Vol. 24 • Issue 23 • Page 40
Outpatient therapy is a rewarding setting, but when patients are coming in just for a few sessions or only for doctor-referred treatments and never returning, how can the practice stay afloat?
"When therapists go into private practice, some OTs start off just as a cash-based model and not living in the world of insurance, and some people live in both worlds," explained Iris Kimberg, MS PT, OTR. "Now, with the industry and the state of managed care, more and more people are going to cash-based practices. OTs wonder, 'How can we make cash-based a bigger component of our practice?'"
Patient to Client
Kimberg recommends OTs look within their current practices and see what they can turn into a cash-based component. The term cash-based is not "just people taking dollar bills out of their pockets," as Kimberg says. It refers to patients paying their own money for services, rather than having them reimbursed by a third-party payer.
Under a typical insurance plan, as a participating provider, "you are allowed to do 10 sessions per year or 20 per year," Kimberg offered as an example. "You are going to max out. Medicare, Blue Cross [and other managed care plans] don't pay for unlimited services anymore. That can provide a therapist with an opportunity if they have a system set up so that a patient can really start out as an insurance-based patient and then become a cash-based patient."
For example, you are treating a patient with bilateral upper-extremity fractures. His insurance covered only 20 sessions, but he still needs additional services. Instead of discharging the patient because his insurance won't pay for the additional treatments, offer him those services as cash-pay.
"This is really a case-by-case basis," Kimberg cautioned. "There are some managed care companies that absolutely forbid therapists from continuing to treat the patient after their insurance sessions are used up, but that is more the exception than the rule. Certainly all therapists can look at their policies and the contracts they have with insurance companies about treating these patients for dollars after the insurance runs out, provided they need the service."
Cash-based services keep the practice's cash flow fresh. And when you take the insurance payments out of the mix, you take out the paperwork as well. "A lot of therapists in cash-based practices find it lucrative," Kimberg said. "They can treat patients longer, have less patient programming and end up making more money."
Another strategy is to offer groups or programs that assist current clients or their families. Insurance companies won't pay for socialization or handwriting classes for children, but an OT with a pediatric practice could implement such cash-based programs to feed off current patients. Other options could include yoga for kids with special needs, support groups for siblings of kids who are disabled or Pilates programs for orthopedic patients. Therapists will need to establish a curriculum for each program, a set timeframe, a maximum number of participants and a reasonable fee. An eight-week handwriting program with six children might charge $300 per child for the entire program, generating $1,800
With any program that is going to bring money into the practice, it's important to be cognizant of whether you are still operating as an OT or, for example, as a yoga instructor who also happens to be an OT.
"It is possible to have the family sign a waiver and release form or get some other form of insurance to cover the OT if something happens," Kimberg said. Consider and educate yourself on those factors "beforehand and not after the fact. You can't make the assumption with some of these cash-based programs that you are going to be covered under your malpractice insurance."
A call to your insurance provider should answer any questions you have regarding the services you'd like to provide.
You may want to discuss medical savings accounts with patients who will need extensive therapy. These accounts allow individuals to save money for out-of-pocket health expenses-such as uncovered rehabilitation services-by deducting pre-tax funds from their paychecks.
"If people know they are going to need treatment for a hip replacement or elective surgery and know they are going to be in rehab or need therapy for 3 or 4 months, they will put money into this account specifically for that and be able to pay the therapist from that account," Kimberg explained.
And some patients are ahead of the curve in adapting to this cash-based trend. They know not everything is covered by insurance and are willing to pay for additional services they find valuable. For example, "aging baby boomers want to spend money on maintaining a level of mental and physical wellness," Kimberg said. Or "a patient may become a fee-based client who receives post-rehab services such as Pilates and other wellness programs."
Offering Many Options
Jennifer Curry, OTR/L, CHT, of Gaspar Doctors of Physical Therapy, in Encinitas, CA, is trained in ergonomics and workstation evaluations and also teaches group exercise classes. She frequently goes on site to evaluate clients' work settings to help rehab or prevent injuries.
Private pay for on-site workstation evaluations is one "way that cash could be brought in," Curry explained. "Another way is teaching a class on carpal tunnel. I teach about tendinitis, carpal tunnel and overuse. I educate the clients, discuss anatomy and symptoms, and then teach them prevention, stretches and exercises, how to use ice or contrast baths, and joint protection."
Curry also does home safety evaluations with clients, especially the older population, and custom splinting. "Someone can come in one time and cash pay, and I can make a splint for any number of diagnoses," she added.
Curry and her team at Gaspar PT utilize group settings for postural exercises. She also teaches her classes how to use gym and fitness equipment. "There are things like stretch bands and items they can travel with to get relief and exercise. Many clients travel where there is no gym, and they can pull a stretch band out of their luggage and do exercises."
From Illness to Wellness
PTPN (Physical Therapy Provider Network), which represents occupational and physical therapists as well as speech-language pathologists, has started offering cash-pay programs for therapists to offer in their clinics. Michael Weinper, MPH, PT, company president, explained that diversifying-adding a cash-pay component to help therapists get away from insurance company reimbursement-was a necessary step as the marketplace has changed.
Years ago, patients with employer-provided insurance had no co-pays and no out-of-pocket expenses. In recent years, as their premiums have increased, employers began passing some of those rising costs along to employees in the form of higher co-pays and deductibles.
This may mean that patients will self-limit their care, Weinper added. "Instead of going three times per week as the doctor suggested, they go once per week or they want to stop sooner than they should. Then therapists are seeing less reimbursement."
On the other hand, people don't see services like veterinary care, for example, as an entitlement. And even in health care, patients have come to expect some aspects of the visit to come out of their own pockets. Weinper points out that if a patient goes to a dermatologist he will sell a patient all kinds of creams; dentists offer special toothbrushes or whitening procedures; physicians may sell vitamins and other products. These are not medically reimbursable services.
"Medical professionals have found other ways [to generate revenue] that are cash-based services," he continued. "What isn't easy from our knowledge of therapists is getting them to understand the value of selling. Most therapists think that it is unprofessional to sell... We feel we can appropriately and professionally approach this, and you can comfortably educate the patient to convert them to a client."
PTPN has established its Physiquality brand to help its member offices offer cash-based services the company believes clients are looking for. Physiquality is centered around fitness services. OTs can choose two fitness programs to offer their clients.
CATZ (Competitive Athlete Training Zone) focuses on sports performance training for athletes ages 8-18. The GRAVITY program combines a proprietary piece of workout equipment with functional exercise during a therapist-led session.
Weinper believes it's a natural fit for PTs and OTs to offer a continuum of care.
"Our research showed us that individuals are more comfortable staying with someone they know and trust," he said. "They know and trust the therapist from their experience of getting therapy in the facility, so converting them to a client is an easy thing to do."
Kimberg reminds OTs to "make sure the service you are providing is worth paying for." Set up a feedback system or a survey that measures how your clients feel about the services you are offering.
Alternative methods for cash pay can help your practice raise its profile, keep your budget in the black and enable you to continue offering services that bring your patients-turned-clients back for repeat visits. n
Christine Tarlecki is a freelance writer from Mont Clare, PA.