• James Park, PT, DPT

In-Network vs Out-of-Network?

How do you go about choosing the right physical therapist? What is the difference between being in-network versus out-of-network, and what does it really mean when you hear "we work with your insurance." The common scenario that most people encounter physical therapy is when they get a referral by their doctor to go see a physical therapist to treat their nagging pain or injury. Patients may or may not be told by their doctor or the front desk staff to go see a specific PT, or sometimes they are given a long list of names and suggested to pick one. In other cases, people have to resort to Google, Yelp or a recommendation from a family or friend, and hope for the best. So ultimately, this begs the question of where do I start and how do I go about navigating what can be a confusing process.


First off in the state of NJ, you don't need a prescription from your doctor to start seeing a physical therapist. This means you can call up a physical therapist directly and schedule an appointment to be seen; this is referred to as "direct access." It is required within 30 days of starting your physical therapy treatment that you need a prescription from a doctor, whether it be your primary care physician or a specialist.


As mentioned before, most people are told to see a physical therapist by their doctor, and usually the first question that comes to mind is "do you take my insurance?" Healthcare providers can decide to be "in-network" or "out-of-network," which has implications on the cost and quality of care for patients. Being "in-network" means that the provider is agreeing to accept a contracted rate from an insurance company in exchange for ease of access to patients who have that insurance. However, this rate is typically very low in terms of reimbursement which often leads to clinics scheduling multiple patients within the same hour for each physical therapist, in order to make up for that lower rate. Obviously, a physical therapist cannot properly give the patient his or her undivided attention and often relies on the help of a physical therapy aide/trainer to assist with the care. This means being attended to by someone who is not as qualified as the physical therapist, who should be providing your entire care. You'll see aides/trainers holding several exercise sheets and dictating exercises to multiple people at once in order to offload some of the demand on the physical therapist. Is this really the type of care that you want and will you get better in a reasonable time frame?


When it comes to being "out-of-network," more and more healthcare providers are joining this category. This means that the provider is not accepting a contracted rate with an insurance company, and can charge the patient an amount that they feel is appropriate, which is understandably higher than the "in-network" rate. Does insurance cover the costs of a visit to an "out-of-network" provider? The answer depends on the type of insurance policy that you carry. Not all plans provide benefits to cover services from an "out-of-network" provider, so the responsibility falls on the patient to verify that information or as a courtesy, the front desk staff of a provider's will do that for you.


If there are "out-of-network" benefits on an insurance plan, there is potential for reimbursement by the insurance company if certain criteria are met. The biggest criteria is whether or not a patient has "met their deductible." The deductible is a financial amount that must be completely paid within the calendar year in order for the policy to start reimbursing or covering services from an "out-of-network" provider. If the deductible is not fully met for the year, then a clinic will offer to "work with your insurance." This means offering an out-of-pocket fee for each visit until the deductible is met, and then only requiring the co-pay amount for any visits afterwards. This can seem like a great deal for many people (if your deductible is low), but this requires you to attend for a "minimum" number of sessions to at least meet your deductible and finish out your treatment plan. Often, the recommendation given is to come 3x/week for a minimum of 4-6 weeks. That frequency is typically unnecessary for most cases and does not equate to guaranteed improvements in your outcome.


In addition to a minimum attendance requirement and higher weekly frequency of visits, an increasing number of "out-of-network" providers are also moving towards an "in-network" environment where multiple patients are being scheduled within the same hour and relying more on aides/trainers. Again, are you really getting the best type of care?


At Hybrid PT, we set out to make ourselves different by creating an environment where we could provide the best care and attention through direct one-on-one treatment for our patients. Our recommendations for how often and how long that you should be seen are purely based upon your specific needs, not motivated by any other factors. If you would like to find out how we can help you, then check out https://www.hybridptnj.com/talktoapt to schedule a phone call with a physical therapist. Our goal is to find out more about you and what you have been struggling with, and get you back to the activities that you love.


Thanks for reading!


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