"Why Don't You Accept Insurance?"

By:  Eric Oliver, PT, Founder, President

IMG_0089.jpg

“Why don’t you accept insurance?”  This is a common question directed to my business in response to our policy of not billing health insurance for our physical therapy (PT) services.  Rather, we provide a bill to the client for them to send off to their insurance.  This puts the responsibility of getting reimbursed onto the client.  Yes, this saves us money because we are not paying a staff member to handle the insurance reimbursement side of the business, but to fully understand why BE doesn’t hassle with billing your health insurance requires you to know a little more about my PT story.

When I first conceived the idea of Beyond Exercise, it was because of my frustration in practicing within other clinics.  No matter where my gut and heart took me, I couldn’t quite find the right practice setting that would allow me to practice the way I believed physical therapy should be practiced—as a one-on-one partnership with the patient.  I wanted to practice without restrictions on visits per week, per month, per year.  I didn’t want a patient’s treatment to be delayed due to red-tape insurance bureaucracy.  I didn’t want to divide my time and attention between two or three different patients at the same time.  I didn’t want to worry about anything else but giving my best effort to the one person in my presence.

When I started practicing 15 years ago, this type of practice setting was considered a novel concept.  My experience working with the US Army in Fort Bragg, North Carolina as an intern planted the seed that physical therapists can not only be highly valuable members of a bigger team of professionals, but they can also be fully AUTONOMOUS.  In Fort Bragg’s Womack Army Medical Center, physical therapists were the first point of contact for a soldier when they had a musculoskeletal injury, as long as it wasn’t something that required obvious surgical intervention.  As long as the injury was within the scope of non-surgical intervention, physical therapists were typically the first to assess the injury, make the diagnosis, create the treatment plan, and execute the treatment plan.  I was in awe with how much independence, skill, and efficiency the physical therapists in this setting possessed.  

The amount of autonomy I found in the Army was hard for me to find in the civilian world of healthcare.  I have worked for physical therapist-owned private practices, doctor-owned practices, and large hospital-owned practices.  These were reputable companies.  I came to realize that the common denominator that seemed to restrict the way I wanted to practice was health insurance companies.  Their rules and reimbursement structures prevented me from spending the necessary time to treat my patients.  When I finally decided that I could not replicate the same feeling of “Army autonomy” within the world of standard therapy practices I new I had to create it for myself.  So began my journey of building a physical therapy practice from scratch—one that didn’t look, feel, or act like the status quo PT practice.  

Creating a place where someone can receive high level, holistic, expert, ongoing care should not be novel and limited to the military, professional teams, or elite training centers.  We should all have the opportunity to access this.  And so here we are—Beyond Exercise—a rehab, wellness, and fitness facility dedicated to placing the client front and center.  It’s been a long road since I started this business, and along this journey I’m constantly being asked if I will ever start billing people’s health insurance for the physical therapy services we administer.  My answer is always, “No, that will never happen.”  Doing so would not only displace the client’s priorities away from front and center, but will also unravel the essence and soul of why Beyond Exercise started—to change how physical therapy is accessed and delivered.   

Because we do not directly bill insurance we often times hear the following statement, “If only you took insurance, I would utilize your services”.  People explain that since they are paying for their insurance premiums they should take advantage of it, or at least have their payments go towards meeting their deductible.  No disagreement here.

I will counter, though, that if you have not met your deductible and you go to an insurance-based clinic the cost of a co-pay on top of paying for your treatment session out of pocket (because you haven’t met your deductible) can cost the same if not more than what we charge per visit.  Recently, I had a client who was referred to another physical therapy practice by her doctor.  She called the physical therapy practice to see how much her initial evaluation would cost because she hadn’t met her deductible.  The cost of their initial evaluation was going to be $400, out of pocket.  This didn’t include her co-pay.  Sure, this was going to go towards her $2k+ deductible, but it was still money out of her bank.  Our initial evaluation cost—$195 (below what many other high quality out-of-pocket physical therapy practices charge).  I’d be remiss if I didn’t say that we can’t generalize all insurance-based clinics when describing out-of-pocket costs for their clients.  In fact, I have heard of less expensive out-of-pocket costs, but I have also heard of more expensive cases.  

Cost aside, though, many times there is a fundamental difference in the quality of care when you compare our practice versus a standard insurance-based practice.  This was the case in the Army when compared to my other clinical experiences in the civilian world.  But, in the case there isn’t a difference between our clinics then maybe a patient in a standard insurance-based clinic won’t be reduced to a body on a treatment table or machine waiting to be told how many exercise reps to do.  Maybe they will receive undivided attention and hands-on care based off of a thorough exam rather than a written prescription.  Maybe they will work with a physical therapist the entire treatment session rather than with an aide.  And maybe they will receive progressive and appropriate exercises specific to returning someone to their desired activity level.  I really hope, for our profession’s sake, that this is the majority of the cases out there in the insurance-based clinic.  

My business and many like mine exist and flourish for a reason, though.  These scenarios are still prevalent out there.  People are still getting frustrated by how they aren’t given enough attention during their rehab sessions and how their rehab doesn’t progress enough to get them to their end goals.  I can’t tell you how many times my therapy team’s outcomes surprise people for their effectiveness and efficiency.  When clients ask why we are able to figure out their problem and do so in an efficient way when others could not, our answer is almost always the same—we had the time to evaluate you, place our hands on you, and listen to what you’re saying in order for us to figure out the issue—formalities that is not always common in an insurance-based clinic. True back and forth communication during a hands-on evaluation reveals a hell of a lot of information; more than a written prescription ever will.  Also, we’re damn good clinicians, and we are constantly working to improve our knowledge and skills.

