Do I Have to Use my Insurance’s “Preferred Provider”?

1.What is a Preferred Provider Network (PPN)?

A PPN is a business relationship between an insurance company and a service provider. PPNs exist in both health care and non-health care contexts. Within the context of health care, PPNs may exist between an insurer and a physiotherapy business. The physiotherapy business is usually a larger set of clinics that come to an agreement with the insurer to provide physiotherapy services to people insured by that insurance company. PPNs are generally characterized by:¹

• A contractual relationship between the insurer and the clinic or group of clinics, often including pre-arranged prices for service.
• The insured individual is often encouraged to attend a specific clinic by their insurance adjuster. The adjuster may make a referral based on their knowledge of the clinic’s outcomes, the availability of a PPN in the patient’s community, or other factors.

The most common PPNs in Alberta relate to motor vehicle collisions. You may also come into contact with PPNs in relation to your employer health benefits or through your long-term disability insurer; however, this article will focus on PPNs in relation to motor vehicle collisions.

In some ways taking care of your own body after a collision can be similar to taking care of your vehicle. Insurers often have preferred provider relationships with autobody repair shops and refer their clients to these shops based on a pre-existing relationship with the shop, discounts provided to the insurer, or because other clients had good service at reasonable prices.

There is nothing inherently wrong with these types of relationships whether for service to your vehicle or when receiving physiotherapy services. So, don’t be surprised if you are in a motor vehicle collision and your insurer refers you to a clinic in your area that the insurer has a contracted relationship with.

2. Do I have to use my insurance’s preferred provider?

You as a patient have the right to choose your physiotherapy provider. You may have a great pre-existing relationship with a physiotherapist that you have seen previously for unrelated injuries. You may also want to choose a physiotherapist or clinic because they are located downstairs from your place of work, or because a friend or family member raves about the physiotherapist they saw, or you may have other reasons to see a provider that is different than the one the insurance adjuster is recommending.

There is ample research that supports that working with a physiotherapist you trust produces better outcomes.³ In fact, having positive patient-therapist interactions in physiotherapy settings are linked with reduced pain, disability, and higher treatment satisfaction.⁴ This would indicate that it is worthwhile either staying with a physiotherapist whom you know and trust or seeking out a physiotherapist with whom you can develop a positive patient-therapist relationship, whether the physiotherapist’s business is part of a PPN or not. It is also reasonable to change providers during your claim if you cannot develop trust with your current physiotherapist.

It is important to note that all physiotherapists are trained to treat patients for a wide variety of injuries and many physiotherapists working in private practice clinics would be able to manage injuries related to a motor vehicle collision.

3.Who can help me with questions or concerns about insurance and motor vehicle collisions?

If you are unsure about how to navigate your experience after a motor vehicle collision, your insurance brokers should be able to assist you. Sorting out your damaged vehicle and finding health-care providers can seem challenging while dealing with your injuries. It’s important to note that the design of the funding system related to motor vehicle collisions in Alberta is intended to limit barriers to access care. This includes the ability for all clinics to direct bill your insurance company for physiotherapy services, especially physiotherapy services for injuries that are considered “minor” such as sprain and strain or whiplash injuries commonly seen after a collision.

The office of the Superintendent of Insurance is there to help you. If you feel you are being pressured to attend a clinic, that the insurer has failed to explain the process, or you feel something is wrong you can find out more by contacting the Office of the Superintendent of Insurance here.

4. Should I be told about my physiotherapist’s involvement in a PPN?

Physiotherapists are required to identify and manage situations of real, potential or perceived conflicts of interest. As a patient you have the right to know when a preferred provider relationship exists.

Physiotherapists are required to disclose and manage any real, potential or perceived conflicts of interest.² This includes avoiding or managing conflicts of interest that arise from receiving financial benefits for providing services, or financial incentives based on patient numbers or service volumes. A conflict of interest can exist within a preferred provider relationship if there are financial incentives that may influence the physiotherapist in how they create and carry out their plan of care for the patient.

These influences have the potential to create a conflict of interest where the physiotherapist’s judgment could be compromised or is for personal gain. Therefore, if a preferred provider relationship exists the physiotherapist should disclose its existence, the nature of that business relationship to you, and explain how they are managing the potential conflict of interest.

In summary

The insurance adjuster may recommend a physiotherapy business within their PPN but it doesn’t mean you have to follow their suggestion. You as a patient have the right to choose your provider and should work with someone you can trust and with whom you can develop a positive patient-physiotherapist relationship. Physiotherapists are trained to treat patients with a wide variety of injuries, and many physiotherapists working in private clinics have the skills to assess injuries sustained in a motor vehicle collision, fill out and submit the required insurance paperwork, and can explain the funding model and billing process in place to address minor injuries following a collision.

Sean FitzGerald, PT

Page updated: 05/01/2023