WHY DOES LIMITLESS THERAPY AND WELLNESS CHOOSE TO BE OUT-OF-NETWORK WITH MOST HEALTH INSURANCE PLANS?
The traditional in-network model for outpatient physical therapy is not sustainable and is not helping facilitate successful outcomes for patients. Insurance companies across the board continue to reduce payment for physical therapy while imposing visit limits, billing and coding restrictions, and denying necessary care altogether. Meanwhile, the quality of care available to patients continues to decrease as in-network practices are being squeezed. Labor, equipment, medical supplies, and space are all more costly than they’ve ever been, but it continues to become harder and harder to offset those costs with these declining and/or denied payments for services. Thus, the physical therapy profession and the healthcare industry as a whole are at a crossroads. Instead of settling for providing sub-standard care and burning out our therapists with almost impossible productivity demands, Limitless Therapy and Wellness decided to put the patient experience back at the forefront of the conversation by moving to a private-pay model.
At Limitless, we believe that any problem can be solved with the right approach to caring for people. Our healthcare system is currently designed to tell us that whatever ails us can only be fixed through medications, injections, or surgery. At Limitless, we know that your body was designed to adapt, survive, and thrive, and sometimes you just need help getting out of your own way and some help moving in the right direction. The in-network model simply cannot consistently provide the level of care and attention needed to achieve these goals. Thus, Limitless Therapy and Wellness has chosen to blaze our own trail in order to make sure that our patients can move from pain to performance without any unnecessary hurdles or roadblocks to overcome.
What is the difference between an out-of-network/private pay physical therapy experience and an in-network physical therapy experience?
Below is a direct comparison to help you see how our practice model compares to traditional in-network practices and how we are likely to help you save time and money while helping you achieve your desired result.
| LIMITLESS PELVICHEALTH | TRADITIONAL IN-NETWORK PHYSICAL THERAPY | |
|---|---|---|
| 1-on-1 care for my entire appointment? | ||
| Time with therapist per session? | 50-70 minutes | 15-20 minutes |
| All visits led by a Licensed Physical Therapist? | ||
| Same therapist every session? | ||
| Frequency of sessions? | 1-2 times per week | 2-3 times per week |
| Therapists with specialty certifications to address my specific diagnosis and goals? | ||
| Direct access and communication with your therapist with guaranteed response within 24 hours? | ||
| Holistic and Up-To-Date Evidence-Based Treatment Approach? | ||
| Cost Transparency? | ||
| Mobile Appointments at Your Home or Office? | ||
| Easy Access to Your Documentation and Medical Records? | ||
| Visit Limits, Treatment Option Restrictions, and Pre-Authorization Requirements? |
Let’s look at an example of how these two types of care play out for a patient.
Sarah
Limitless
Jessica
In-Network Therapy
Sarah and Jessica are both 35 year old females with urinary incontinence and pelvic pain with intercourse. Sarah has chosen to work with Limitless, while Jessica has chosen to go to an in-network practice.
