Out-of-Network vs. In-Network: A Physical Therapist’s Perspective

I am a physical therapist who works in a physical therapy clinic that doesn’t participate in any insurance plans. So what does that really mean? What happens when a physical therapist is out-of-network? 

Many insurance companies deter people from going outside of the insurance network because of the higher expense. I get it. You’re paying a bunch of money every month for your health insurance. So why shouldn’t you use it and go to a doctor inside your network? Should you really bother paying more for a physical therapy service?

... Well that depends.

Not all physical therapy is equal. Simply put, you get what you pay for. There are benefits to staying in-network and only seeing providers who participate in your plan. There are also drawbacks. The same exists for seeing providers outside of your insurance network.

I could probably write a book on this topic, but I’ll try to make it brief for the purposes of this blog article.

When a medical provider participates in an insurance plan, they are only allowed to collect the insurance deductible and co-pay from the patient. The remaining cost of the visit gets billed to the insurance company so that the provider can get paid for the services rendered.

Problem #1:  In this in-network scenario, the insurance companies tend to dictate what the provider can do for each patient, in terms of the types of services permitted and the number of visits allowed.

But is the insurance company the expert on what the patient actually needs? This means that you might not receive all possible treatment techniques available, if they weren't approved by the insurance company. It can also result in less visits than what’s actually medically necessary for you. Of course there are pros and cons of both of these things. Probably less pros though.

Problem #2:  Insurance companies typically reimburse the in-network provider a small amount for each visit, depending on the specific insurance plan and the services delivered.

This tends to create a high-volume "factory like" environment where PT clinics schedule many patients at the same time. The result is less one-on-one time with the provider, and more time with unlicensed staff. This can prolong recovery time. And in some cases, depending on the cost of your copay, it can actually mean more money out of pocket than if you just went to see someone out-of-network who could spend more individualized time with you.  

Problem #3:  With a higher volume of patients and less time with each patient, the in-network provider is likely exhausted, worn out by the end of the day, and more interested in doing as little as possible to help you. In other words, they’re not able to give you their best.

Is this true for all providers? Probably not. But speaking from my own experience where I treated 16-25 patients in a typical 8-hour shift, my shoulders hurt, my back hurt, and all I could think of in the last couple of hours some days was survival.

So why have insurance? In my opinion, it’s to pay for the simple-to-fix things or the real medical emergencies. Insurance is good for the routine MD visits, the well visits, the sore throats and sinus infections, the steroid injections and MD visits to learn that all you need is “X, Y or Z” to help relieve what you have. It’s for the things that are more routine and typical. Honestly I believe there are many things that can be treated by in-network PT clinics. Keep in mind that I used to work in one. Although I got burnt out quickly. Insurance is also for emergency room visits and reducing the cost of expensive treatments.

Many of the best providers are out-of-network. The providers that can really help you with more complex conditions simply don’t participate with insurance. Why? Because they don’t want insurance companies to dictate what their patients need. They don’t want to treat dozens of patients each day and be unable to spend the time they feel is needed to get to the root of each person’s problem. Also, they want to be valued for their services without compromising the quality of care as they perceive it.

In the clinic where I work, I often treat clients who went to the “other” places first. They didn’t find the help they needed until they found us. I help people who have 10 different things going on with their bodies that all need to be addressed simultaneously with a more holistic approach. Sometimes I see people with simple conditions who realize they’re saving time and money in the long run by seeing me. I treat people who are not satisfied with their insurance company’s definition of medical necessity. Most importantly, I help people who prioritize their health and commit to not only having the pain go away, but working towards a full recovery.

Disclaimer:  The views expressed in this article are based on the opinion of the author, unless otherwise noted, and should not be taken as personal medical advice. The information provided is intended to help readers make their own informed health and wellness decisions.