Be Understood - When good enough just isn't good enough

There are over 18 years of practice between the 3 physical therapists at Headquarters Physical Therapy. We don’t say this in a boastful way and are constantly in search of ways to improve ourselves and the quality of care that we deliver, but, even in such a short amount of time we have seen our fair share of insurance related nightmares as it pertains to our patients receiving coverage for the care that they need.

We’ve seen D1 scholarship hopefuls be denied physical therapy for their shoulder injuries because “insurance doesn’t pay for kids to play football”.

We’ve seen patients recovering from ACL reconstruction be denied physical therapy after 3 months of care because “as long as they can walk they will eventually run”.

We’ve seen patients with knee pain be cut off from physical therapy despite still having pain with going up stairs because they don’t have stairs at home and work in a building with elevators.

And these are just a few of the horror stories about how health insurance companies have failed their customers. But the blame isn’t fully on them. The healthcare system, while often discussed in terms of the third party insurance companies and the large institutions such as hospitals that determine pricing, the truth is that the individual provider and the consumer (patient) have just as much responsibility to make forward change that is needed for everyone to receive quality care that is affordable.

Why is it this way?

Insurance companies have the power to raise premiums, deductibles, and copays however they see fit. As a response, providers and institutions tend to restructure the delivery of their services to maintain the profit margins necessary to keep the lights on and salaries paid. Unfortunately, in order to remain competitive with one another this can create environments where overbilling and overutilization of care are easy waters to wade into.

So while there is a continuous dance between providers and insurers for services delivered and services paid for, the ace in the hole for the insurance companies is authorizations. If an insurance company wants to preserve profit margins on a particular subscriber the simple solution for them is to deny payment altogether. In the world of physical therapy, more and more insurance companies are contracting with third party companies to review and oversee authorizations for physical therapy visit coverage. So, even if your plan has 50 visits per calendar year, you may only be approved to use 6 visits or so for your current injury. And once those 6 visits are used, your physical therapist then has to repeatedly file paperwork, call, and defend your case against a “peer-reviewer” for perhaps an additional 2-4 visits. All current trends in this practice point to a more stringent usage of these services by more insurance plans as we move forward. In other words, the ability to use the benefits you pay for is likely to become more challenging.

The other variable when it comes to being authorized for physical therapy coverage is necessity. In essence, health insurance companies are only willing to pay for things that are considered medically necessary. Even if you are considering having an elective surgery such as a total knee replacement or a rotator cuff repair, it will need to be shown as necessary based on your provider’s documentation as well as your current level of function. This is how it should be for most things - insurance should be reserved for necessities. If insurance did not have such a reservation, then pricing would skyrocket out of control further than it already is.

What does that mean for you?

So when we think about the purpose of physical therapy, what is considered “necessary”? The thing with physical therapy as it pertains to this conversation is that the vast majority of insurance coverage for physical therapy is concerned primarily with pain and minimal functional capability. What does this mean for you? Let’s say you go to your physical therapist and you report that your knee bothers you when you run over 5 miles. You can run anything under 5 miles just fine, and you can run over 5 miles if you run at about 70% of your typical running pace. On top of that, you have little to no pain with daily activities like walking, going up and down a flight of stairs, and getting out of your car. It’s pretty fair to say that your insurance company, if they utilize a third party reviewer, is likely to deny you a good amount of visits. Now, one could argue that a good physical therapist should be able to give you a good amount of education and an independent plan to make solid progress despite the amount of visits, and while this is true, it’s also likely that you will have additional questions, possibly some setbacks, and likely some logistical challenges to this plan that you did not originally anticipate. All of these things are valid reasons for you to want more visits until you feel confident and self-sufficient in your pain management and performance goals.

Unfortunately, in regards to physical therapy and what is “necessary”, that has already been pre-determined by the insurance companies. Their concern is not that you can play a sport that you love (unless it is your means of income). Their concern is not that you don’t have the energy to take 3 flights of stairs at work but would prefer to do so just to add some physical activity into your daily routine. Really, their concern is that you can do what is “good enough” to live life, but maybe not the life that you really want to live.

What can you do about it?

Ask yourself this question, “Is what I am able to do now all I care about being able to do from now on?” If you want more from your physical self, you may need to explore other options. The beauty of out-of-network physical therapy options is that no one can tell you what is important to you. If you want to run a 5k, then you can work with someone to help you do that. If you want to continue to lift weights despite not knowing how or having significant fear of injuring yourself, you can work with a physical therapist to help craft an intelligent and successful plan.

As necessary and essential as health insurance is for everybody, we can’t rely on health insurance to provide us with everything that we want out of life. Sometimes, we have to take the situation into our own hands and own our circumstances, our goals, and ultimately our progress towards the next level of success.

While this is a scary thought for most people, we know that we are the best physical therapists and nutritionists in Portland, Oregon to give you a scientific approach with a human touch to help you accomplish whatever it is you want regardless of who or what may tell you otherwise. If this is something that interests you, hit the button below to reach out to a physical therapist or a nutritionist to schedule a consultation.