Buying health insurance is easier—and faster—than it’s ever been. Much like fast food, however, speedy convenience now can cause plenty of woe later. (For example, I’m betting a good portion of your patients purchased plans without even knowing how a deductible works for health insurance—let alone what their deductible actually is.) But as unpleasant as a post-taco-run stomachache can be, surprise medical bills are much more painful.

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I’ll take the #2 with the large deductible.

Does this scenario sound familiar to you? A patient with a painful problem needs your office’s help. He or she calls to schedule an appointment. After you cheerfully schedule the patient, he or she asks, “So, how much is this going to cost?”

“Uh-oh,” you think. You explain to the patient that his or her copay will be $50 per visit, but that’s after the patient has met his or her deductible—which is $5,000. Furthermore, the patient’s coverage is subject to prior authorization—and don’t forget that PCP referral, as the one from the patient’s surgeon isn’t enough on its own. Oh yeah, and the patient’s policy is limited to 20 PT visits per year. After that, insurance will stop paying.

The patients who come to my office come for relief from their aches and pains, and I want to be part of that relief. But how can I when it’s my job to deliver what frequently ends up being bad news? And why are people so shocked to find out the details of the insurance plans that they are choosing for themselves?

Wait—I didn’t order this. Did I?

Health insurance is complicated. And just like I should never, ever be allowed to order off of a Spanish menu without help from someone fluent in the language (“Salsa de pimienta fantasma? Sounds delicious!”), our patients shouldn’t be choosing their health plans without help from someone who understands the terms of those plans. And preferably, they should be receiving that help before potential problems arise. With many people skipping brokers and agents altogether, the responsibility of explaining plan benefits often comes down to us: the provider’s billing, reception, or management staff. Although we’re not insurance salespeople—and can’t necessarily recommend one plan over another—we can teach people what we know and thus, help make them savvier consumers.

In my experience, there are three areas in which patients need our help:

1. Definitions of Terms

Has a patient ever told you, “I shouldn’t have to pay anything because physical therapy is covered?” (Insert Inigo Montoya meme here.) You can be “covered” for a service and still have a $10,000 deductible or an $80 copay, and when you’re paying that much money out of pocket, the term “covered” suddenly loses its comfort.

2. Referral Requirements

As an outpatient PT office, we see a lot of post-op patients coming in with referrals from their surgeons and orthopedists, and patients become rightfully perplexed when we ask for yet another referral from their PCP. After all, their primary doctors often haven’t been very involved in the surgical care episode. On top of that, some plans tout that no referral is required, but in some cases—often unbeknownst to the patients—if they do get a PCP referral, it can help reduce their cost-share. And all of that doesn’t even take into account the different direct access laws for each state—which may or may not conflict with the insurance policy. Confusing? You bet!

3. Medicare Secondary Payers

Through the years, I’ve noticed that more and more Medicare secondary payers are paying less and less. Many of our Medicare patients laugh when they get a measly bill with a dollar-and-change balance for each visit that their secondary has deemed “patient responsibility.” Dozens of our patients this year were also shocked that their Medicare deductible wasn’t covered by their secondary insurer.

Translate the menu, por favor!

Give a man a fish fajita and you’ll feed him for a day; teach him how to fish—okay, you get the picture. Education is key! Rather than simply explaining how much a single physical therapy visit is going to cost, it’s time for us to help our patients learn how to determine that information for themselves. My goal isn’t to put my front office staff out of a job, but to reduce the amount of sticker shock our patients experience—in our office and elsewhere. (For a more detailed overview of strategies for suppressing sticker shock, check out WebPT’s most recent webinar.) After all, there is nothing more discouraging than seeing my PT colleagues work so hard to help patients feel better, only to have those patients quit prematurely due to cost or confusion over their insurance benefits.

To that end, I’ve teamed up with WebPT to create a comprehensive, easy-to-read guide to help your patients:

  • learn what common insurance terms mean (and don’t mean);
  • ask the right questions while shopping for insurance—thus help them avoid surprises later; and
  • understand how to read an Explanation of Benefits to reconcile their medical bills and track deductible and out-of-pocket spending.

Download the PT Patient's Guide to Understanding Insurance

Patients confused about their insurance coverage? Avoid uncomfortable conversations later. Enter your email address below and give them the PT Patient’s Guide to Understanding Insurance.

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What strategies have you implemented in your practice to help contend with patients’ confusion over insurance coverage? What’s worked—and what hasn’t? Share your experiences in the comment section below.


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