Latest / The ACL Athlete Podcast / 164 | Your Insurance Ran Out. Now What? - Part 1

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164 | Your Insurance Ran Out. Now What? - Part 1 · The ACL Athlete Podcast

• 0:19
  SPEAKER_00: Welcome everyone to the ACL Athlete Podcast.
• 0:23
  SPEAKER_00: This is the podcast where we talk about everything related to the ACL, whether that's the injury itself, the rehab process, return to sport, and more.
• 0:33
  SPEAKER_00: I'm your host, Dr.
• 0:34
  SPEAKER_00: Ravi Patel, performance physical therapist and coach.
• 0:38
  SPEAKER_00: Between myself and fellow guests and experts, you'll learn through the lens of the patient, the healthcare professional, and the coach.
• 0:46
  SPEAKER_00: The goal of this podcast is to equip you, the athlete, with the education to make the best informed decision about your care and your ACL journey.
• 0:57
  SPEAKER_00: Thanks for joining.
• 0:58
  SPEAKER_00: Now let's dive into today's episode.
• 1:04
  SPEAKER_00: What is up, team, and welcome back to another episode on the ACL Athlete podcast.
• 1:10
  SPEAKER_00: So I have been on some type of tear recently, and I'm not sorry about it.
• 1:16
  SPEAKER_00: And we're just gonna keep this rolling because I've been feeling very passionate about where we're at in this current state of ACL rehab.
• 1:25
  SPEAKER_00: 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.
• 1:34
  SPEAKER_00: And while I'm still trying to respect that kind of theme, if you will, I'm not also going to hold anything back, right?
• 1:42
  SPEAKER_00: And 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.
• 1:50
  SPEAKER_00: And it's because I think there's just not enough transparency in this process.
• 1:54
  SPEAKER_00: And the goal of this podcast is to give you the real deal.
• 1:58
  SPEAKER_00: 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.
• 2:07
  SPEAKER_00: And so I'm starting this episode out hot, and it's because I'm going to be talking about insurance to some degree, but it's just more so of talking about options, right?
• 2:18
  SPEAKER_00: And so when we look at the title of this episode, it's your insurance ran out.
• 2:22
  SPEAKER_00: Now what?
• 2:23
  SPEAKER_00: And 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.
• 2:30
  SPEAKER_00: And so, therefore, we're going to break this up for you guys so it's digestible.
• 2:34
  SPEAKER_00: But I promise you, if you are going to fall into this bucket, guess what?
• 2:39
  SPEAKER_00: 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.
• 2:54
  SPEAKER_00: And so it will run out at some point, uh, whatever care that you have.
• 2:58
  SPEAKER_00: So then what is that going to look like for your process?
• 3:02
  SPEAKER_00: And so today I am going to be talking about insurance or referencing insurance, if you will, because I live here in the States.
• 3:09
  SPEAKER_00: But this is something that can literally apply across any healthcare system, if you will.
• 3:14
  SPEAKER_00: 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.
• 3:23
  SPEAKER_00: And I know people from all over listen.
• 3:25
  SPEAKER_00: So I want to make sure this is as applicable as possible to people who are listening.
• 3:30
  SPEAKER_00: But as I had mentioned, I'll be saying uh health insurance here.
• 3:35
  SPEAKER_00: 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.
• 3:49
  SPEAKER_00: So I remember when I was first starting the podcast, I did a poll and talked about insurance.
• 3:56
  SPEAKER_00: And 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.
• 4:07
  SPEAKER_00: And most people kind of said it was 30.
• 4:10
  SPEAKER_00: The average was somewhere around 30.
• 4:12
  SPEAKER_00: Um, I remember seeing responses from 20 visits to a few folks just saying they had unlimited visits, right?
• 4:19
  SPEAKER_00: And I promise you, as we currently stand in 2024, the average is still probably 30, somewhere around there for most people, um, with just general health insurance.
• 4:32
  SPEAKER_00: 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.
• 4:41
  SPEAKER_00: The people who have unlimited insurance visits, it does exist.
• 4:46
  SPEAKER_00: That insurance kind of model does exist.
• 4:48
  SPEAKER_00: And depending on the type of insurance you have, uh, maybe the job that you work, there's so many different factors that kind of play into that, but it is a very small percentage of the population.
