Behind the Decision: Pelvic Health Physical Therapy and Insurance - Episode 23
In this episode, Dr. Kari Roberts discusses why many pelvic health therapists choose not to work with insurance companies. She explains the limitations and restrictions imposed by insurance that can impede patient care. Dr. Roberts emphasizes the importance of a personalized approach, where treatment plans are decided by the therapist and the patient together, free from third-party interference. She also highlights the economic forces at play and how they affect the quality of care provided. Ultimately, she advocates for out-of-network care as a way to ensure the best outcomes for patients.
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Dr. Kari: Why are so many pelvic health therapists out there not taking insurance? If you have wondered that question, stick around, because I'm going to get into the nitty gritty of that right now. Welcome to the Marone Pelvic Health podcast. Hi, I'm your host, Doctor Kerry Roberts. On this show, we will be discussing a variety of things regarding your pelvic health. These conversations will be a mix of education, personal experiences, and a blend of tips you can apply to have a healthier pelvis. The goal of this show is to normalize conversations around pelvic health and help women stop suffering in silence. Now, the million dollar question. If I've been asked this once, I've been asked this a thousand times, friends, family, patrons, leads, anybody. And then I love it when people ask me the same question over and over and over, expecting to get a different reason. Why don't you take insurance? What's the deal? I jokingly say to my clients and friends that insurance is the devil. Insurance can put so many restrictions on what we do as medical providers, and rightfully so, because they have, they have ownership in what's going on medically so they can make their rules. But the fun part is as providers, we can choose if we want to follow them or if we don't. So personally, why have I chosen to open a practice that is not in network with insurance companies? I say that in network because that is a huge caveat. Many insurances out there do provide out of network benefits, which means in network benefits are when the provider is in a contract with the insurance company. They've negotiated rates, they've figured all of that out. So that's when you say, do you take my insurance? What you're really asking is, are you in network? Do you have a contract with my insurance? No, I'm not in network with anybody, and I'll get into that in a little bit. But I follow all of the laws and all of the rules. My business is up and up, both medically and from a federal and a medical perspective, that it is a legit business, licensed, insured, the whole bit. So that, yes, all of my services, since I am a medical provider, all of my services are covered, are coverable services through any insurance company. I have chosen to not be under contract with any insurance company. So that means you can come and see me and you can pay, and then you can be reimbursed as an out of network benefit, which means, yes, I followed all of the rules, but no, I'm not under contract with insurance companies. So more specifically, why am I not under contract with insurance companies? I decided to go out of network with my, my business because I have been a physical therapist for a long time. I have considered leaving the practice. Do I dislike treating patients? Absolutely not. Do I dislike being a physical therapist? Absolutely not. But what do I dislike? I dislike all of the rigmarole that comes with insurance companies. I dislike the manuscripts that I have to write when I'm writing my notes. I hate when I see a patient, and I'm like, you need two months of therapy, and the insurance company says, we're only going to pay two. I don't like that someone else is having an impact on the care or the plan that I deem medically relevant. And that confidence that I have in my clinical experience that was initially based on my now 20 years of experience. But as I dove deeper and deeper into pelvic health and as I continue to dive deeper and deeper into my craft, now, I've taken time out of my personal life to become a pelvic health specialist. I've taken time to become a corrective exercise specialist for pregnancy and postpartum population. I have taken the time to read more books. I've taken the time to listen to more podcasts. I've taken the time to meet with more providers. Chiropractors, massage therapists, nutrition, registered nutrition, dieticians, ob gyns. The list goes on and on. I have taken the time, my personal time, to make those connections and understand those providers better so that I can be a better provider for what I'm doing with pelvic physical therapy. And I just think that with all of that effort and knowledge that I've gained, I am so assured in what I recommend for my patients that I think there's only two people that should be dictating our plan. It should be me as your provider, and it should be you as the patient. You and I will come together, and we will be partners on your journey to work on whatever you're dealing with. Whether it's painful sex, whether it's leaking bowels or leaking bladder, whether it's abdominal pain or separation after you've given birth or carried a baby, all of those things. I want the two of us to be partners. I don't want it to come down to just dollars and cents. I don't want someone that is not as educated as me, that's not as skilled as I am, that doesn't have the experience that I have, that has not sat with you in this room and looked at you in the eye and really understood how having that bladder issue is affecting what you're doing with your children, or what you're doing at the park, or what you're doing when it's time to travel. I'm looking at you face to face. I'm connecting with you as a human, and we are coming together and