Episode 164 | Your Insurance Ran Out. Now What? – Part 1

What is a team and welcome back to another episode on the ACL Athlete Podcast. I have been on some type of tear recently, and I’m not sorry about it. And we’re just going to keep this rolling because I’ve been feeling very passionate about where we’re at in this current state of ACL rehab. And what’s interesting is last year I told myself, you know what, I’m not going to say anything negative about insurance or healthcare. And while I’m still trying to respect that kind of theme, if you will, I’m not also going to hold anything back.

I’m sure if you’ve listened to any of the recent episodes, it’s been something that has felt just a little bit more of a passion to share. It’s because I think there’s just not enough transparency in this process. The goal of this podcast is to give you the real deal. I’m not here to sugarcoat things. I’m here to make sure you are as prepared as possible to enter this process, because it will change your freaking life.

I’m starting this episode out hot. It’s because I’m going to be talking about insurance to some degree, but it’s just more so of talking about options. When we look at the title of this episode: it’s your insurance ran out, now what? We’re going to break this down into a two-part episode because no one wants to hear me talk about this for probably an hour plus. Therefore, we’re going to break this up for you guys, so it’s digestible. But I promise you if you are going to fall into this bucket, guess what? Every single one of you will fall into this bucket except for the small subset of people who have unlimited resources or visits that are available or an incredible healthcare system. You’re likely going to fall into this kind of category. It will run out at some point whatever care that you have. What is that going to look like for your process?

Today, I am going to be talking about insurance or referencing insurance, if you will, because I live here in the states. But this is something that can literally apply across any healthcare system, if you will. It could be insurance, it could be limits on your socialized medical health system like NHS, it could be a variety of different places in this world. And I know people from all over listen. I want to make sure this is applicable as possible to people who are listening. But as I had mentioned, I’ll be saying health insurance here. But take whatever medical system you’re in. And kind of approach it as like, suppose whatever that coverage is for you or what is expected through your medical system and how you should take this concept.

I remember when I was first starting the podcast, I did a poll and talked about insurance. One of the things that I wanted to kind of gather from some random places, was just like some voting on the average number of visits from people, and most people kind of said it was 30. The average was somewhere around 30. I remember seeing responses from 20 visits to a few folks just saying they had unlimited visits.I promise you as we currently stand in 2024. The average is still, probably 30, somewhere around there for most people with just general health insurance. But now let’s speak about these outliers, because I think that this is really important to highlight here as we dive into this episode.

The people who have unlimited insurance visits. It does exist. That insurance kind of model does exist. Depending on the type of insurance you have, maybe the job that you work, there are so many different factors that kind of play into that, but it is a very small percentage of the population. The general population, as we talk about here, especially here in the U.S. very small subset.

Oftentimes people think it’s unlimited, but there’s stipulations around the two. Maybe there’s some fine print or maybe there is that little asterisk there that says unlimited. But then when you actually get to that point, it’s unlimited until X number of days, or maybe meeting normal everyday activities.

I remember being in the insurance-based model and it was constantly on the phone arguing with these insurance companies on why our patients needed more visits. When you think about it, just in a general sentence, you’re like, this is ridiculous, man, this is healthcare people. If we are trying to say: “Hey, this person needs visits for X, Y, and Z.”

You think that because we are so forward in healthcare to just give people the visits that would make sense. But of course, there’s people who abuse the system. There is revenue that is the main driver here. So that could be for the PT clinic. It could be for the patient themselves. It could be for the insurance company.

It’s a tug of war between actually providing care for people and actually revenue associated with it. This is the thing that is this constant battle. And the thing is, is that the care shouldn’t stop when someone can walk, go downstairs or just use the bathroom. And that’s the thing that a lot of insurances will be like, well, they can meet the activities of daily living, we’re not going to cover this anymore. It’s pathetic.

This is the thing that should be connected to the person’s goals, in my opinion, point [blank]. I wished that we could just like assign some sort of like criteria, if you will, that is a little bit more particular to the person. And they’re also being accountability with this. If the physical therapist, for example, if there’s something that the person is not meeting, or this is being prolonged after a certain period of time, well then therefore there is an audit of that.

