Episode 9 | 40 Visits – Using My Own Insurance to Plan Out ACL Rehab

What’s up everyone, and welcome back to the  ACL Athlete Podcast. Today, I’m pretty excited about the topic. It’s gonna be an interesting one, talking about insurance in ACL rehab. I’ve been getting a lot of questions and having some conversations around insurance and how it’s been working for people and mostly not working for people related to ACL rehab, whether it’s clinicians or patients.

And this all kind of got fueled by me having a conversation with someone, and then I posted this on Instagram, which gained a lot of conversations. So the post itself is a narrative that needs to change: needing physical therapy three times a week, right after ACL  surgery. Most people have limited insurance visits.

Talked to someone today who maxed out visits after seven weeks with their PT. We have to do better, and I stand by that. I think that it is something that we need to do better with. There’s no reason to be doing physical therapy three times a week when you first start out after ACL surgery unless you got the benefit of just unlimited visits. But if there’s a cap of visits, then this needs to be strategized more, which we will kind of go into later in the episode. But first, that made me ask a follow up question— How many physical therapy visits did you get for your ACL rehab and I got probably around 40 or 50 responses.

 There were some people who were like, I didn’t get any so I had to pay for them all out of pocket, to people who had almost unlimited (120) visits, but most people sat around 20 or 30. That was most of the responses that I got. And so when I did the average, it was around 30.

And I’m gonna actually read to you one of the person’s responses. So she said I maxed out after 12 visits. My parents paid out of pocket for two sessions a week after that for four weeks. Then when they couldn’t afford it anymore, I wasn’t able to rehab for a month. Finally, I was able to see my public school system’s trainer.

For the last three months, I did a six month total rehab after injury, including that month off. After he heard that my insurance would not cover a full rehab, he agreed to see me outta empathy for free. Talk about Lucky before any of this mess. My insurance tried to refuse to even cover the surgery, saying that an ACL repair can repair itself and the tear qualifies as a sprain, which is just mind blowing …so insane. And there were other responses similar to this, so we won’t go into the details of those. Just know that you know, healthcare and insurance, it is going to vary. This isn’t the time for me to just kind of rant about it, although I could, but I’m not, you know, I want to keep this very tactical today, but it’s just going to range a lot based on the country that you’re in, and the type of insurance that you have.

Maybe the way that is being filed, there are a lot of things that go into this. Now, a thing that I want to touch on. The quality versus quantity of it. Now, you know, you heard some of the variations between zero and 20, 30, 120, and one thing that I just want to make a statement about, because I will hear this from people where they’re like, I’m going to physical therapy three times a week, and I’ve been doing this for, let’s say four months.

They’re still doing the same stuff that they were doing for two months. Or they’re not being challenged or they’re going in and they’re getting soft tissue work done, or ultrasound. There are certain times where those things can be warranted, but that’s not what should make up the bulk of it, and you sure shouldn’t be doing the same exercises two months later.

The quantity aspect is very important to understand and making sure that the quality is more prioritized throughout this process. So today what we are going to do is use my own insurance as an example to set up acl rehab. So I want this to be a process where if someone can look at their insurance and get an idea of what would be the best care for them, I want that to be the case.

So we’re gonna use my insurance today as an example. So I called my insurance to look at how many visits I have, and it’s pretty terrible in terms of the insurance. Small business, high deductible. But you know what? We’re gonna roll with it. So we’ve got 40 visits maximum for combined physical therapy, speech and occupational therapy.

My deductible is $4,000 and my out-of-pocket max is $4,000. Yep. I know. It’s really terrible and. Then I asked about if I needed more visits what would that look like? So then she mentioned that I needed a medical authorization in order to see if I could get some.Typically this looks at the medical necessity of it, like is it impacting your activities of daily living? But sadly, that’s really it. You know, this can be put a different way to be able to authorize more but a lot of times what you will see is insurance cutting off visits because you can walk, you can take a shower, you can drive a car, but it doesn’t fulfill that gap of trying to get back to sport.

And that’s the biggest issue here, is that the people who are getting injured with ACL injuries are typically people who are athletes, people are getting injured, playing or doing something they love. But the thing is, is that insurance only deems it medically necessary to do your only normal everyday stuff, not necessarily the sports stuff.

And that’s where this big gap sits. So now we’re gonna look at strategizing this. So we have to start with the end in. What is the end goal I’m trying to get back to? And then we need to reverse engineer that to be able to be very strategic about these visits. So let’s say for example I don’t know, like I wanna get back to dodge ball in nine months.

Okay, so we’re gonna use that as the threshold there. You know, you’re gonna look at your insurance plan. For me, I have 40 visits, so you could see that stretched out over this period of time. We’re going to use six months because the realistic nature of using and stretching out 40 visits over nine months is just not really gonna happen.