• 5:01
  SPEAKER_00: The general population, as we talk about here, especially here in the US, very small subset.
• 5:08
  SPEAKER_00: Oftentimes, people think it's unlimited, but there's stipulations around it too.
• 5:13
  SPEAKER_00: Maybe there's some fine print, or maybe there's that little asterisk there that says unlimited, but then when you actually get to that point, uh it's unlimited until X number of days, or maybe meeting normal everyday activities.
• 5:28
  SPEAKER_00: 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.
• 5:39
  SPEAKER_00: When you think about it just in a general sense, you're like, this is ridiculous, man.
• 5:43
  SPEAKER_00: This is healthcare.
• 5:44
  SPEAKER_00: People, if we are trying to say, hey, this person needs visits for X, Y, and Z, you'd think that because we are so forward in healthcare to just give people the visits, that would make sense.
• 5:55
  SPEAKER_00: But of course, there's people who abuse the system.
• 5:57
  SPEAKER_00: There is revenue that is the main driver here.
• 6:00
  SPEAKER_00: So that could be for the PT clinic, it could be for the patient themselves, it could be for the insurance company.
• 6:05
  SPEAKER_00: So it's this kind of tug-of-war between actually providing care for people and actually revenue associated with it, right?
• 6:12
  SPEAKER_00: And so this is the thing that is this constant battle.
• 6:16
  SPEAKER_00: And the thing is, is that the care shouldn't stop when someone can walk, go downstairs, or just use the bathroom.
• 6:25
  SPEAKER_00: And that's the thing that a lot of insurances will be like, well, they can meet the activities of daily living.
• 6:31
  SPEAKER_00: We're not going to cover this anymore.
• 6:33
  SPEAKER_00: It's pathetic.
• 6:34
  SPEAKER_00: And so this is the thing that should be connected to the person's goals, in my opinion, point blank.
• 6:40
  SPEAKER_00: And I wish that we could just like assign some sort of like criteria, if you will, that is a little bit more particular to the person.
• 6:49
  SPEAKER_00: And they're also being accountability with this, right?
• 6:52
  SPEAKER_00: So if the physical therapist, for example, if there's something that um 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, right?
• 7:04
  SPEAKER_00: 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.
• 7:13
  SPEAKER_00: There's no particular stipulations, especially based on someone's goals, typically outside of just daily living, right?
• 7:21
  SPEAKER_00: 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.
• 7:31
  SPEAKER_00: But with that said, instead, most PTs are fighting to get their patients even 20 visits care that should be entitled to you, right?
• 7:41
  SPEAKER_00: It's funny.
• 7:42
  SPEAKER_00: I had an athlete who had a great out of network benefits for her insurance, and her insurance claimed it covered 70% of the visits, up to 60 visits.
• 7:53
  SPEAKER_00: That's awesome, especially for out of network visits.
• 7:56
  SPEAKER_00: Guess how much she actually got covered?
• 7:58
  SPEAKER_00: Six visits.
• 8:00
  SPEAKER_00: Literally six visits, and then just decided to stop covering the rest.
• 8:04
  SPEAKER_00: She was fresh off of an ACL surgery working with me.
• 8:08
  SPEAKER_00: 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.
• 8:17
  SPEAKER_00: And mostly because I don't deal with insurance and the ACL athlete, we don't use insurance at all.
• 8:22
  SPEAKER_00: 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.
• 8:42
  SPEAKER_00: And so the agent and I got on the phone, they had nothing to share in terms of reasoning besides we can't cover any more, and then pass me on to a multitude of people down the chain, and they couldn't come up with a reason.
• 8:55
  SPEAKER_00: Guys, I spent hours on the phone, hours on the phone, multiple calls, talking to managers, all these things.
• 9:02
  SPEAKER_00: And I finally got to one person and I got so pissed I asked one of them.
• 9:06
  SPEAKER_00: I was like, What's something you really love to do with your body that is physically active?
• 9:11
  SPEAKER_00: They obliged, surprisingly, and they said, I like to play tennis.
• 9:15
  SPEAKER_00: I said, Imagine that getting taken away from you and having a major reconstructive surgery to your knee.
• 9:22
  SPEAKER_00: Your insurance gives you six visits.
• 9:25
  SPEAKER_00: Do you think that this makes sense just logically as a human being?
