Coupon-Style Insurance: What It Actually Covers

What if your health insurance works more like a Bed Bath & Beyond coupon than a true safety net?

In this episode of The Talking Rehab Podcast, Dr. Fred Bagares, DO—Sports & Spine specialist and founder of MSK Direct Virginia Beach—breaks down why even the best insurance plan often leaves you paying more, waiting longer, and still not getting the care that matters most.

Through the story of Nate, a weekend pickleball player whose shoulder injury led him through the endless maze of copays, prior authorizations, and denials, you’ll see how the “coupon system” in healthcare rewards transactions—not outcomes.

Dr. Bagares explains why direct-care models are changing the game for people who want clarity, access, and results—not just coverage.

If you’ve ever wondered why your MRI, PT, or specialist visit feels like checking a box instead of getting better, this episode will help you understand what you’re really paying for—and when it’s worth stepping outside the insurance coupon aisle.

🕰 Timestamps + Key Themes

[00:00] The coupon analogy – why insurance feels like a discount that never applies
 [01:00] Nate’s story – from shoulder pain to four months of red tape
 [03:00] How “in-network” limits real choice and quality of care
 [05:00] The fine print – what’s excluded even when you’re “covered”
 [06:00] Prior authorizations and hidden hoops
 [07:00] The illusion of savings – why EOB discounts aren’t real deals
 [08:00] What insurance rarely covers: clarity, speed, and commitment
 [09:00] Direct-care contrast – 90-minute visits, diagnostic ultrasound, PRP, shockwave
 [10:00] How to use insurance for catastrophe—and care for recovery
 [11:00] Two truths: Insurance protects • Direct care delivers
 [11:30] Closing reflection – Stop letting a coupon decide your recovery

If this episode helped you see healthcare differently, hit subscribe and share it with someone stuck in the insurance maze.

For Clarity Visits and advanced treatment options like PRP, Shockwave Therapy, or Magnetic Peripheral Nerve Stimulation, visit
👉 MSKDirectVB.com or FredBagares.com.