we are saying, this is what I think you need in order to help you get to the next step. I don't think that Joe Schmo processing a bunch of random files is the person that should be dictating what they deem medically necessary. They're not a doctor of physical therapy therapist. They are not a pelvic health certified specialist like I am. They don't have all these other credentials like I do think that we should make that choice. Insurance companies also, let's keep in mind insurance companies are traded publicly. To be traded publicly primarily, your goal is to be profitable for the benefit of your shareholders. That's your number one goal. Your goal is not to provide as many services that's needed from the folks that are paying you for your coverage. Keeping that in mind, the more insurance companies charge you and the less that they are paying out to providers like me, the more they can keep those dollars in their pockets and they can divvy up those dollars to their shareholders. There has been a huge shift with the economics, especially how it looks here in America. Inflation is up. I'm not going to make this an economic podcast, but it is what it is. We live in a capitalistic society. Inflation is up. Profits are down all over the place, with small businesses as well as large businesses. But as people's dollars tend to this, that income tends to get less and less. Or disposable income, I should say, gets less and less. The profits that these insurance companies is turning continues to grow and grow and grow. How is it growing? Because they are historically paying less and less and less for these needed services. Just because an insurance company says that they're not going to pay, or just because they're saying they're not going to pay as much does not mean that the service that we are providing is not warranted. It does not mean that the services that we provide are not needed. And it does not mean that the services that we provide cannot change someone's life. So I do not want a third party dictating what my plan of care is going to be. I do not want a third party dictating how often I'm going to see you. I want that to be between me and I want that to be between you. And the easiest way to do that, the path of least resistance is to just have flat billing down the street. You can drive 15 minutes up the road in either direction. I'm at a corner here either direction. And you can go to a big hospital system, and if you have a high deductible, you're going to be paying cash until you hit that high deductible. You can go to either one of those offices and you're going to pay anywhere from $450 to $850 per 45 minutes visit. I have looked at these bills with my own two eyes, or you can come here for a flat rate, a couple of get and get 100 out, or, sorry, get an hour visit with no distractions, with a specialist, with someone that's not bouncing back and forth. So just because you're going in network and just because your insurance company says that they're paying, it doesn't necessarily mean that you're getting better service, and it doesn't necessarily mean your insurance company is paying. Because if you have a $10,000 deductible, which these days is not absurd, or even a $5,000 deductible per person, how many visits of that 850 will you have to get to before the insurance even kicks in? Things to think about. So that's the long reason why I do not. I'm not in network with insurance. I do believe that this is a coverable treatment and I do believe it's valuable. So that's why I've done all of my due diligence on the back end to make sure that all of these services can be covered with your out of network benefits. But I am not going to have someone dictate what my plan of care looks like. If you want to come in three times a week, and then you need to come in once a month, if you need to switch between in person and telehealth, if we need to buddy up, and maybe we really need to dig deep into how your body is processing stress and how we can get your body to process stress effectively so that you can go and do those other things that you enjoy. I want to be able to meet you wherever you are. If you're coming in with pelvic pain, but you slept wrong and now you've got this crook in your neck and now you're not able to do your job and you just happen to have a PT visit, I'm not going to send you back to your doctor and make you get a new order with a brand new code so that your insurance can pay. I'm going to treat the person that's walking in right now. I'm going to treat you as a whole person. Those are the restrictions that the insurance company puts on you, and those are the restrictions that I don't have to worry about when I decided to be a cash based employee or cash based provider. So if that sounds good to you, I think that you should definitely not let insurance hinder you from getting the help that you need. And if a couple hundred dollars per visit is just something that does not work within your budget, still reach out to pelvic providers in your area. You never know. They might have pro bono programs, they might have other programs. They might have other ways of still giving you the top notch care that you need, but in a way that fits your budget. So if that sounds like something that you would like to consider with me, I would be so happy and honored for you to reach out to me. Reach out to me. My contact information is in the closing and I look forward to hearing from you soon. That's it for the more behind the scenes of what's going on here in pelvic health. Next couple of weeks, I will come out with some more content, talking more about diagnoses and how public health can help with that. Until next time, thank you for listening to this episode of the Morone Pelvic Health podcast. Please do me a favor and leave a review so that more people can find this content and make sure you like and subscribe yourself so you never miss another episode.