I’m really excited to publish this interview of fellow Private Pay PT practice owner, Ann Wendel PT, ATC, CMTPT of Prana Physical Therapy. She took the time to give really in-depth answers to some of the most common questions I’m asked by PTs looking to start/convert to a Cash Physical Therapy practice.
Give us the background of your Fee-for-Service PT practice? What are the general logistics: setting type, treatment length, employees, rates, etc.?
I opened my practice, Prana Physical Therapy in 2003. I sublet office space from a Pilates studio and ran the business successfully for 3 years. I eventually went to work for a large orthopedic practice because I needed health insurance and benefits. I worked there for 4 years, keeping my business license active even though I wasn’t seeing patients on my own.
A few months ago, I met another P.T. who had a small private practice. The timing and location were right, and we hit it off immediately; so, I took a leap of faith, quit my job, and went to work with her several days a week as an independent contractor. We are currently seeing patients in a co-op building, where we have two rooms for treatments. There are 3 P.T.’s in the practice. We are moving to a larger, free standing building next month, in order to have space for a gym. We treat for 1 hour, one-on-one with no ancillary employees. We are each responsible for our own marketing efforts, we schedule our own patients and do our own paperwork. We are 100% out of pocket, as a non-participating provider for all insurance companies. We do not treat Medicare patients, because we do not contract with Medicare. If the law ever changes to allow P.T.’s to “opt-out” of Medicare, we will be happy to treat Medicare patients out of pocket. We provide Wellness Services for all ages, and Medicare aged patients may see us for Wellness.
I also contract with another P.T. clinic owned by a friend of mine, and provide specialized services for their patients (Trigger Point Dry Needling, Pilates and Yoga Therapy). In essence, I run my own “virtual” practice, where I own the business; but, I don’t have a “bricks and mortar” clinic. In addition to treating patients, I write and teach.
When you started your practice, did you immediately go 100% Private-Pay or did you start out as a fully or partially insurance-based practice? What was the biggest reason you decided to start/convert to a Cash practice?
I have always been private pay/cash based. This practice model was what led me to go out on my own from the beginning. I truly felt that I could not offer the quality of care that I wanted to provide if I was constrained by insurance rules. The specialized services that I offer cannot be carried out in 25 minutes in a crowded gym/clinic setting. I need one hour one-on-one with each patient in order to provide the full treatment. Often my patients have been discharged from traditional physical therapy because they have received the maximum number of visits covered by their insurance, or they have reached a plateau with the traditional treatment they have received. My patients are looking for something that will help them get back to a fully active, pain-free life. Since insurance companies look at range of motion and strength only as they relate to functional tasks, these patients often appear on paper as if nothing is wrong (i.e. they just have some pain that limits their higher level activities); but, people deserve to be treated until they are back to living their life in the manner that they desire. Whether that includes kicking a soccer ball around with their grandchildren or running a marathon, they deserve high quality care, even if their insurance denies it.
What were the key factors that made you believe a Cash PT practice was viable in your area?
Northern Virginia is a unique area of the country due to our proximity to the nation’s Capital. This area draws people from all over the world who have advanced degrees and influential, high paying jobs. Information from a 2005-2009 U.S. Census Bureau survey sample of three million households shows only three localities in the U.S. reported a median income above $100,000, and all were in Northern Virginia. I knew that residents of Northern Virginia took the time to educate themselves about the latest advances in healthcare, and they had the money to seek out the most highly qualified practitioners, who would assist them in returning to the active lifestyle they desired. People in this area are not passive consumers of healthcare. I knew that the business had great potential to be successful.
What was your biggest fear about moving into the Self-Pay realm?
Probably the same as everyone else’s – the lack of a steady paycheck! When you have a family, a mortgage, and are still paying off your student loans, there isn’t any room for taking a pay cut! The very fact that this is an area of the country in which a cash-based practice can thrive means that the cost of living is astronomical here.
How did you deal with this fear and move forward anyhow?
It took me a while to find the right situation (location, businesses to contract with, etc.); but, once I started down the path, things moved very quickly. In my experience, when everything comes together at the same time and I have a good feeling about something, it usually means it is the right thing to do. I felt that if I worked diligently I could at least make as much as I was making at my current job, and probably be a lot happier. There is also the knowledge that as a P.T., you can usually pick up PRN hours at a local hospital or rehab center if you need to supplement your income when you first start out on your own.
What was the biggest challenge you faced as you started your practice?
Getting referrals – there are a few very large, multi-site clinics in this area, one of which is POPTS, so getting the doctors to refer is always the biggest challenge in the beginning. It forces you to be creative in your marketing and in how you connect with people to generate word of mouth referrals.
What is the biggest ongoing challenge of running your Cash practice?
There are two things that frustrate me on a daily basis. One is that P.T.’s have limited Direct Access in Virginia. The stipulation is that you have to pay for the Direct Access Certification, and then you are allowed to do evaluations and 14 business days of treatment before you must have a script for P.T. from the provider of the patient’s choice. This gets tricky sometimes, because many of my patients take good care of their health and have not seen their PCP in over a year. The PCP often doesn’t want to write a P.T. script for the patient unless they see them for an office visit. The patients argue that they don’t want to see their PCP for something they know he/she will just end up sending them back to us to treat; but, we have to explain the law to them. It is maddening that many other types of practitioners (massage therapists) I know can see/treat any person who wants to come in while we have to wait for a script. Sometimes people claim it is too much of a hassle and they just go get a massage; but, that is pretty infrequent. I know that the Virginia Physical Therapy Association is working with the APTA on Direct Access, so it’s just a matter of time.