• 9:29
  SPEAKER_00: How would that be for your mental health, you think?
• 9:31
  SPEAKER_00: What about physical health?
• 9:33
  SPEAKER_00: There was a super long pause and then just literally dodged the question.
• 9:38
  SPEAKER_00: 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.
• 9:49
  SPEAKER_00: 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.
• 9:59
  SPEAKER_00: So, for those of you who have to get insurance visits verified or have been denied, and your PT or healthcare 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.
• 10:16
  SPEAKER_00: And any of my PT friends who are listening, you guys are probably nodding your head, especially if you take insurance.
• 10:21
  SPEAKER_00: You're like, Yeah, we got to deal with the ins and outs of this all the time.
• 10:25
  SPEAKER_00: And it's such uh a thing to juggle and so many hoops to jump through, just to be able to essentially provide good care for you as an ACL or whatever healthcare system you're in, there's always these hoops to jump through.
• 10:38
  SPEAKER_00: So this is something that can make it tough because it's almost an uphill battle.
• 10:43
  SPEAKER_00: And this is one of the many reasons we at the ACL athlete do not accept insurance.
• 10:50
  SPEAKER_00: And so now I'm going to exit my soapbox here about this story because it's just one of many that exist in terms of experiencing insurance and athletes not getting coverage that they need.
• 11:03
  SPEAKER_00: So this is something that can be really tough, right?
• 11:07
  SPEAKER_00: So as we try to get back on topic here more specifically, so you have those people who do actually have the unlimited.
• 11:16
  SPEAKER_00: That's cool.
• 11:17
  SPEAKER_00: 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.
• 11:30
  SPEAKER_00: So now let's say you're with a great PT and solid, fully decked out clinic.
• 11:35
  SPEAKER_00: That's awesome.
• 11:36
  SPEAKER_00: You've got unlimited visits.
• 11:37
  SPEAKER_00: Welcome to the minority of minority.
• 11:40
  SPEAKER_00: Not only do you have unlimited visits, but you also have a great guiding clinic.
• 11:44
  SPEAKER_00: You are in the small percentage of ACL rehab, to be honest.
• 11:48
  SPEAKER_00: Now, let's say you have unlimited, but you're at a clinic where the PT gives everyone the same exercises.
• 11:55
  SPEAKER_00: Oh, yeah.
• 11:56
  SPEAKER_00: And they also see three to four patients in 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 the space to be able to start to get you to more dynamic stuff like running, jumping, cutting, especially in more of an open space, right?
• 12:15
  SPEAKER_00: And that's okay.
• 12:16
  SPEAKER_00: Not every clinic is going to be built that way, and a lot of models aren't built that way.
• 12:20
  SPEAKER_00: And that's okay.
• 12:21
  SPEAKER_00: But in terms of the other factors I mentioned, with you know, same exercises, time-based protocol, lots of volume and patience, those are factors to really consider, right?
• 12:32
  SPEAKER_00: But it's quote unquote free and unlimited.
• 12:35
  SPEAKER_00: By the way, it's not free, you're just paying into that more than likely in other ways.
• 12:39
  SPEAKER_00: But with that said, this can be handcuffs for you without you knowing.
• 12:44
  SPEAKER_00: I've talked with ACLers who have felt stuck all the time.
• 12:48
  SPEAKER_00: And usually it comes down to convenience and finances.
• 12:52
  SPEAKER_00: It's where you've been, they're nice.
• 12:54
  SPEAKER_00: Guess what?
• 12:54
  SPEAKER_00: We don't get into physical therapy because we want to make a lot of money.
• 12:58
  SPEAKER_00: It's because we're usually nice people.
• 13:00
  SPEAKER_00: We're very extroverted type people, or at least can present that way.
• 13:05
  SPEAKER_00: We uh like to connect with people, learn about people.
• 13:09
  SPEAKER_00: We don't choose physical therapy for the money.
• 13:11
  SPEAKER_00: So, this is something where you're going to likely have a nice physical therapist.
• 13:15
  SPEAKER_00: It's just a part of the nature of the job.
• 13:17
  SPEAKER_00: It's like going to a Chick-fil-A and saying you didn't get good customer service.
• 13:22
  SPEAKER_00: It's very rare to find.
