Cash Practice

What you need to know about starting a cash-based Physical Therapy practice.

And why you too should see a provider who works in this model.

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  • Why I started Arrow Physical Therapy

  • How you can do the same

  • What you need to know before getting started


People will question your choice:

I chose to start a practice that was cash-only. That means I do not bill insurance directly. This is not only a huge paradigm shift for patients but also for other providers. One of the first comments I heard was, “so you’re only going to treat rich people?”

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Not only is that not the case (see comments below), but if that were the truth, that is my decision and it’s a perfectly fine one. There is something negative associated with trying to make money if you are doing it through healthcare. We are supposed to be altruistic (I am), giving (I am) and find enough value and purpose in our work of service that it fulfills us (it does, but I still have bills to pay …. Including the $100K I owe for my education!). There are so many other reasons behind my choice that it is too bad that the gut reaction of others can be that it is not a great decision. But, again, that is why I trusted my own gut. And I am learning to not mind what others think of the decisions that are right for me.

It is my pleasure to be able to offer a different experience at Arrow Physical Therapy. The goal is to tailor care specifically for the patient and to eliminate the hassles of using an insurance-based system.  This model reduces unnecessary medical visits, clarifies the process of getting patients the care they need and leads to a quicker return to function, sport and a pain-free life. Arrow PT believes in quality, patient-centered care.  This includes being transparent about the cost of service.  Unfortunately, this is not the goal of most health insurance companies and as such, insurance companies make it difficult to provide patients with the best care due to their confusing processes, pre-authorization requirements, extensive paperwork, and poor reimbursement to providers.  

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The bottom line is that cash-based practice has been a good fit for my patients - those who have a large expendable income and those who don't but who budget in the right care for them. I attempt to make my services as affordable as possible and never let a patient walk through the doors without knowing what the cost will be. I do not ask a patient to come for more visits than they need, I hold them accountable to their part of the deal (compliance with the homework I give them), and when I see them on regular spread out intervals, they get better. This is value. 


The insurance model isn’t working right now:

It is these factors listed above, and namely, poor reimbursement that lead to challenges in seeing patients one-on-one in the clinic without the use of aides or other care extenders.  

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This burden of low reimbursement falls on the providers in the system and can cause clinics to make choices such as reducing treatment time, providing less access to continuing education for clinicians and using non-skilled treatment methods such as therapeutic modalities even when their utilization is not warranted. 

Though Washington State is a direct access state (you may legally attend Physical Therapy without the referral of your physician), most insurance companies still require a referral from your physician in order to cover the cost of physical therapy. A quality therapist will always refer you to your doctor if needed once they see you, but in many cases, this is an unnecessary first step in getting you to start therapy.  By requiring this, your insurance company is adding delay to your care as well as increasing your cost by requiring additional (perhaps un-needed) medical visits. 

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Additionally, if you were to see a doctor who works in a large practice and that large practice has a physical therapy department, your doctor will likely be pressured to refer you within that system rather than potentially sending you to the physical therapist who specializes in your condition or is best suited for you in other ways.

The biggest flaw I see with the insurance model right now is the concept of pre-approval which is getting more and more common.

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With pre-approval, your insurance company is deciding if physical therapy is medically necessary before you can begin treatment. And they only allot a certain number or sessions and time in which to get you better. Please do not confuse bureaucracy with a medical license. Just because your insurance company doesn’t view your pain and functional limitations as medically necessary, doesn’t mean that they aren’t.


Cash models do work:

Ever been to physical therapy and felt that it didn’t work? Maybe you saw your provider for 15 min, had an aide ultrasound your sore elbow with gooey gel all the while unable to explain what this voodoo magic was doing for you, and then another tech counted reps while you performed (possibly incorrectly) the exercises you are supposed to be doing at home. This is all too familiar in my profession. And guess what? That visit is covered by your insurance. You will only have to pay for your co-pay. But, guess what else? That visit is not worth your time or money. It is a low-value service. 

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What if you spent what it was worth to get the care you needed to actually get better. And what if you only needed a few visits to do it? Saving time and money for the patient is the name of the game in cash-practice, NOT me making money off of my patients.


Consider some specialties:

Although I would like to think that this model would work with any quality therapist providing a valuable service, I do think that a large part of my success at Arrow Physical Therapy has come from having a few specialties that people are willing to spend money on. My three main patient populations are individuals with hip impingement and labral tears, CrossFit athletes, and dancers.

These specialties developed organically for me and I was specializing in these areas before I opened my cash practice. That does not have to be the case though. Perhaps you can start general and find some niches over time. However, I will reiterate that because I have something that is unique, people understand that they will need to pay for that. They want to see someone who understands their needs and often they have already seen other providers before they get to me. At that point, their focus is on getting better and in so many words, they don’t care what the cost is.

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I market directly to these special populations on my website, my blog posts and in my social media. Countless frustrated hip impingement patients from all over the country and world have contacted me because they have read my blog posts. They are looking for a practice similar to Arrow PT in their area. Additionally, I have CrossFit athletes from all over the world who follow me on social media because of my posts. I coach CrossFit and athletes can be certain that the first words out of my mouth are not going to be “you should probably stop doing CrossFit”. So, they are happy to spend some cash to understand not only how to get out of pain and back into the gym, but how to better execute the movements that they encounter in that sport. Same thing with dance. Though I do not dance any more, I was a ballerina for 20 years. I understand the stresses on the body and can speak the language. I also understand how to encourage a dancer to transition to strength training rather than yoga or Pilates if warrented. Again, I speak to these points in my direct marketing strategies. I make my specialties clear.  

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This strategy closes the loop. Provide information and people see you as a specialist. Once they come in and you start treating lots of these types of patients, you do become the specialist. I became a specialist over the course of 10 years because I treated these populations and had doctors sending these folks to me. But, now, as a cash practice, I have to announce to the world that these are the areas I am good at. These are the types of individuals who I prefer to treat and in fact, are the very folks who see my marketing efforts. I target them. Not their physicians (who will be hard pressed to send patients your way in many cases because you are not in-network). My specialty is in returning these patients to their activity, not in following the treatment directions of someone else who sent them my way. Once those patients have a positive experience, they help spread the word about my practice to their communities.

Recognize what you enjoy treating or what you are good at treating and build on it. This can be tough. Physical therapists by nature are very humble and don’t like to make the success of the patient about their treatments. But, if you are skilled at something, announce that. Get outside of your comfort zone and let people know that you are good at it. This took time for me but to be honest, I am now protective of these patient populations. I recognize I cannot possibly treat every hip impingement, dance, or CrossFit patient that might benefit from my treatment, but I do feel strongly that I know what correct treatment looks like for them. By sharing my information by way of social media and content on blogs and such, I am informing other practitioners, aiding in the future care of more patients, and further marking myself as an expert in the area. Think of this as a selfless act. Make it about others and you will be more comfortable with the process of “tooting your own horn”.


Be different. Be valuable:

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People who appreciate your work will pay your prices: This is a HUGE one! I think every business owner or independent contractor has likely gone through this struggle. When you first start your business you undersell yourself just so you can get clients. But, this shouldn’t last. People who respect your work and want to equally invest in themselves will pay your prices.

But, you have to be valuable. You cannot offer run of the mill therapy and expect that people will pay cash for that. You have to offer something more. And unfortunately, that is not always possible in today’s healthcare model. So, be different. See if cash-practice is right for you. Feel free to contact me directly for further consulting.