that was given to us has to be given to the patient”. That’s why I try to get my patient’s insurance information in the beginning so I can let them know all this information because in the very beginning days of fearless physical therapy, I didn’t have access to these websites or I didn’t know I had access to these websites and a few patients came back with surprises. Then it’s also why if possible I try to encourage my patients to do the cash pay option because especially if they have a high deductible because it is cheaper than the alternative. See when a patient is Cash pay I give the insurance company my cash pay rate is which is discussed with the patient before treatment begins. Yes, they’re paying that cash pay rate every visit, every month, or on a payment plan. They don’t have to worry about what codes are being built. So, for instance, say I spend an hour with you and each code is broken up into 15-minute increments and the average code is between 30 to 45 dollars. well if each code that was billed for the session is $35 that’s at least $140 that the patient will have to pay for that visit if their insurance decides not to cover it. 

The thing is billing gets even more complicated because the unit doesn’t necessarily have to be the full 15 minutes as long as I have enough time. I have seen patients get billed for 6 units in a 60-minute session and the billing wasn’t fraudulent and this was before the patient was placed on a modality like electrical stimulation. So before any of the things that clients love such as massage, electrical stimulation, or ultrasound get added on that bill is now at least $210.It’s not like the therapist is trying to pad the bill themselves or I should say we call ourselves doing what we feel the patient needs to get better or what the patient is responding best to and then therapy sessions can get quite expensive. That’s $210 dollars for 12 sessions that in the example earlier talked about.

So when I suggest to my patients that maybe they want to look into the cash pay option it’s not because I’m trying to be greedy and gouging dry it’s because I’m seeing what the insurance company is saying and I see that it’s actually going to be a lot cheaper for them to go the cash pay rate. I’m not trying to be unrealistic and I mean I grew up on free lunch myself so I understand that not everybody can pay cash pay rate and so I will gladly accept insurance but I try to educate my patients on what they could possibly end up receiving in the mail because of the insurance plan that they chose. 

Honestly, the payment isn’t even the most frustrating thing about dealing with insurance. What really can become a bother is insurance companies can dictate how many visits the patient can be seen. That is something that should be up to the patient and the therapists are the patient and the doctor. The insurance company can dictate what procedures are considered medically necessary. Here’s the rub, nine times out of 10 the person on the other end of the insurance company that is determined with medically necessary is not licensed in that field so it’s not like you have a physical therapist dictating to another physical therapist okay you should try this and that for the patient no it’s somebody who has a piece of paper with a list of buzzwords that they look for a list of tests that they look for and numbers and they make the determination from there.

 I will never forget the arguments I used to have when I worked in North Carolina trying to get patients more visits approved and being told that it was not medically necessary. For one patient I laid out all the different issues they had and the balance of why they weren’t saying this and that and I’m going back and forth with the insurance adjuster why this person needs more visits and why it’s necessary. I get upset and say “This person’s appropriate proprioception is messed up, they don’t know where they are in space. This person is not just the fall risk when walking this person is a fall risk if they try to roll over in bed.” As soon as the person heard the word “proprioception”  they said, “Oh the proprioception is off I can give you six more visits for that.”  I’m like that’s what I just said, I had to sit there and lay everything out for you. Because I couldn’t think of the appropriate word right then you were going to deny more visits. I just so happened to remember a million-dollar word that I learned in school and oh that qualifies a patient but the test saying the same as that cotton-picking thing doesn’t qualify the patient.

I’m not trying to say insurance companies are bad because they can be very helpful especially if you have something catastrophic going on. A lot of times insurance companies are really good for paying for things like surgeries or hospital visits but for other things, they aren’t the best. So when it’s time for you to choose your insurance company you need to make sure you educate yourself about what they pay for and what they won’t pay for how much your deductible is going to be. If you have a low out-of-pocket or a low premium chances are your deductible is going to be high. you need to check to see if your insurance company requires pre-authorization for certain procedures and know that even though you may need a procedure and maybe a week, two weeks sometimes a month before they authorize it. I’m just asking you to please educate yourself on which insurance plan says and the restrictions got to make place on you so there are no surprises later on. I can tell you that for things like home health, there are some insurances that only give the patients five visits no matter what the situation is and then nickel and dime the clinicians when they ask for more. I can also tell you that your doctors and other medical professionals don’t have as much control over the situation as you make think so just because you’re a doctor, nurse or therapists or whoever is adamant that you need certain treatments it doesn’t necessarily mean that it’s going to be approved. So please make sure you educate yourself on your insurance plans.


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