I’m reminded of a former patient of mine who was desperate to solve his back pain.  He was a retired police officer who lived in Cleveland but moved to Cincinnati to live with his daughter because his back pain was so bad.  He had consulted with doctors at a prominent clinic in Cleveland, and he did his physical therapy there, too, which consisted of basic stretches and ab exercises.  He walked into the clinic holding a large walking staff, heavily leaning onto it to alleviate pressure from his back.  The physical therapy prescription he brought in with him—“herniated disc; evaluate and treat”.  He was at the end of his rope.  Tired of taking prescription pain relievers and considering the last option his doctor’s gave him—surgery—he decided to attempt physical therapy one more time, in a new city with a practice he’d never heard of.  Under my evaluation, I determined his symptoms were not coming from his herniated disc.  His MRI truthfully showed that he had a herniated disc.  I didn’t dispute this fact.  It just wasn’t the source of his symptoms. After three treatment sessions of hands-on manual work he was walking into the clinic without his walking staff and without pain.  Fast forward a couple years after I discharged him and while walking around the Cincinnati Reds game with my wife, I bumped into him.  Still no walking staff in his hands, he was looking happy as can be hanging out at the game with his son.  He told his son that he owed his life to me.  I thought that was too much of a compliment, but I knew what he meant.  He’s active.  He’s happy.  He’s pain-free.  And he was giving me the credit.  I smiled, and my wife smiled.  He asked what I was up to these days.  I told him I had started my own practice.  He grinned.

Recollecting this story simply suggests the power of a thorough, non-rushed clinical exam.  In no way am I suggesting that surgery and other medical interventions are a waste of time.  There is indeed a time and place for it.  Imagine, though, if this retired police officer didn’t find his way into my treatment room.  He could still be in pain, or he could have moved forward with a surgery destined for failure.  This was avoided by performing a thorough exam and skilled hands-on manual treatments in concert with, rather than in lieu of, performing only stretches and ab exercises.  The path to his successful outcome was born out of spending the necessary one-on-one time to both determine the root cause and perform the necessary physical therapy treatment interventions rather than simply providing interventions that were merely convenient for the time I had with him. 

In this story, though, I didn’t mention that I treated this gentleman while working for another practice.  This practice took insurance.  I gave quality care while working for this practice.  Quality care can be done in an insurance billing clinic, but it didn’t come without a price.  In order to accommodate to this person’s needs I either leaned on a student aide to help me fulfill someone else’s therapeutic exercises in the gym while I was treating him, or I purposely blocked out extra time to treat him.  Both scenarios yielded their own consequence—either I neglected the other individual from an appropriate therapy visit, or I limited my employer’s ability to capitalize on extra treatment units that would generate revenue for them.  I did this a lot throughout my career while working with other clinics—either relinquish control of my treatment sessions to someone else who wasn’t as qualified as me, or take revenue away from my employer’s bottom line and therefore risk my own livelihood. 

I didn’t like that I had to make these choices.  I didn’t like that there wasn’t a win-win.  It stressed me out, and I grew miserable with the prospects of continuing my career as a physical therapist.  During my career working in an insurance-based clinic, I almost left the profession—twice.  I wasn’t alone.  My colleagues at the time were stressed out.  They still are.  I hear it’s worse now that insurance reimbursement rules and rates continue to change.  And it’s not just in the world of physical therapy but also in other aspects of healthcare.  Playing the insurance game forces clinics who are dependent on insurance reimbursement rates to see more people per hour, get more creative with billing, and utilize support staff rather than hire more physical therapists because more therapists would cost the company too much money.  This job scenario isn’t why people like me get into the field of physical therapy. 

To say that I am currently happy with my career and the direction of this “niche” style of practicing physical therapy is a huge understatement.  In order for the physical therapy profession (and for that matter, healthcare in general) to fully meet the needs of the community we need to truly place the patients front and center, and maybe this “niche” style of practicing will become more mainstream.  I don’t see insurance companies going away anytime soon.  But if niche becomes ubiquity, rather than a patient asking why I don’t take insurance, maybe they’ll start to ask other clinics why they bother to take insurance.  

I know there are more therapists leaving the insurance-based world to achieve what a former boss told me didn’t exist—the “Garden of Eden of physical therapy”.  I have talked to and visited other therapists in Los Angeles, CA to Austin, TX to Boulder, CO to Portland, OR to Miami, FL and here in the O-H.  Just as I do, these therapists see a shift in how people view physical therapy and healthcare.  More and more people are getting more savvy about shopping around for the best healthcare out there.  Whether or not it’s covered by their insurance is of limited concern these days.  In fact, 99.9% of our clients have insurance, but they still choose to see us.  They know what they want—quality attention to detail, quality care, respect for their time, and positive outcomes.  Every single physical therapy website says they do all of these things, but not all of them can back up that claim.  Actions speak louder than words, and my company’s actions are obviously in line with what people want.  

Back when I bumped into my patient at the Reds game he told me that I deserved to have my own clinic.  Maybe I do.  In reality, though, it’s you who deserves it.  At the end of the day we don’t exist without the people who need us, and there’s a lot of you.

This is why we don’t bill insurance.  

Eric Oliver is a physical therapist, certified running coach, run form specialist, and the founder and president of Beyond Exercise, a physical therapy, wellness, and fitness facility in Cincinnati, Ohio.  They do not bill health insurance, and they never will.