Is It A Smart Move To See An Out of Network Therapist?

Insurance probably doesn’t cover therapy the way you think it does.

As a pelvic therapist, insurance sure doesn’t cover therapy the way I think it should.

Therapy coverage has changed a lot over the past decade. Long gone are the days when most people paid reasonable co-pays for PT with commercial plans. Most private insurances require the patient to meet their deductible before ANY therapy coverage occurs. (The insane news here: the national average in-network deductible is now between $2,000- $2,825, depending on if you have an employer sponsored plan or a marketplace plan.*). These high numbers mean you have to pay for your therapy in full until that amount is met.

Many of the patients seen in pelvic therapy are relatively young and otherwise healthy, so they often have not met their annual deductible. When you factor in the fact that in order to work with insurance companies, most in-network therapy providers set their rates at 3-4 times (or more!) that of a typical out of network therapist, the benefit of OON therapy for many patients becomes clear. Further that with the fact that considering in-network PT rates, even once you meet your deductible, that 15% or 20% co-insurance responsibility you now have may still be higher than you would think.

But here is the kicker (and what made me finally cry uncle and accept defeat as a former in-network PT): the insurance companies don't seem to understand pelvic therapy. So they set restrictions on what diagnoses can be treated (denying pain with intimacy, certain types of pelvic pain or prolapse, etc.) and what treatments can be completed. Over the years, I have seen patients denied coverage for valuable pelvic health related treatments such as biofeedback, transcutaneous tibial nerve stimulation, aquatic therapy during pregnancy, dry needling, and even manual therapy when provided on the same day as other interventions. Even the time spent completing valuable and essential patient education (which I think is one of the MOST critical aspects of quality pelvic health therapy) is not considered a covered service under some policies.

Also, the insurances often set arbitrary visit limits or deny ongoing care, discharging therapy before a person actually gets better. So you often get less therapy, for more money.

With out of network therapy, the cost is straightforward, the care is complete. We do what we know we need to do to get you better. And we think that is smart.

-Rebecca

*Kaiser Family Foundation, 2022 and Office of Health Policy, Issue Brief, January 2022.