This is a common question that we are asked at Surf and Shore Performance Center. When we start to talk with our patients and digging deep into insurance plans, it quickly becomes evident that many people do not actually understand their benefits or insurance plans. It also becomes clear that the current health care system is inefficient and outdated.
To get back to the initial question the short answer is… there isn’t one. The fact is, when most ask if we “take” insurance, what they are typically asking, “can I pay my copay to see you?”
Yes, we “take” some insurance plans in that once the deductible is reached, the visit will be covered at a varied percentage. Most people don’t fully know or understand their deductible. In-network providers need to take a copay, but the deducible must be met, out of pocket before insurance covers a percentage of any medical visits.
While there are many different insurance plans and for some picking one is the choice between some Kaiser plan and one from HMSA, UHA, or HMAA that your company chooses for you. If you are picking one on your own from HMSA you have 12 options to choose from. For most healthy individuals the ideal plan will include a HSA or FSA. With these plans deductibles are higher, but if your healthcare costs are, you will be banking money each year.
A HSA is a health saving account. An account used only for healthcare purposes. Often, a business will match the amount placed into a HSA account each month either by a full match or a percentage. The benefit? This money grows throughout your career into a large sum of that is tax free. You can use this as a storage place for your money to use when you need it for healthcare purposes.
A FSA is a flexible spending account. This is similar to the HSA in that it is tax free money you can use for healthcare. The big difference is that you and your company will put a lump of money in your account at the beginning of the year and what ever is not used at the end of the year, you lose back to your company.
Other plans- HMO, PPO, and other plans are also common. With these plans there is a network of providers that have a contracted rate and are often lower costs per visit, as long as the health care provider you that you see is a part of this network.
Your deductible is the is the amount of money that you must pay out of pocket before insurance will cover a percentage of the healthcare costs. Insurance plans often have different in-network and out-of-network deductibles. With HMSA most plans have the same deductible, and are included in the max out-of-pocket expenses as part of the plan.
Example: Jim’s plan has a $2,000 in network deductible and has a $3,500 out of network deductible. He has a hamstring strain and needs PT. If he chooses an in-network provider he will pay out-of-pocket at his initial physician visit. Then for an un-necessary X-ray, then for PT, until the $2,000 deductible is reached. After that Jim will be covered at 100%. If he chooses an out of network provider he is responsible for $3,500 before covered at 80%.
Studies have shown that the national average for a mild hamstring strain is 10 visits. The typical PT clinic will want you to be seen 2-3 times a week for 5-6 weeks. The cost per session can vary from $50-300 per treatment session depending on what the PT is done and how long you are there. Many clinics now are having 1 PT “treating” 3-4 patients at a time and relying on aids and techs to complete treatments.
Though this company “takes your insurance” the financial responsibility is strait from your pocket. Least until you reach your $2,000 deductible. In this scenario you would not likely reach the $2000 deductible so no part of the treatment would be covered by insurance.
Unfortunately with our health care system being so cryptic most people believe that their health care will cost them a $20-50 copay. We believe that there should be more transparency and effort put into health insurance plan understanding. In this day and age because deductible and copays are on the rise and benefits within each plan are becoming less and less because the healthcare system is being overused.
With active healthy individuals the reality of health care is that it is a failsafe for emergencies. With car insurance if you have an accident it will be covered through your insurance, but if you need an oil change or a new part for your engine, that’s on you. If you go to the cheapest car shop and get the cheapest oil (one you will have to visit more often with hopefully satisfactory results), wouldn’t it make sense to go to a quality shop that uses quality parts and oil?
Why you should choose Surf & Shore over an in-network Clinic?
We provide one-on-one sessions with Doctors of Physical Therapy that understand your active lifestyle and goals. We average half the visits per plan of care than the national average. We deliver great outcomes. Long term this will save you precious time and money.
We think outside the box and encourage input from patients to get the best results for a healthy and active lifestyle.