Transcript

0:00

what if I told you your health insurance works more like a bed bath and beyond coupon than a safety net? I know that sounds a little provocative, maybe even a little bit unfair, but kind of stay with me. Why do people pay the highest premiums in history averaging over$26,000 a year for a family plan, yet still feel like they're standing in the checkout line, arguing whether the coupon even applies to what they need? I'm Dr. Fred Begar and this is The Talking Rehab Podcast. Today we're talking about what insurance truly gives you, what it doesn't, and why that gap shows up most clearly when you're dealing with pain. Before we dive in, if this show has ever made you see your body or your recovery in a new way, hit that subscribe button. It's free, it's quick, and it tells me these conversations matter to you. Thanks for being a part of this movement. Now let's get into it. Let me start by saying something that might surprise you. I'm not here to tell you insurance has no value, but think about it, when you have a coupon in your wallet, even if you haven't used it yet. You feel like you're holding onto something that gives you special access or a better value than what's currently on the market. Insurance does the same thing. It gives you predictability with a network of physicians, offices and hospitals. You look at the back of your card and it clearly states the copay amounts, the deductible limits, and your brain says, okay, I know what this will cost if something goes wrong. You're in network, you're covered. Plus it gives you an emotional buffer. If something catastrophic happens like a car accident, cancer diagnosis, heart attack, you're not bankrupted that peace of mind is real and it certainly does matter. so I'm not dismissing insurance. I'm just asking you to see if it clearly does what it actually is supposed to. Let me tell you about Nate. Nate's a 38-year-old engineer plays pickleball on the weekends. One Saturday he reaches up for an overhead smash and feels something tearing his shoulder. He experiences very sharp pain, can't lift his arm up over his head. Fortunately, he has good insurance through his employer. Family Plan, 26,000 a year in premiums. He feels protected. So he does what you're supposed to do. He goes to the nearest urgent care. The next morning he pays his$50 copay, sees a physician, has a quick examination, is told it's probably a rotator cuff strain. Here's some ibuprofen, a sling. Make sure to follow up with your primary care physician in a week if it's not better. A week goes by, he still can't lift up his arm. He calls to make an appointment with his primary care physician. It takes about three to five days checks in, pays another copay. Then he is told, let's get you to an orthopedic surgeon. I'll send the referral. It's a two week wait for the referral to process an appointment to finally open up. At this appointment, he sees the orthopedic physician assistant and they're suspicious of a rotator cuff tear. They would like to get an MRI to see how bad it is. However, there is prior authorization required. This takes another 10 days. Ultimately, the MRI is denied because there needs to be a six week trial of physical therapy. Nate goes to physical therapy twice a week.$25 copays each visit. Six weeks later, nate spent over$800 out of pocket. His shoulders a little better. He can lift his arm higher than before, but it still hurts when he reaches overhead and he certainly is not back to playing pickleball. He returns to see the orthopedic surgeon who orders an MRI of the shoulder again. This time the insurance authorizes it and he finally gets the MRI, which reveals a partial thickness tear of the rotator cuff. Now the question is whether he needs surgery since rehab has not worked out for him. The surgeon says surgery is certainly an option, but let's try steroid injection. If that doesn't improve, we'll talk about surgery. He asks about waiting longer or any other treatment options, something like platelet rich plasma or PRP. The surgeon says, I don't think it will work. Plus insurance doesn't really cover it. The surgeon walks out and his physician assistant comes back in with a steroid injection and says, ready. This is the moment Nate realizes something. Does his coupon actually address his needs? You know how coupons always have that fine print. Participating locations only applies to select items. Limit one per customer. Insurance has similar restrictions, but the stakes are certainly higher. First. Insurance ultimately controls where you can go. Just like participating locations only, you don't get to pick the expert the insurance network does. The best shoulder surgeon in your city might be out of network, which means you either pay full price or settle for whoever's in the directory. The second the insurance controls what you can buy, think about those coupons that say excludes premium items. Insurance will cover an MRI, but shockwave therapy for chronic tendonitis, platelet-rich plasma, which might actually help trigger healing within the tissue. These are typically not covered by traditional insurance. There's definitely evidence behind these treatment options to help solve your problem, but unfortunately, they don't qualify for this coupon. Third insurance likes to create hoops. You know those coupons that say valid only on Tuesdays between nine and 11:00 AM after purchasing two other items. That's kind of how prior authorization works. Your doctor knows what you need, but the insurance company needs to prove it first, This also means you suffer with your injury a little bit longer while the insurance company sorts out the red tape. Unfortunately, this also leads to more frustration. Fourth insurance companies give you the illusion of savings. Look at your explanation of benefits. Sometime it'll say something like, provider bill$2,450, insurance discounts$2,100. You owe$350. And you think, wow, I saved$2,100. But here's the thing, that retail price was created inside the insurer's own system. It's not a real number. It's actually an inflated number that doesn't correlate with anything that is based on a quality metric. However, it does give you the appearance that you are getting a deal. And finally, insurance rarely covers what matters most. Your coupon might get you 20% off, but it doesn't help you find the right product. It doesn't tell you if it actually works. It doesn't give you someone who cares about whether or not you succeed. Insurance coverage, transactions, visits, procedures, and line items. It does not guarantee clarity. It does not guarantee speed or access. It doesn't guarantee someone will actually figure out what's going on with you and commit to you getting better. And when your problem is pain, when it's disrupting your work, sleep, and ability to play with your kids, those are the things that matter the most. Now, let me tell you what actually ended up happening with Nate after four months in the insurance system, copays, referrals, prior authorizations, mixed messages, he found his way to a practice that worked differently in his first visit. It lasted approximately 90 minutes. Comprehensive examination, diagnostic ultrasound, and an actual conversation about what's going on, not just about his shoulder, but about his life, his own personal goals. What does he need to get back to? What timeline matters to him? They reviewed his MRI together, not in 90 seconds. They took the time to show him exactly what was going on and all of his treatment options. Then they built a plan, nothing generic, not dictated by what the insurance would approve, I plan designed around his overall. Exercise goals like getting back to pickleball or even just regular exercise. They ended up using PRP to help the healing in addition to a specific rehabilitation protocol. There was no gatekeeping, no automated systems to go through. No waiting weeks for follow-ups. Three months later, he was back to pickleball. was it more expensive upfront? Yes, it cost about$2,000 out of pocket. But here's what he told me for the first time, someone actually committed to getting me better, not just documenting what they had tried. If you've ever been through the insurance system, it can definitely feel like this. Sometimes you have to go outside of the traditional healthcare system in order to get what you actually need and deserve. Not just access, not just approved procedures, but to find someone who actually owns the outcome and is willing to help navigate your clinical course. So what do you do with this? I'm not telling you to cancel your insurance. That would be absurd. Insurance is essential for catastrophic care for emergency surgeries. The unpredictable, expensive, and life-altering moments you have to keep your insurance. Just know when to use it. Here's what I want you to understand. You can hold these two truths at the same time. Truth number one, I value having insurance. It protects me from financial catastrophe. Truth number two, I'm allowed to get care outside of it when the stakes are high and the coupon doesn't cover what I actually need. Insurance is a reimbursement tool. It's not the same thing as care. Care is a relationship where someone who knows your story and owns your outcome care provides clarity when you're confused and momentum when you're stuck, You don't need insurance company's permission to go outside of the system and find a clinic that understands your clinical needs. The goal isn't to ditch insurance. The goal is to stop letting steer your recovery when it's not equipped to do so. You don't judge the worth of a coupon by how it looks in your wallet. You judge it by whether it actually works when you need it, and if you find yourself months into an injury, it's time to ask whether you're trying to use a coupon that was never designed to cover what you actually need. For Clarity Guides, next step tools are to explore advanced treatment options like PRP Shockwave Therapy or Peripheral Nerve Stimulation. Please visit fred baggers.com or MSK direct vb.com. Until next time, take care of yourself and don't let a coupon tell you what you deserve. Thank you for listening to The Talking Rehab podcast. I hope that this podcast stimulates you to question your own practice and how you approach rehabilitation. I truly appreciate your time and attention. If you enjoyed listening, make sure to like and subscribe to the podcast. I wish you a movement filled day. Take care.