And I know that some of this stuff goes on, but it’s almost like this kind of black and white kind of process of like, oh, well, they can do this now or  X number of visits. Let’s cut them off. There’s no particular stipulations, especially based on someone’s goals, typically outside of just daily living. Being able to use the bathroom and go downstairs, walk all those things, which is just crazy that that’s kind of like the threshold we set for our coverage. But with that said instead, most PTs are fighting to get their patients, even 20 visits care. That should be entitled to you.

It’s funny. I had an athlete who had a great out-of-network benefits for her insurance. Her insurance claimed it covered 70% of the visits up to 60 visits. That’s awesome. Especially for out of network visits, guess how much she actually got covered. Six visits, literally six visits. And then just decided to stop covering the rest. She was fresh off of an ACL surgery working with me. It was one of the only times in the recent years, I hopped on the phone and battled it out with insurance. on behalf of another patient. And mostly because I don’t deal with insurance and the ACL athlete, we don’t use insurance at all. But with that said, this is something where she had some benefits that was rightfully hers.

She was entitled to. And they were giving her a hard time and she had a whole long road ahead and they were only covering six visits. And they said that they would cover 70% of those visits for 60 visits. So times 10 of that. And so the agent and I got on the phone, they had nothing to share in terms of reasoning, besides we can’t cover anymore. And then pass me on to a multitude of people down the chain and they can come up with a reason.

Guys, I spent hours on the phone hours on the phone, multiple calls talking to managers, all of these things. And I finally got to one person and I got so pissed. I asked one of them. I was like, what’s something you really love to do with your body that is physically active. They obliged surprisingly. And they said, I like to play tennis. I said, imagine that getting taken away from you and having a major reconstructive surgery to your knee. Your insurance gives you six visits. Do you think that this makes sense? Just logically as a human being. How would that be for your mental health you thing? What about physical health? There was a super long pause.

And then just literally dodged the question. But I could tell that there was acknowledgement of it because there was such a long, awkward pause that I wanted to happen and they just dodged it and said, I’m sorry, I’m not sure what to tell you or what I can do for you. It was literally like talking to a robot and this goes down to the core of like how they train people to be able to handle these conversations because they know people are going to push back on this. So for those of you who have to get insurance visits verified, or have been denied and your PT or health care provider is providing to get those for you. Tell them.

Thank you. Because this is the BS that happens all the time behind the scenes, literally all the time. And any of my PT friends who are listening, you guys are probably not in your head, especially if you take insurance, you’re like, yeah, we gotta deal with the ins and outs of this all the time. And it’s such a thing to juggle and so many hoops to jump through just to be able to essentially provide good care for you. As an ACLer or whatever healthcare system you’re in, there’s always these hoops to jump through. So this is something that can make it tough because it’s almost an uphill battle.

This is one of the many reasons we are the ACL athlete do not accept insurance. And so now I’m going to exit my soap box here about this story, because it’s just one of many that exists in terms of experiencing insurance and athletes, not getting coverage that they need. This is something that can be really tough, right? So as we try to get back on topic here, more specifically, So you have those people who do actually have the unlimited that’s cool.

One caveat that I’m going to add here is that this can also be, if you fall into this category of unlimited physical therapy visits, this could be handcuffs without you knowing it. In your progress. So now let’s say you’re with a great PT and solid, fully decked out clinic. That’s awesome. You’ve got unlimited visits. Welcome to the minority of minority. Not only do you have unlimited visits, but you also have a great guide in clinic. You are in these small percentage of ACL rehab. To be honest. Now, let’s say you have unlimited, but you’re at a clinic where the PT gives everyone the same exercises,

They also see three to four patients and an hour, or the clinic only has weights to like 20, 30 pounds. not a lot of variety or maybe they just don’t have this space to be able to start to get you to more dynamic stuff like running, jumping, cutting, especially in more of an open space. And that’s okay. Not every clinic is going to be built that way. And a lot of models aren’t built that way and that’s okay. But in terms of the other factors I mentioned with, you know, same exercises, time-based protocol, lots of volume and patients, those are factors are really considered.  But it’s quote unquote free and unlimited, by the way, it’s not free.

