Direct-Pay vs. In-Network

 In Direct-Pay

For many of us, understanding our insurance benefits is a frustrating task. Deductible? Co-pay? Co-insurance? Out-of-network? In-network? What does it all mean?

Let’s dispel the myth of Direct-Pay vs. “In-Network” insurance coverage, and how moving to a direct-pay service can save you money and headaches.

Operating as a direct-pay clinic, KA-PT is able to treat you to the full extent of our medical practice without being limited by insurance. Many insurance companies utilize a third-party reviewer system which decides how many visits a patient may receive. The number of visits is often based on a basic diagnosis code and not on the patient’s ultimate goals. As a direct-pay practice, we are able to keep our pricing low, treat each patient as their need requires, and still SUBMIT your paid claim to your insurance on your behalf. Insurance companies can directly reimburse YOU. Patients at KA-PT can use their HSA, FSA, credit card and cash to pay for services.

More often than not, the out-of-pocket expense for treatment at KA-PT is less than what a patient would pay for the same services at a clinic that accepts their insurance. Insurance deductibles and co-pays have increased exponentially in recent years and many insurance plans do not cover PT until the patient’s deductible is fully met. It is not uncommon for an in-network insurance company to charge $250 per visit and ALL of this expense is the responsibility of the patient until the deductible is met. And even once the deductible is met, insurance companies may only cover a portion of your bill.

Before you decide to get physical therapy based on which clinic is in-network with your insurance, make sure you research how much you will be paying vs. going to an out-of-network, direct-pay clinic like KA-PT.

Here is an example:

“In network” insurance coverage
You have a $5000 deductible
$250/visit x 5 session=$1250 out of pocket expense to the patient

KA-PT direct-pay coverage “out of network”
You have a $5000 deductible
$120/visit x 5 sessions=$600 out of pocket expense to the patient
*KA-PT can provide invoices to submit to insurance.
*Patients can pay for services with the HSA/FSA money their current insurance plan provides.

As you consider your PT options, it’s important to ask your in-network provider a few questions:

  1. How much of your PT session will your insurance cover if you have NOT met your deductible?
  2. How much does the in-network PT provider charge/visit on average?
  3. How long are the treatment sessions? At KA-PT you get a full 60 min with the PT
  4. Question the quality of care the “in-network” clinic provides. Are you working with the same therapist each session? Is that therapist a Doctor of Physical therapy? Do they utilize Physical Therapy Assistants (PTAs) or PT technicians.

As you start to look more closely at your options, you may be surprised to see that by selecting a direct-pay provider like KA-PT you will be saving money and time!

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