So we’re gonna use six months as this threshold to get to. So the way that this works out, so it’s six months, 24 weeks in total, that’s 40 visits. So if we just divide that simply, that’d be six to seven visits per month. Okay. So if we’re looking at month one, let’s say day one starts post-op day one. The way that I like to look at this is the first week definitely having two visits just to assure everything is going well and more than anything, being able to get into the flow of what needs to be done, and then I think it’s adequate to back off and only do one time a week for the next, maybe two, three weeks.

So maybe let’s say for the first month, cuz we don’t wanna burn these visits and we can’t really speed up the stages of healing and what’s going on. The surgery is very fresh, so you know, there’s a lot of trauma to the knee, if you will, and it’s rebuilding so we can’t rush human biology and how it heals.

So we need to make sure we’re doing the basics of getting the quad going, range of motion, minimizing the swelling, mitigating the pain with it. All these things are really important in the early phases, and I think a really good program will help set this up. That way there’s not a need for two to three visits every single week.

And then if we’re looking at months 2, 3, 4, 5, 6, I just have six visits kind of spread out throughout there. So you can do two on one week and then one visit, two on one week, and then one visit, however you wanna strategize it to be able to make sure that this stretches out to six months. If we’re looking at this as a whole, you take the total months, so six months here, and then you take the total visits, and then you just reverse engineer that to see how that is going to work out to make sure it stretches over the period of time.

If you’re talking about adding prehab in, you’re gonna do some prehab before the surgery to get things going, you can take anywhere from two to three visits, maybe even more to be able to take away from that total, because I think it’s important that you do do that if you have the opportunity for it.

And then if you’re looking past this, so let’s say six months and you still need to get to that nine month timeframe– let’s say you’re kind of in these return to sport phases, so then you can start looking at a performance coach, whether that’s in person or online. With technology, it has been really cool to see how remote coaching has evolved over time.

But there is this opportunity to make this a continuous plan. Something you can think about that I think is also a good idea is maybe only being in physical therapy itself for three to four months, and then finding a coach, a performance coach to work with. Now, does this mean that you can use all your insurance visits for that?

No. But it would be very much worth the investment of paying money to get a good coach to make sure that you are still making progress and getting back to that place of where you want to be. So for me, I’m gonna play dodgeball. I’m gonna hire a coach after three or four months, and then month to month we will either meet or do it remotely if I feel comfortable that I can do this stuff on my own, be able to get coached, have a program and have accountability. I think that there is a huge place for it, and it’s something that I do a lot with my own athletes. There is a ton of value for that. And the reason that I say this is that this all comes back to the root of all of it.

One is that ACL rehab is very unique. . It’s not something that only takes four to eight weeks, which is kind of how insurance has been designed, if it’s a musculoskeletal injury, like a, you know, a hamstring strain or your shoulder hurts. Typically it’s something that doesn’t take nearly as long.

But what we know about the timeframe is that we need at least six, nine months of ongoing training and rehab to make sure that you get there. Right? So it’s a very unique injury from a time standpoint. And the needs of that. But then we also have a system that is not designed for it. So we have to create it ourselves and take it into our own hands.

And the thing that gets really tough is that clinics are very much incentivized on productivity. When you come in the door, that’s a clinic making money. They bill it to your insurance and then they get reimbursement back from that. So it’s really difficult. When there’s a dilemma between the number of visits that you have and the productivity a clinic needs to have.

So that is just something that is tough. So that’s why I think being able to be more in control of this process by looking at the number of insurance visits you have and being able to sit down and see, okay, this is my timeframe and what I want to get back to– How can I strategically use my insurance.

Biggest thing I want you to take away from this is to look at your insurance visits and see how many you have. Start with the end in mind so figure out what your goals are and reverse engineer it from there. Have a conversation with your surgeon, especially with your physical therapist about what this may look like and if you guys can team up.

If there is a potential opportunity to partner with a coach, maybe it’s something where you do physical therapy for three to four months and then you start working with a coach to be able to get back to more of the performance side of things and then making sure that you have this plan.

I think that this is what is so important with this process is that it’s assumed that insurance is going to cover everything and all of a sudden it maxes out and then physical therapy can’t do anything even though they want to help. It’s like, well, like you either gotta pay out of pocket or decide to just do it on your own, which should not be the case, ever. Even if I were to tear my ACL, I would outsource it to someone else and have the physical therapy because I just don’t want to keep myself accountable for it because it’s just a long process. Right? So don’t be afraid to look elsewhere if physical therapy doesn’t seem to be providing what you need, whether it’s the care or even the support that you need through this process.

So that’s it for today, everyone. I just wanted to come on here and use my own story, my own example of my insurance, and see how that would relate to ACL rehab. Appreciate all of you for listening. This is your host, Ravi Patel, signing off.