What I would love to say is “YES, we happily take all insurances!” But that’s not true. In fact, until 2018 we didn’t take any insurances, but now we are in network with a few. Here at the start of 2018, the health insurance industry is more volatile than ever, and is only getting worse. What that means to consumers is that insurance companies are finding more ways to push the cost of healthcare back onto consumers, employers and even healthcare practitioners. This isn’t a bashing of insurance companies, but it is meant to educate readers so that they can make educated decisions about who they buy their insurance policies from, and how they use their benefits. Keep in mind that in the U.S., the health insurance industry is booming! Despite what you may hear in the news, they are having record-breaking profits by the billions. Just do a google search on “profit of health insurance companies.” The health industry in general is a profit-driven commodity, which means that profit is often prioritized over your well-being.

I’ve had the unique experience of seeing insurance issues from a variety of perspectives. Of course, as a consumer I’ve had a variety of health insurance policies for me and my family. As a small business owner, I’ve had the painful experience of only being able to afford mediocre policies for my employees, sometimes with companies that did not include my own clinic in their network. As a health care practitioner who relies on insurance reimbursement for the majority of my income, and must comply with a numbing array of individual insurance company policies, I’ve felt the disappointment of not being able to help clients because of their insurance limitations, and also the maddening frustration of spending countless hours of personal time trying get authorizations or payments for our services. And finally, my Dad, a retired health insurance broker, has been able to give me a perspective from “the other side,” which helps to lower my blood pressure, just a little bit.

So here’s the bottom line: Never before have consumers (you) had to pay so much to get so little back from your health insurance benefits. It COSTS you, in copays, coinsurances, deductibles, premiums, lower wages, and more importantly, in your health. If it is expensive to get medical help, you are less likely to get the help you need. This makes it extremely important for you to get real value for the services you choose to spend your resources on. Health care services are not created equal. Those of us in small, private practices know that we must perform well above the standard of the large health care institutions to earn a sustainable market-share for our businesses to stay viable. We don’t have the luxuries of a referral system from a massive organization that profits from referring clients to its own providers, and we can’t afford to engage in costly marketing programs. We live and die by the quality of service that we provide and the relationships we build, which has to be good enough to inspire you to tell others about us. Shop around and find out details of what your services will be. Look at our service model for comparison.

On top of the increasing out-of-pocket costs that consumers are being saddled with, insurance companies are targeting utilization management strategies to decrease their costs. Basically, the less you use your insurance, the more money your insurance company gets to keep. On the consumer side, high out-of-pocket costs make it less likely that you’ll use your insurance. On the provider side, the growing trend to decrease utilization is to make the administrative tasks involved with providing care so burdensome that the providers (doctors, therapists, etc.) give up, or can’t afford to, spend the countless hours of unbillable time trying to get pre-authorizations, re-authorizations, file appeals, etc. Your insurance might say you get 60 visits per year, but if your health insurance company is using Evicore to administer its rehabilitation benefits, you can count on having to fight for coverage to get more than about 10% of your visits, and even that will have extra paperwork for your healthcare provider to manage. The only way your insurance company profits from hiring Evicore to administer your benefits is if Evicore can prevent you from using your insurance enough to not only increase money in the insurance company’s pockets, but to also pay for hiring Evicore as well. I will admit that there are plenty of health care providers who are guilty of over-utilization, meaning they provided unnecessary services to increase their revenue, but that is not what Evicore is working to prevent. They are flat out trying to make it so difficult for providers and patients to use insurance that they either stop treatment or pay cash.

This trend is not sustainable. The high profit margins of insurance companies at the expense of your cash-flow, health, and the quality of service that healthcare workers can provide creates a poorer, unhealthier population. One of the buzzwords in the healthcare world right now is “population management,” which is supposed to imply improving the overall health of our population by giving large organizations chunks of money to be responsible for your health, and healthcare costs. We used to call this managed care back when HMOs were all the rage. The HMO (Health Maintenance Organization) concept did poorly because when they were given a chunk of money to cover all your healthcare expenses, they found ways to not give you service, so that they could keep more of that money in their pocket. Now we have ACOs: Accountable Care Organizations, and it is basically the same concept, only now they are encouraged to try preventing health problems, and there is a degree of patient satisfaction tied to payment.

Even in physical therapy services you’ll see ways for practices to provide services with less cost; scheduling multiple clients at a time with one therapist, use non-clinicians (aides) for providing care, providing low-skilled care that can be performed by aides, overlapping appointment times, extending appointment times with unnecessary procedures that allow unattended billing time, etc. Those are examples of “profit-centered” service models, not “patient-centered” service.

It is hard to not be appalled when you know that insurance companies are having billion dollar profits, and I can’t get more than 6 visits for a knee reconstruction rehab without fighting the same company. Not all policies are like that, but the lower the premium cost, the more likely that is to be true, and right now they are so expensive that individuals and employers are choosing more and more of the lower-premium plans.

Our mission at Prevail Physical Therapy is to provide the highest value of service available. Not all health insurance plans allow that, so we don’t take all insurances. Some insurances make us try to fight for your visit authorization, but we have a policy to engage in “reasonable measures” for insurance authorization, because to do so otherwise enables ongoing bullying from insurance companies. Only when people stop buying such policies will they change, so investigate the insurance product you buy with your agent or HR department.

We committed to this career path because we like to help people. We started this business because we believe we can provide a better service than what is normally available, but it means we cannot succumb to the tactics used to increase profits or offset insurance burdens, so we may not be in your insurance network. We do have multiple payment options in addition to insurance reimbursement; Cash, check, credit card, HSA, FSA, payment plans, pre-purchase discounts, sponsored group discounts, and healthcare credit accounts.

Be sure to advocate for your health insurance consumer rights!