• 13:24
  SPEAKER_00: Um, and it's something that even when you do experience, you're like, this is probably better than most fast food in general in terms of customer service, right?
• 13:32
  SPEAKER_00: And so this is something that is by nature, as a physical therapist and physio in this line of work, you're gonna have someone that's nice.
• 13:40
  SPEAKER_00: And to come back to the topic of, you know, it's where you've been, they're nice, and you're not paying anything out of pocket.
• 13:48
  SPEAKER_00: 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.
• 13:55
  SPEAKER_00: So it sounds good in theory, right?
• 13:57
  SPEAKER_00: 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.
• 14:10
  SPEAKER_00: So it's convenient and financially it's great.
• 14:12
  SPEAKER_00: 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.
• 14:19
  SPEAKER_00: I'm gonna repeat that.
• 14:21
  SPEAKER_00: It's six months later in your ACEL rehab process, but it feels like you're only two months out.
• 14:26
  SPEAKER_00: 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?
• 14:37
  SPEAKER_00: So 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 the people who are the ones who might have like insurance that does take them through this process.
• 14:52
  SPEAKER_00: Well, okay, this is the kind of categories that you might live in.
• 14:56
  SPEAKER_00: So then therefore you have to be able to audit it and see, okay, is this working for me?
• 15:00
  SPEAKER_00: Cool.
• 15:01
  SPEAKER_00: Then if it is, keep rolling.
• 15:03
  SPEAKER_00: 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?
• 15:12
  SPEAKER_00: And it might be having to decide and almost operate in this mindset.
• 15:18
  SPEAKER_00: If I was paying full cash, and 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 healthcare is providing, would I pay for it?
• 15:33
  SPEAKER_00: And then put it at a number that makes you uncomfortable, right?
• 15:37
  SPEAKER_00: And if you're like, all right, yeah, I'd pay 200 bucks a session for this, yeah, this is really good quality work.
• 15:43
  SPEAKER_00: I'm getting the focus that I need.
• 15:45
  SPEAKER_00: It's a great clinic.
• 15:46
  SPEAKER_00: I feel like I know where I'm going.
• 15:47
  SPEAKER_00: Um, I could talk to my physical therapist.
• 15:49
  SPEAKER_00: I get really good care.
• 15:51
  SPEAKER_00: Awesome.
• 15:52
  SPEAKER_00: 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 and specific to you, right?
• 15:59
  SPEAKER_00: Then that is something I encourage you to reflect on and be like, well, if this costed me X amount, would I do this?
• 16:05
  SPEAKER_00: And then the other thing you can also kind of put on yourself is also, um, would I take my loved one to this place and work with this person?
• 16:13
  SPEAKER_00: Right.
• 16:13
  SPEAKER_00: Do you think that you're giving them the best care?
• 16:16
  SPEAKER_00: And so then therefore, you can kind of get outside of yourself in a couple different ways outside of what's just, you know, typically the norm.
• 16:23
  SPEAKER_00: 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?
• 16:35
  SPEAKER_00: And then the other thing is would I take my loved one, the person I care about the most in this world, would I take them to this person and this clinic and have them go through this whole process with them?
• 16:46
  SPEAKER_00: And you might say yes, you might say no.
• 16:48
  SPEAKER_00: 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.
• 16:55
  SPEAKER_00: So 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.
• 17:14
  SPEAKER_00: Now, what do you do?
• 17:15
  SPEAKER_00: 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.
• 17:23
  SPEAKER_00: There's not a right answer with this, but you're going to know all of your options that are available to you.
• 17:29
  SPEAKER_00: 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.
• 17:43
  SPEAKER_00: So that's going to be it for part one today, guys.
• 17:46
  SPEAKER_00: Do me a huge favor and make sure to listen to part two next week.
• 17:50
  SPEAKER_00: I promise you it'll be worth it.
• 17:52
  SPEAKER_00: And it'll be worth you being able to plan out this process and be as set up as possible for this.
• 17:59
  SPEAKER_00: So set your schedules for the next week if you're listening to this live as it's released.
• 18:04
  SPEAKER_00: Um, if you are listening to this and it's in the past, great.
• 18:08
  SPEAKER_00: You can jump right straight to it.
• 18:10
  SPEAKER_00: So I will catch you next week.
• 18:12
  SPEAKER_00: Until next time, this is your host, Robbie Patel, signing off.