| FIRST VISIT | SARAH | JESSICA |
|---|---|---|
| Cost/Investment | $295 | $150-500 |
| Time Demand | 90 Minutes | 15-60 Minutes |
| Customer Experience | Sarah’s therapist was ready to start her appointment ON TIME and listened to her entire story and history to help diagnose the root cause of her problem. Her therapist did a whole-body movement and hands-on external and internal assessment, discussed her diagnosis and findings with Sarah, and then performed treatment for 45 minutes. Then, Sarah and her therapist sat down and discussed a comprehensive plan that included follow-up visits once per week for 6 weeks with a customized home exercise routine and a plan for reintroducing pain-free sexual intimacy and strength training in the gym. Sarah was blown away as no one had ever spent that much time with her and she felt that her therapist was very invested in seeing her get back to 100%. |
Jessica’s therapist was running 10 minutes late from her previous patient, and she was still monitoring another patient who was performing exercises on the other side of the room while starting Jessica’s appointment. Jessica’s therapist performed a quick movement screening and then demonstrated a few kegel-type exercises for Jessica to try while she went to check on her other patient. Jessica was unsure as to her diagnosis or why she was doing the exercises she was doing. Jessica’s therapist checked back in with her and then handed her a cookie-cutter printout of some pelvic floor and abdominal exercises to begin trying at home. She was told she needed to check out at the front desk and schedule appointments 2 times per week for 6 weeks. Jessica couldn’t help but feel like just another name on the schedule. |
| SIX WEEKS LATER | SARAH | JESSICA |
|---|---|---|
| Cost/Investment | $1795 (Evaluation + 6 Follow-Up Sessions) | $1950 (Evaluation + 12 Follow-Up Sessions) |
| Time Demand | 7.5 hours + commute time (unless appointments are mobile, then NO commute time) | 13 hours + commute time |
| Customer Experience | Sarah has remained highly motivated throughout the process as she continues to feel like a priority. Sarah has enjoyed coming to her appointments because her therapist has always been prepared and ready to take things to the next level. She has felt continuous improvement over the course of 6 weeks and has returned to doing her normal weight-lifting routine in the gym without any urine leakage. She has also been able to enjoy pain-free intercourse for the first time in years! Sarah has been equipped with the knowledge and tools to keep future episodes of pelvic pain at bay. |
Jessica has been disappointed by the fact that he has seen at least 4 different providers over the course of 6 weeks, and none of them have been on the same page about how to progress her back to her weight-lifting routine or how to reintroduce sexual intimacy in a pain-free way. She has been given 2 or 3 different lists of exercises to do at home and she’s not really sure which ones are the right ones. She has also found it hard to keep her appointments and stay motivated because of her lackluster experience. Jessica would say her incontinence is about 50% better, but she is still unable to lift weights without urinary leakage and is afraid to try to resume intercourse with her husband since she has not received any consistent guidance about how to do this safely. |
| Outcome/Next Steps | Sarah no longer needs weekly appointments with her therapist and has returned to all of her normal activities. She plans to reach out to her therapist if her pelvic pain or incontinence returns. Sarah’s therapist reaches out monthly to check on her. |
Jessica has decided that she needs to see her OB/GYN, who recommends dilator training for her pelvic pain but simply refers her to the instruction manual for the dilators as to how and when to use them. After starting to use the dilators, Jessica feels worse and begins to wonder if she will ever be able to enjoy intercourse again without pain. She doesn’t know what to do next. Should she go back to physical therapy? Should she ask her OB/GYN for other solutions? Does she need surgery? Or should she just accept the fact that she’ll never be able to lift weights without urinary leakage or enjoy intercourse without pain ever again? |
| SIX MONTHS LATER | SARAH | JESSICA |
|---|---|---|
| Cost/Investment | $1795 (Evaluation + 6 Follow-Up Sessions) | $3500 (Evaluation + 12 Follow-Up Sessions, 2 corticosteroid injections, MRI) |
| Time Demand | 7.5 hours + commute time (unless appointments are mobile, then NO commute time) | 15 hours + commute time |
| Customer Experience | Sarah has been diligent in continuing to perform her exercises at home, which have helped her remain pain-free with intercourse for 6 months. She has been lifting weights 3-5 days per week with no urinary leakage, and she has also been able to sign up for a half-marathon, which she has always wanted to try. She has been able to complete her training with no increase in pelvic pain or urinary leakage. |
Jessica did not have any faith that physical therapy could help her pelvic pain or incontinence because of her subpar experience, so he decided to try to take some time to see if things would get better on their own. Within 3 months, her pelvic pain with intercourse was worse than ever and she began to experience urinary leakage with coughing and sneezing again, so she returned to her OB/GYN for another consultation. Her OB-GYN ordered a pelvic MRI and ultrasound, which showed normal age-related changes but no obvious pathology. She was told that she could be referred for an exploratory surgery or she could try seeing a different pelvic health physical therapist. Jessica is frustrated and doesn’t know where to go from here. |
| Outcome/Next Steps | Sarah’s entire perspective on life has changed. Rather than thinking she would always have to live a life of pain with intimacy and urinary incontinence, she has become much more proactive about her health and knows that she is capable of living a happy and healthy life. She listens to her body and reaches out to her therapist directly when she has questions or isn’t feeling her best. |
Jessica decides to hold off on surgery, but is desperate to find relief from her pelvic pain as it is taking a toll on her personally and on her marriage. She finds herself withdrawing from her friend groups since she can no longer enjoy a lot of the physical activity they used to do together without the embarrassment of frequent trips to the bathroom to change pads from urinary leakage. She meets with her primary care doctor, who agrees to prescribe her prescription pain medication and muscle relaxers for her pelvic pain, which is her only temporary relief. She knows that she doesn’t want to take the medications long-term, but he feels like she has no other choice. |
SUMMARY
Sarah spent almost 50% less than his friend Jessica, while spending half the time and achieving a superior outcome. This outcome doesn’t account for the intangibles of the incredible experience Sarah had with her devoted therapist who created an individualized plan for her and helped her stay motivated to complete the plan.
