Should I Contract with Medicare?

This podcast will help you to become more confident with your patients , more successful in your practice or business and a leader in pelvic health , and we're going to have some fun along the way . Join us as we rise together .

We're Jesse and Nicole Cozine , founders of Pelvic Sanity Physical Therapy and the creators of the Pelvic PT Puddle , and this is Pelvic PT Rising .

Before we dive in , though , nicole , just a reminder . If you guys listening haven't done this yet , could you please fill out our state of pelvic rehab survey ? We do this every year . This is our fourth year in a row . We've already gotten hundreds of responses from you guys already . Really appreciate it if you've already done that .

If you haven't , it'll take you about five minutes . There's no trick questions . It is just getting a sense of where the field is , how we're doing with things like burnout and how happy we are in the places that we're working , how much mentorship we're getting .

Those are the kind of things that we think is really important to track year over year and just see where we're at and where we need to continue to push and advocate for . So not only is it doing your field a service , you might be doing yourself a service .

This is the first time this year we are offering a little reward for two people actually who fill out the survey . Our grand prize winner will be randomly selected and they will get to choose one of Nicole's full length clinical courses to go through , whether that's Essentials , essential Strengthening , rectal Course or Interstitial Societies .

And our second place winner will get a chance to choose between one of Nicole's master classes . So either the medical procedures masterclass or the down training masterclass . So a little incentive for you guys to fill that out . It'll take you five minutes . You can find it at publicptrisingcom slash survey . Any other notes or anything , nicole , before we dive in .

But I think ultimately , a lot of times this question is asked out of fear that this is the world that they have come from . Probably this is the world that you know you can get people from . Maybe you've had physicians say something to you like , oh , what insurances are you taking ? And that starts to get in your head .

Or Uncle Fred at the Thanksgiving dinner table thinks the cash is nonsense and no one will ever pay for your services . All of that can be pretty daunting , and so one of the questions that I always want to ask and this gets passed that I think that fear response what would you do if you knew you would be successful ?

It's really hard to get out of insurance contracts . It takes time and a lot of folks have gotten in and found it a little bit more difficult than they thought to stop doing that or get out . But especially for this Medicare question , do you love the population ?

Then you also need to ask yourself do I have a heart or do I love treating the Medicare aged population and really , at the end of the day , that's a 65 to 70 plus population . Do you love that age of patient ? Do you love the conditions that they're going to come in with ? Do you want to serve those folks ?

I was walking through pelvic sanity one day and I saw somebody in with a walker and I was like , oh my God , what is that person doing here ? And they had a reason for it in another story and they weren't Medicare and all the things . But it's not our ideal patient . It's not something that we I particularly love treating .

Do I think that Gladys and Edith deserve great pelvic healthcare ? Yes . Do I think that they deserve to not have incontinence ? Yes , Like we can do a really great service like helping them to avoid prolapse surgeries and all kinds of things , Absolutely . But that's not our ideal patient at pelvic sanity and that's totally okay .

You're getting high volume and you're trading it for low margins and in the cash world you're doing the exact opposite . You're accepting low volume but you're getting high margins . So you have to put in less work in order to get more out of the business .

It doesn't mean you don't have to work hard , but it means that for every dollar that is coming into the business , you're getting 60 , 70 , 80 cents from that dollar instead of 10 , 20 , 30 cents from that dollar .

So that affects the number of patients you need to see , that affects your volume , that affects every aspect of your business and those are two pretty diametrically opposite models . So understand what you're doing when you're accepting Medicare or another insurance is you're basically buying into this high volume but low margin life .

And if you're going into your own practice to escape a high volume , low margin life , then that's probably not going to be an overall great choice for you . So be thinking about . Those are the big picture of those two sides of physical therapy or occupational therapy in our world today .

So if we think about the pros of contracting with Medicare , really I see two . The first one is the biggest one , it's patient volume . You very likely , if you contract with Medicare , will not have a volume problem ever again in your business and if you are , you need to go out and do a little bit more marketing to physicians .

That's the second pro your business is going to be more physician friendly . There is a dearth of pelvic rehab providers and even bigger desert of people who are working with this population . If you take Medicare , volume should not be your issue and it might actually be a con on the other side .

We'll talk about that a little bit more when we get to the cons . But you're basically solving your volume problem and for some people that feels really good .

Because I think , especially when you start off and you've got two patients in that week and you've got 30 hours to fill , that feels not great and the phone isn't ringing and you're not busy and people ask oh , how's it going ? How many people did you see ? And it just gets uncomfortable and sometimes it's hard to live with that uncomfortableness .

I think sometimes that's where we get people who start with a cash vision and then decide to add in an insurance is they have a hard time growing as quickly as they think they should and instead of doubling down and trusting the model that they're in , it's a jump to . Oh gosh . I've made this terrible mistake . I better take insurance .

You take that and you internalize it as like , oh crap , I should take Medicare . I would get so much more patients from that doctor if I did , which is a whole other thing , because you probably I mean you might not as well . But I think the point is well taken .

To go back up to what Jesse originally asked is like if you knew that you would be successful , would that question bother you ? Someone asked me that question now and I'm like , no , actually we do not , and this is why . And then I usually ask questions like well , what percentage of your patient population is Medicare ? And they usually say , oh , 20 .

