Why I don’t take health insurance

This is the most frequent question I have been asked since starting my private practice.moneypile

The short answer– It is not an efficient use of my time (I would have to at least double the rate I charge to compensate for the amount of time it would take to bill and be reimbursed by insurance companies) and it is not effective in providing the best services for families (see long explanation below).

The long answer– Health insurance is a broken system because whomever pays seems to drive the care; it makes my client the insurance company, rather than the family I am trying to help.

Each insurance company has its own rules about what an occupational therapist can do, what diagnoses can be treated, and what type of treatment is covered.  Each company requires different documentation, testing, and authorizations.  In the end, only about 50% of what I feel I am trained to do and could do to help families and children is covered under an average plan, and I spent hours of time on meeting eligibility requirements that are not clinically meaningful to me or the client.

Additionally, health insurance will only pay for my time working directly with the child, not my time documenting the required test score, reading emails with questions from parents, consulting with school teachers, or training caregivers on home programs, so anything “extra” I do (because it improves care) is not reimbursed.  In a nutshell, that health care systems make money for the time directly spent with the child, so that is all they focus on.

The constraints of working through insurance providers in a large health care system significantly limits my effectiveness.  This model of care does not allow families to demand high quality services and does not allow a provider to be paid for high quality services.

Pediatric occupational therapists tend to work either within a school system under an educational model or in health care under a medical model.  However, we are trained to do much more than this.  I want to work under my own model of care to explore what is the most effective and efficient way to help families.  In my model of care, I can provide excellent services, which I feel is best done through an individualized, private pay model tailored to each family.  In a private pay model, you are my client and you determine the services you want — not the insurance company, your doctor, or the school district.   My model of care allows you to control what services you want to pay for and to know exactly what you will get for your money.

There are some strong counter-points to my argument.  There are some clients that are best served in the clinic or hospital settings for a medical problem where occupational therapy services are beneficial.  There is also the benefit that health insurance can equalize access to services to some degree, allowing families that otherwise could not afford care to get therapy services.  For these and several other reasons, I have and still do work in the clinical setting for a large health care organization, where my employer does health insurance as payment.  However, I feel that in my private practice, my top priority is providing excellent care that is affordable, and I an unable to do so with an insurance payment model.

I’ve had people ask why I don’t take insurance for some patients and allow private pay for others.  I determined this to be unfeasible.  If an insurance company will reimburse me a set percentage of what I charge (let’s say 50%), then I would need to increase my rate by that amount (so instead of $75/hr, it would be $150/hr).  It isn’t ethical to charge different amounts to different people depending on their payment method, so clients who need to private pay would be paying more for my services.  It is grey area that many health care providers are struggling with, but in the end my decision was to focus on my goal of quality and affordability of care, which is best done through a private pay model.

Related post on understanding pediatric rehabilitation coverage.

 

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Paige Hays is an occupational therapist who provides in-home, pediatric occupational therapy services in the south metro area of the Twin Cities, MN. She is a mother of 2 girls, avid DIYer, and a highly skilled and experienced OT. She specializes in working in pediatrics, with diverse expertise ranging from cognition and sensory issues to working with children with neuromuscular disabilities or complex medical needs. www.paigehays.net