Did You Know? The Behind the Scenes Coverage (or Lack Thereof) for Health Insurance
I am a firm believer in sharing information as a provider in health care to the patients we see each and every day. For this reason, I wanted to write to you today to share some behind the scenes discussion between physical therapy providers in regards to health insurance coverage for services.
Why do you ask? Great question.
I feel it’s extremely important that you as the insured understand the restrictions insurance places on providers in an effort to help you notice WHY there have been so many changes in our disease management system but furthermore to have you part of the conversation.
I also feel it’s extremely important for you to understand the WHY behind SHIFT Physical Therapy and Wellness, but before I get into all that, buckle up and hold tight as I do my very best to explain what is happening in physical therapy that affects the insured.
Over the course of 15 years I’ve practiced Physical Therapy, we have seen a declining rate of insurance reimbursement for services provided. You as the insured, have also seen increases in premiums, outrageous deductibles, and the ever climbing copays. YOU (as well as your physical therapy provider) have also spent more time than ever talking to your insurance company in order to determine which services are covered, are not covered, why they didn’t cover it and/or WHO they will cover.
Unfortunately, society has accepted this as status quo but did you also know that not only has the insured made it more challenging for you to obtain coverage for services, they have also been putting several restrictions on your providers (the experts in getting you on the path to reach your goals) by decreasing reimbursement rates, minimizing which treatments they will cover in your sessions, and dictating what they deem is “medically necessary” for your health.
When taking a continuing education course this past year, our peers and professionals in health and wellness were discussing physical therapy claim denials for individuals who had goals to return to recreational activities such as golfing, running, working out, getting back to a sport (and the list goes on). Insurance companies were denying the coverage of physical therapy services based on goals the patient had to return to these activities deeming the activity “not medically necessary.”
NOW, HOLD UP! Since when does the insurance company get to determine what is medically necessary for YOU?
Is it “MEDICALLY NECESSARY” for your grandfather to continue going to the gym and living an active lifestyle that allows him to maintain his independence? That seems pretty necessary to me!
Is it “MEDICALLY NECESSARY” for you to get back to running following an injury. The same running that improves cardiovascular health, and improves your mental and emotional state is not medically necessary? HMMMMM…..I beg to differ.
Is it “MEDICALLY NECESSARY” for the pregnant mother to get back to her workout classes during pregnancy and following postpartum recovery? The same classes that keeps her strong, comfortable, safe, and confident in her lifting abilities while pregnant.
Due to what the insurance deems as medically necessary, physical therapists are ending a plan of care with their patients when more can be done. Essentially, the insurance providers are saying your are “good enough” and will no longer cover services even if that means you haven’t reached your goals.
It is time that our overall health and wellness is NECESSARY NOW and not after sickness, injury, or after surgery. It’s time that our insurance providers recognize the necessity of PREVENTION and PROACTIVE services that aide in avoiding and minimizing the risk of disease, injury, pain, mental health issues, while focusing on services that aide in natural and holistic health. Services like physical therapy, chiropractic care, massage, acupuncture, homeopathy, and nutrition (the list goes on and on).
That is why here at SHIFT Physical Therapy and Wellness, we have chosen to be an out of network provider for services. We want to make sure every person knows that they are cared for here and that the decisions made are not due to insurance dictating what can or can not be done when it comes to your health. Yes, you may be paying out of pocket for services but you also get the value and quality you deserve. YOU are the advocate for your health. YOU get to determine the value you have on your health and wellness and YOU get to determine what you feel is medically, or what we like to say, LIVING necessary. It is time to make the SHIFT.
You MATTER!
Written by: Jackie Giese, just a girl trying to share perspective.