You’re just paying into that more than likely in other ways. But with that said, this can be handcuffs for you without you knowing. I’ve talked with ACL or who have felt stuck all the time. And usually comes down to convenience and finances. It’s where you’ve been there. Nice. Guess what? We don’t get into physical therapy because we want to make a lot of money is because we’re usually nice people.

We’re very extroverted type people, or at least can present that way. We, uh, like to connect with people, learn about people. we don’t choose physical therapy for the money. So this is something where you’re going to likely have a nice physical therapist. It’s just a part of the nature of the job.

It’s like going to a Chick-Filet and saying you didn’t get good customer service. It’s very rare to find. It’s something that even when you do experience, you’re like, this is probably a better than most fast food in general, in terms of customer service. Right. And so this is something that is by nature as a physical therapist and physio in this line of work, you’re going to have someone that’s nice.

And to come back to the topic of, it’s where you’ve been. They’re nice. And you’re not paying anything out of pocket. Like every time you’re not paying a copay or these kind of big little expenses per session, like it’s just kind of something that’s going through your insurance. It sounds good in theory.

But if it’s not great care or maybe it’s met its limits of what it can provide, it’s an opportunity cost, mostly in getting you back to what you love. but Hey, you’re saving money and it’s right down the road. It’s convenient and financially—-it was great. So just watch out for this because you might get stuck in it and it’s six months later, but you feel like you’re only two months out. I’m a repeat that. It’s six months later in your ACL rehab process, but it feels like you’re only two months out. Is this something that is just really your knee is struggling to progress or is it really your environment and the resources and the guidance you’re getting that is potentially slowing you down?

This is something that I want you to audit and see, because I know that the first part of this. podcast.

I did want to highlight the people who, are the ones who might have like insurance that does take them through this process. Well, okay. This is the kind of categories that you might live in, so then therefore you have to be able to audit it and see, okay. Is this working for me? Cool. Then if it is, keep rolling, if it’s not, then it’s just being able to take that step and pause and reflect on it. Audit it and then make sure, like, do I need to redirect. And it might be having to decide and almost operate in this mindset. This is one of the things I encourage anyone in this episode to do is like, If I was paying cash for this. Insurance-based or whatever my health care is providing.

Would I pay for it? And then put it at a number that makes you uncomfortable. Right. And if you’re like, yeah, I’d pay 200 bucks a session for this. Yeah. This is really good quality work. I’m getting the focus that I need. It’s a great clinic. I feel like I know where I’m going. Um, I could talk to my physical therapist.

I get really good care. Awesome. And also, maybe you’re getting also programming outside of that. So you know what to do when you go home and it’s really dialed in the specific to you. Right then that is something I encourage you to reflect on and be like, well,

if this cost me X amount, would I do this? And then the other thing you can also kind of put on yourself as also, um, would I take my loved one to this place and work with this person? Right. Do you think that you’re giving them the best care? And so then therefore you can kind of get outside of yourself in a couple of different ways outside of what’s just, you know, typically the norm. And you’re able to look at this from not only a true financial perspective of an investment. if you didn’t have insurance or whatever healthcare coverage you have involved, would you pay for it? And then the other thing is, would I take my loved one?

The person I care about the most in this world, what I take them to this person? And this clinic and have them go through this whole process with them. And you might say, yes, you might say no. it might be something where you’re like maybe for this current period of time or this phase, but after that, I’m not really sure.

These are just kind of questions to think about as we tee this up for part two, where we do actually talk about the particular options and we take a deep dive here into your options because your healthcare coverage, your insurance, whatever was there to help you initially is gone. Now, what do you do?

So stay tuned for part two, because we are going to get deep into it. And I’m excited to talk about it and lay it all out there. There’s not a right answer with this, but you’re going to know all of your options that are available to you. So then that way you can make a very well-informed decision, because majority of you listening to this, if not all, are going to fall into this category of having to figure something out, once your coverage does run out.

That’s going to be it for part one today, guys. Do me a huge favor and make sure to listen to part two next week, I promise you it’ll be worth it, and it will be worth you being able to plan out this process and be as set up as possible for this. Set your schedules for the next week.

If you’re listening to this live, as it’s released. If you are listening to this and this in the past, great. You can jump right straight to it. I will catch you next week until next time. This is your host, Ravi Patel, signing off.