The Insurance Conundrum: Understanding Your Health Insurance Coverage

“I have insurance, my plan will cover it”. Words I’ve heard and read far too often that end up being the prerequisite for some healthcare horror story. The harsh reality for many patients is that they end up being caught in the middle between a provider that is trying to be reimbursed for their services, and insurance companies that are operating as for profit institutions.  We often tend to forget that most prominent insurance companies have stock symbols, therefore their loyalties are with the shareholders (e.g. CI, UNH, ANTM, AET).

Notice the correlation across the board between the record high stock prices and the implementation of Obamacare?  When hospitals are billing hundreds of dollars for a dose of Tylenol it’s pretty obvious that the system itself is “sick”.

The good news is that you don’t have to be a helpless bystander!  Here are some general tips to help you navigate the healthcare minefield.

  1. Become an informed consumer.  We can’t predict accidents and illnesses, but evaluating your past history and being honest with yourself about your health care needs is the first step to choosing a plan and provider that work for you.  With insurance premiums on the rise it’s a constant struggle between what we can afford vs. what level of coverage we need.  Somewhere within those endless documents you tossed to the side from your insurance plan is a benefit breakdown letting you know exactly what you are covered for.  Not being aware of the coverage limitations of your plan is just as irresponsible as being unaware of your credit card’s interest rates.
  2. Don’t assume anything.  Just because you have coverage for a particular service doesn’t mean you can flash your insurance card and they will pick up 100% of the tab.  The bulk of policies operate on the concept of cost sharing.  Deductibles, coinsurance, copay’s are all insurance terms that essentially mean the same thing: “You the member are responsible for this portion of the bill”.  We’ll revisit this later on.
  3. The “same” insurance, does not mean the “same” benefits.  You have probably heard or said the following statement, “My friend has the same insurance as me and he went to this great place and didn’t have to pay anything”.  Once again…don’t assume anything!  While the insurance carrier name on cards may be the same, there may be dozens of different plans that fall under that same umbrella.  All of which have vastly different levels of coverage.  In addition, your friend/co-worker may have had past surgeries, gone to dozens of doctors, or had previous outpatient services that resulted in them meeting their deductible and/or out of pocket max.  The best way to find out is to call the provider you are considering seeing.  A great provider will be able to gather some information from you and call your plan to verify the policy and go over that information with you prior to any appointments you have with them.  This should at least give you a fairly accurate estimate of what the cost of care will be and enable you to budget accordingly.  If a provider is too busy or unwilling to do this for you perhaps that should be your first red flag.
  4. Find a provider that fits your needs.  This can be just as tricky as picking an insurance plan.  You’re putting your health in someone else’s hands, this is an important decision and you owe it to yourself to do your homework.  The internet can be a valuable tool here.  There are an endless variety of resources available that you can utilize such as yelp, google, zocdoc etc. that will show you what past patients experience’s have been like.  Use this to your advantage!
  5. You can go “out of network.”  As constraints on In-Network providers get more stringent many providers are seeing the writing on the wall and choosing to go Out-of-Network or simply becoming cash only businesses.  Don’t let this deter you from considering those providers as viable options.  The reasons for providers making this switch is important to consider in order to understand why they would do this despite being financially less appealing to potential patients.  Let’s discuss this within the scope of physical therapy.  In-Network providers are contracted with insurance plans to accept a certain reimbursement for services in exchange for the “privilege” of being in their network.  This allows them to cast a wider net in regards to the patients they have access to, but it also forces them to operate under a certain business model in order to stay viable and make a profit.  In New York City this results in many in-network providers using a group therapy model in which one licensed physical therapist is treating multiple patients at the same time (up to 5 in my experiences), or even worse, having under-qualified aides heavily involved in patient care.  They are sacrificing quality care in exchange for volume.  This will typically result in utilization of more visits to get better, so instead of paying $100-150 out of pocket 6-8 times in most one on one settings you end up paying your co-pay of $30-50 15-20 times.  All of a sudden the math does not seem as one sided.   You may need to ask yourself if you are satisfied with only receiving a few minutes of individual attention each visit.   Is your visit laced with time filler’s like hot packs and ice packs which feel nice but at the same time can all be done on your own time?  We wouldn’t accept this kind of distraction from our barber/doctor, so why is this ok from the person we are relying on for the treatment of our injuries?  That’s not to say there aren’t phenomenal healthcare professional’s working under these conditions, but how can we expect them to put their best foot forward when they have multiple patients and responsibilities competing for their attention?

Going out of network enables the therapist to treat patients one on one and provide the individual attention needed to maximize progress in your recovery at each and every visit.  Office staff isn’t overwhelmed with a constant stream of patients and can take time to go over any questions or concerns you may have about coverage, insurance authorizations, billing and so on which can avoid confusion and potential increased costs down the road.  The choice can be overwhelming.  If you still have questions or need assistance do not hesitate to reach out and someone on our staff would be happy to assist.

Until next time Happy Rehabbing!

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“I have been to several PT practices over the years, and Perfect Stride deserves five stars. I worked with Vikash, who was knowledgeable and thorough and got me back on my feet – literally! Although I did not work with any of the other therapists, I observed they maintain the same high standard as Vikash. And Austin does a great job of keeping everything running smoothly. I am glad my doctor recommended Perfect Stride!”


– Brian C

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