Out-of-network pt vs in-network pt

When it comes to getting pelvic floor PT, different practice models exist. This can be confusing to both patients and providers when making decisions on where to seek care. In an effort to help clear up the muddy waters that surround this, please read below.

Out of network/Cash Based Pelvic PT

Cash-based physical therapy (also known as out of network) is a model where patients can refer themselves directly to their specialist PT and pay directly for services out of pocket. At Sarton PT, our cash based practice is considered out-of-network so patients can still recoup a portion of their payment from their insurance company paid up front. This model allows for us to charge for the time spent (55+ minutes and 1 on 1 with a specialist the entire time), a higher level of experience, a concierge experience and keeps third-party payers out of the mix. This type of model is fee-for-service which means patients pay for each session as they go or they can buy a package of sessions for a discounted rate to complete their plan of care. Our practice then provides a receipt or invoice upon request which can be submitted to an individual’s insurance provider for reimbursement that will go straight to you, the patient. 

In-Network insurance based Pelvic PT

An insurance based physical therapy model is where patients utilize their in network health insurance benefits to cover the cost of physical therapy. Patients are responsible for their copay, full deductible, or coinsurance for each visit and the remaining cost is covered by their insurance provider. This model will typically dictate how many visits you can be seen for with your therapist, will require you to pay the entire amount up front until you meet your deductible (so if its high, you may never meet it), and it will often require authorizations and lengthy reports your PT will need to write which takes away from your hands on treatment time.

Why not stick with an insurance-based practice?

While paying less upfront may initially sound enticing, obtaining physical therapy through insurance has its drawbacks. We highlighted several points above, but below are additional reasons to consider an out-of-network/cash based provider.

• Due to current insurance reimbursement rates, treatment times are usually limited to 20-30 minutes (and that includes the time to get dressed and undressed) when going to in network facilities. In order for these practices to cover costs of physical therapy staffing and overhead they need to see a higher volume of patients every day. To achieve this, in-network PTs must see a patient for shorter times (20-30 minutes) and then often transfer them to a physical therapy aide who only has on the job training and no formal certification. PTs in these types of practices often burn out having to see 16-18 patients/day and co-sign notes from the aides.

• Unexpected denial of coverage of insurance is not uncommon resulting in an in-network practice resulting in patient responsibility of payment in FULL for past and future payments.

• Physical therapy providers who are in-network are limited to an in-network list of providers

• Often patients may have to follow certain rules and restrictions such as obtaining pre-authorization before starting treatment and then obtain further authorization after 6 visits or so.

• In many cases, insurance restrictions severely limit treatment options; for example, physical therapists can only treat a certain body part written on a prescription. This prevents outside the box thinking and treating. All good clinicians know that no system or body part works alone and treatment must be holistic on every level.

• Declining reimbursement each year from insurance companies often causes providers to cut corners, shorten treatments and cram more patients in.

Why choose a cash-based practice?

Although there is a higher financial cost upfront at a cash-based physical therapy practice, you also get what you’re paying for. This includes:

• Longer treatment sessions, anywhere from 55 to 120 minutes, one-on-one with your advanced trained physical therapist (NO AIDES ever). This allows the physical therapist to do their typical treatment in addition to extensive education teaching you to become the CEO of your body, collaborate with your other providers, and teach effective home exercise programs ensuring success.

• Patients know the total cost of their PT session upfront. There are no surprises by insurance companies denying coverage and often patients get a decent amount back from their insurance company for the treatment once they submit their superbill.

• Patients are not limited to a specific list of in-network providers.

• Patients are not beholden to the restrictions placed by insurances (how you are treated, what you have treated, how many times you are able to be treated). Patients can receive the comprehensive treatment they deserve and require addressing all systems and all body parts.

• Patients have more control and flexibility over their plan of care and treatment strategies.

• A concierge experience where the PT is present and focuses solely on the patient without having to worry about passing you off to an aide or hurrying through the treatment in 20 minutes to get to the next patient. Our PTs also are available to do telehealth with you, see MDs with you, and even treat you in the privacy of your home.

Why Sarton Physical Therapy?

Our philosophy is this: Deliver life changing care that utilizes both an external and internal treatment systems approach with advanced manual techniques including visceral mobilization, myofascial release, advanced coccyx, hip, and spinal mobilizations, prescriptive exercise program and extra treatment modalities including a class IV laser to immediately reduce inflammation and pain. We working closely with other health care providers for a team approach and offer acupuncture, guided imagery and osteopathic treatment in addition to PT under one roof.

At Sarton, patients will experience concierge-like services that are not found anywhere else beginning with therapists who are able to take the time to listen to their patients and deliver a unique individualized treatment plan to get you back to doing what you love. Our team is led by a master clinician with 25 years experience in the field who has taught courses nationally and treated thousands of patients over the years successfully. To learn more, please see our website at pelvichealing.com and our IG page @pelvichealing.