And I'm like , ok , well , what about the other 80% ? Don't they deserve we can help those people , so why don't you send those to us ? So I feel like , yeah , we just need to think about if you were going to be successful , would you take that ?

We do not contract with Medicare or any insurance , and that's not a ideological position . That is a business decision and a patient care position . So it's not that we think you're wrong if you're doing it . There's some states where reimbursement is still really high . Looking at you , washington state , I have no idea why it's super high there and nowhere else .

But there's places where this can make sense for certain private insurance companies . But trying to say it's not an ideological position , it's a practical position , because what happens when you sign a contract with Medicare is you give up control of your pricing .

So for those of you guys who are thinking about Medicare or doing it right now , you're probably getting reimbursed about $110 , $115 per session and then you have to have a bill that takes out a pretty hefty percentage of that 7% to 10% generally . So now we're down to about $100 per session that you're getting paid .

So you're also , in doing this , you're betting on the future of Medicare reimbursement , and if you're doing that and you're betting on it going anything but down , I've got a oceanfront place in Kansas . I'd love to sign it Right . Right , because it's clearly going to be continuing to drop , and so you're looking at that in the future as well .

You've given up control of your pricing . You're going to have a reduced profit margin , which basically means you're going to have to see more patients to make the same amount of money as you would have had to do in a cash-only practice , and so that can also lead to other issues , but other cons . Here your documentation time is going to dramatically increase .

You're going to be doing the approvals and the research and whatever else that you need to be doing . For all of these folks . You're going to need a more robust EMR . Payment is going to be delayed because you have to send it in and get approved .

I know Medicare's on the better end of those insurance reimbursement timelines , but you're still not getting paid the day of your service . Now you're a HIPAA-covered entity when you weren't before as a cash practice . But here's another really big piece of this . I think I see a lot . We did a podcast last week on being too busy to grow .

To me this happens a lot when you take Medicare , because you do fill up with this volume . But maybe your dream was to work with pregnant and postpartum moms and now you've got a whole population of 75-plus-year-old retirees , which is again great . They deserve great care .

But maybe you're even getting elbows and shoulders and knees and toes at this point and it's preventing you from being able to market and go out and build the business that you really wanted , because you're so busy trying to service all these Medicare folks and you're not willing to say , oh well , I'm not going to take any more patients on my schedule , I'm not

going to block that , I don't want to lose the relationship with the physician , I don't want to lose business .

And then you wind up basically creating an insurance-based job for yourself where you're having to work a ton for low margins and you've never really been able to invest in the infrastructure , the marketing , the relationships to build the patient population that you really wanted in the first place .

So , again , if you got out of the place where you were from because you hated documentation , there was so much progress notes and this , and that I mean there's a shit ton of documentation that you must do in order to get that reimbursement from Medicare and really any insurance company as well , and the fact that you lose control of your price .

Now might , again , a lot of things like that work for a solopreneur don't work if you have visions and goals of growing beyond yourself . Where that on average , $100 , $110 reimbursement is great for a solopreneur , that's not taking into account the fact that you might be taking more time .

I'd be costing you twice as much time to service that one Medicare patient .

All that is to say , though , you still come back with $100 for that patient , but as soon as you need to pay an employee and do payroll taxes and do all that kind of stuff , now all of a sudden that becomes a huge problem for your profit margins , and you don't have control over that aspect of your business , and I don't think a lot of people that are

wondering at the beginning should I take Medicare . But I have visions to grow beyond myself or necessarily thinking about it that way in terms of the opportunity , costs or what it's going to do for the future business .

A lot of times we're making decisions out of fear for the current business that we think we have and not trusting the process or trusting ourselves that we would be successful in the long run .

It doesn't mean that there is a right or wrong answer to this , but we do want you , if you're going to go into it , going in with eyes wide open as to some of the cons , understanding what the pros are and then thinking back to that big picture is , if you knew you were going to be successful , is this really the business you want to build ?

And if it is , absolutely , go for it , do the thing . That's fantastic . If it's not , we would highly encourage you not to jump into a business that you don't really want to build out of fear . And if you've already made that leap and you're kind of nodding along and being like I see exactly what you're talking about now , you can go backwards .

We have a friend of ours who's gone back and forth from insurance to cash a whole bunch of times and he gets more and more pissed each time he has to do it . But you can get out of those insurance contracts . You can decide to stop seeing Medicare patients . You can limit the number of Medicare patients that you have on your schedule .

You can do all of those things and really get back to why you started your own practice , and if this is something where you're struggling because the business isn't growing as quickly as you would like it to , or those you think you should , we help you guys . That's like literally our thing , that's our jam , so feel free to reach out to

us . We've helped more than 500 businesses .

You can , and I don't care where you're located , I don't care what the socioeconomic status is , I don't care what the average age of your population is you can build a successful cash based practice and we want to give you the confidence you need with that , but then also the tools that you need in order to do that .

So if that's something that you want to do and that you're afraid or you're not getting where you want to be , that's right , where the Accelerator program is meant for . So we will be doing another cohort of that .

But if it's something you're interested in looking into , get on the waitlist for that at pelvicptrisingcom slash accelerator , because we want you guys to be able to build a business that you want , like that's what we get set up at in the morning .