The second frustrating issue is the inability of P.T.’s to “opt-out” of Medicare. I wrote a whole blog post on this issue on my website. When the code was written, it was written in a way that it stated that “P.T.’s are not practitioners, and therefore may not opt-out of Medicare.” What this means to all P.T.’s is that we are one of the few healthcare professionals (along with chiropractors) who are forbidden by law to ever take cash payments from Medicare patients. This is true even if you never contracted with Medicare. If you are a P.T., and you do not participate with Medicare, you cannot treat Medicare patients in physical therapy. You can see them for “wellness” but not for treatment of any specific injury or functional disability. What this does to me, as a small business that does not accept insurance, is it prevents me from treating an entire (growing) segment of the population. It also prevents that segment of the population from seeking out the provider of their choice because they cannot pay out of pocket for the services they desire. I believe that this will change with time; but, I know that very few P.T.’s are actually aware of this issue, and they are unknowingly breaking the law by taking cash from Medicare patients. The audits are cracking down on small practices, so I think that everyone really needs to know these laws inside and out. [Editor's Note: for more specific info on this topic, see "Can I accept an out-of-pocket payment from a Medicare patient?"]
How did/do you overcome these challenges?
Building a good reputation with both healthcare practitioners and potential clients helps with the first issue. Once the doctors and nurse practitioners get to know you, they are more likely to write P.T. scripts for their patients to continue therapy with you.
As for the second issue … sense of humor? Just kidding! I actually think that the best way to change this law is to make Medicare folks aware of the fact that the government is limiting their choice of physical therapists regardless of their wishes or ability to pay out of pocket. If you want to see people get mad, try to explain to someone who has worked their whole life and saved up money to be able to provide for their healthcare needs that they can’t come to you for treatment because the law prevents it. I think that if we educate Medicare patients about this, and encourage them to help us fight this law; we will have much more success in getting the ability to opt-out of Medicare.
How do you market to your patient population and how does it differ from the way you market in an insurance-based clinic?
Marketing just gets the word out there to get people to take interest in what you do. As a cash-based practice, we need to convert that interested consumer into a patient. We have to finesse the initial phone conversation so that what they hear is that they are getting quality, individualized care offered in a one hour session with the same therapist each time. We have to explain that even though they are paying up front, they will be reimbursed by their insurance and will usually come out ahead financially in the long run. If most patients have a $20.00 to $30.00 co-pay and they are reimbursed all but $30.00 for each visit, and they get better in fewer visits, they actually save money. We have to explain all of this without the patient getting stuck on “you don’t take insurance.” It is a process really, of educating the public about quality care, and specialized services to help them reach their long term goals. People expect to pay out of pocket for massage, haircuts, facials and personal trainers; they just need education to believe that it is worth paying out of pocket up front for health care.
What do you think are the primary reasons your self-pay patients decide to come to your clinic rather than one that bills insurance/Medicare?
My mission statement, website and other materials are written with my perfect clients in mind. I want to draw the type of clients with whom I enjoy working and the ones who will most benefit from the type of work I do. Many of my patients have been to traditional physical therapy before, and were either discharged because they were “good enough,” or they were at a plateau because something critical was not being addressed. These patients find me through their doctor, or are referred by area P.T.’s, or they search and find me online. They are looking for the skills I have or the environment in which I practice and that makes them a perfect fit for me.
What would be your best advice for someone who is considering starting/converting to a Cash-pay Practice?
I would recommend first to identify the demographics of the area in which they live. If you live in a rural, depressed economic region patients may not be able to pay out of pocket or may live too far away to easily reach you several times a week. If you live in an area that is made up of primarily Medicare aged folks, you won’t be able to go private pay. You really have to know the area to determine if a cash-based practice can survive. You also have to know yourself – are you willing to take a big risk on this? Are you ready to work really long hours? Do you have the personality to meet with physicians and potential clients to market your skills? Do you have specialty certifications or skills that make you stand out as a provider? Are you organized? Are you motivated to keep going even if it is tough in the beginning? You may want to ask others who know you well for their feedback on this idea. [Editor's Note: for more info on this topic, see "Is a Cash Based Practice Viable in my City?"]
Ann Wendel, PT, ATC, CMTPT
Ann holds a B.S. in P.E. Studies with a concentration in Athletic Training from the University of Delaware, and a Masters in Physical Therapy from the University of Maryland, Baltimore. She is a Certified Athletic Trainer (ATC) licensed in Virginia, a Licensed Physical Therapist, and a Certified Myofascial Trigger Point Therapist (CMTPT).
Over the past two decades, Ann has continually developed as a health care professional. She started her career working with high school, college and professional athletes, and later went on to work at an area hospital treating patients with a wide variety of Orthopedic and Neurological conditions.
In 2003, Ann completed intensive training as a Thai Yoga Therapist, reaching the Advanced Level in her course of study. She owned and operated a private practice in Alexandria, VA from 2003-2006, combining yoga, Thai massage, physical therapy and Pilates. Ann has completed 300 hours of a 450 hour Pilates Teacher Training Program through Core Dynamics Pilates, and enjoys combining Pilates and physical therapy in the outpatient orthopedic setting. Ann received her CMTPT through Myopain Seminars in 2011 and now utilizes Trigger Point Dry Needling as a treatment modality. Most recently, Ann has been a staff physical therapist at Commonwealth Orthopaedics since 2007, and in October 2011 she returned to private practice as an independent contractor with Core Wellness and Physical Therapy.