WHICH PATH WILL YOU CHOOSE TO GET BACK TO MOVING AND FEELING YOUR BEST?
“I want to call my insurance company first to see if I have any out-of-network benefits to cover working with Limitless.”
From time to time, when discussing our practice with new patients, they express a desire to check with their insurance company first to see what coverage they have - which they should! It is always a good thing to understand the terms of your health insurance plan.
However, if you decide to make this call to your insurance company, we want to help you get an ACCURATE depiction of your coverage. Too often, we find that patients are told that they don’t have coverage when they actually do because they didn’t ask the right questions.
Sometimes, a patient simply asks “Do I have out-of-network benefits?”, which usually results in a “No” or “only after your deductible of $XXXX is met.” This is meant to discourage you from utilizing an out-of-network provider. But without knowing your in-network coverage and terms, you can’t even begin to make a comparison.
Here is a great list of questions to ask your health insurance company if you would like to determine what coverage you have. It is important ask these questions EXACTLY as they are worded in order to get accurate information:
- What are my out-of-network benefits for physical therapy?
- Do I have a separate out-of-network deductible? If so, what is it and how much of it has already been met this year?
- What do you (the insurance company) need from me (the patient) in order to get reimbursed for out-of-network physical therapy?
- The answer is typically just a claim form attached to a superbill, which we provide for all of our patients. But it is good to confirm this before proceeding.
- What is my in-network deductible? How much of it has already been met this year
- Do I have an in-network co-pay for physical therapy, and if so, what is it?
- Are there any limits to my in-network physical therapy benefits for the year? (This can be a maximum # of visits, maximum allowable $ amount per case, etc.).
“I’ve checked my benefits and I still want to call around and talk with practices that are in-network with my health insurance plan.”
Sometimes, after checking their benefits, our new patients want to call other practices who are in-network with their insurance to inquire about cost and availability. This is a totally reasonable step to take in the decision-making process. At Limitless, we simply want you to be well, whether that happens with us or with another practice or provider. But we also want you to fully understand the difference in cost and quality of care you may receive by going in-network. As shown in our case study above with Logan and Tom, going in-network is often just as expensive or even more expensive than working with Limitless, with a very different experience and result.
What questions should I ask when calling in-network practices so that I can make an accurate comparison with Limitless?
If you call other physical therapy practices in the area, we highly recommend using the list of questions below to so that you can make a direct comparison between Limitless and the other practices you are considering:
- How much 1-on-1 time will I get with my physical therapist at each visit?
At Limitless, you will get 90 minutes with your physical therapist at your first visit, and 60 minutes with your physical therapist at each follow-up visit. - Will I see the same provider at all of my sessions?
You will always see the same therapist at all of your visits. - How many visits per week are typically prescribed for someone with my problem?
Limitless patients are seen, on average, once per week. - How long is the average plan of care for someone with my problem?
The average plan of care for a Limitless patient is 6-10 visits, but that varies based on a number of factors. - Do you have physical therapists on your team that specialize in treating my problem?
At Limitless, we have physical therapists that specialize in orthopedics and sports medicine, as well as women’s health and pelvic health. - Can you tell me the exact cost of my first visit?
At Limitless, the cost of your first visit is always the same and is always quoted to you over the phone before scheduling. - Can you guarantee me that I will never get a surprise bill?
At Limitless, the cost of your first visit is always the same and is always quoted to you over the phone before scheduling.