Dear Colin: My doctor referred me to physical therapy at a location I dont prefer. He said he refers his patients to this clinic because its within their hospital network, which seems to neglect patient preference. Dont people have a say where we go for care? Can networks really dictate where patients go for PT? Samantha, Happy Valley
Sounds like you and your doctor are part of a managed care organization (MCO), which is a contractual arrangement involving you, your doctor and an insurance company to control costs and profits. A key feature of MCOs is that you are required to use their selection of doctors, physical therapists and other providers or pay an additional amount (which is cost-prohibitive for many).
By enrolling with your MCO, you are agreeing to this restrictive arrangement, so the answer to your question is yes, they can dictate where you go for physical therapy if you want them to cover it. Of course, you can go out of network to see a physical therapist, but it will cost you.
Your problem probably is going to become more prevalent, as MCOs aggressively recruit doctors to sign on as network providers, leaving private practice. Consequently, these doctors are pressured to refer to the MCOs providers regardless of patient requests.
Dr. Robert Sandmeier, a Tigard-based orthopedist, says, The current idea of how to control health care costs is to have one coordinated care organization provide everything (insurance, hospital care, physicians, physical therapists) and force people to stay within that system, which supposedly will improve care quality and reduce cost. Unfortunately, monopolistic approaches havent worked in other industries, so why do people assume health care is any different?
And choice seems to be the key. MCOs believe all medicine/rehab services are the same regardless of where you go. But you should be able to see the provider you wish and have services covered, and the fact you cannot is perceived by some as a violation of their rights.
But is it?
Connie McKelvey, a Portland-based attorney specializing in health care law, says, The MCO arrangement is legal because essentially its a contract voluntarily entered into between you and the MCO. Always carefully review the plan terms in advance to see if your provider is contracted with the plan or if there is an option allowing you to go outside the network (of course, cost might preclude choosing the `ideal plan). Further, if you later believe you need services outside your network, I strongly suggest you use your appeal rights under the plan.
The MCOs goal to insure a greater proportion of the United States population has fallen far short, with more than 47 million Americans still uninsured. Studies also show that 30 to 40 percent of all U.S. health care spending is wasted on services that provide no discernible value. What makes this disturbing is that health care spending may be the single most influential factor affecting the countrys economic state, so innovations are desperately needed in a broken system thats becoming more and more volume-based and restrictive instead of patient-centered.
So you can either request your current plan cover your requested physical therapy (highly unlikely) or switch to one thats more accommodating. Otherwise, paying cash is probably the only remaining option.
Colin Hoobler is a licensed physical therapist, hosts a live health segment on KGW Channel 8 and has written two books on exercise as treatment for disease and injury