Chiropractors - Thinking about Getting off the Insurance Hamster Wheel?

Hi everyone, this is Michael Misko with Misko Health Law and welcoming you to another edition of ChiroSecure's Growth Without Risk Facebook Live programs. Joining me today, I have a special guest, Dr. Vince Leone from Specialized Practice Consulting, and our topic today We're gonna discuss and try to address some of the concerns and, and to be frank, some myths switching over to a cash practice. So welcome, Dr. Leone.

Hey, Mike, great to be here. Thanks so much for having me. Really appreciate it.

Oh, it's my pleasure. So usually, and, and we've had this discussion offline, we, we both to a certain degree are very much in favor of Cash practices, me more from the standpoint of risk mitigation, efficiency, not having to run on the hamster wheel, so to speak, and do all the things other than treat patients that insurance companies demand that you do for the declining dollars that they pay you, only then to find out 18 months later that you didn't do all the things that they want you to do well enough, and then they want to take all the money that they paid you back. And and that has caused many providers to question the sanity of that process. And so I have focused on Moving them over to a cash model within the confines of the rules, whether it's Medicare, Medicaid, or commercial payers, whether they stay in network or not. And you work with docs to make sure that they do that transition efficiently, train their staff, and teach them how to be profitable. In that context, we have 2 different— I help set them up and you bring it home, so to speak. But in your experience, and you converted your own practice to cash at one time, did you not? I did.

Oh yeah, absolutely. When we, when I went on my own, I just quickly found out that what I call the high volume, low fee, heavy insurance grind was just not for me. My father practiced for over 50 years and he practiced that model for many years. And I, to me, it just seemed broken to me because it's like you put the doctor on a hamster wheel. They're completely trading time for money. There's no leverage. And so what I found was, hey, I want to first of all get off insurance because we were 95% cash and the insurance dictated what I could charge, not so much what I could do, but certainly the value I could place on my services, which I didn't like. I didn't think that was fair. I didn't think it gave me the freedom to actually have the practice I wanted. When we went to cash, we chose what I call high-ticket niches, which are high-value cash services. that addressed a specific problem. And that gave me the leverage to charge what I want, to create a robust protocol that's all cash. And it just, our practice exploded. And that's what I teach doctors to do now.

Okay. As you went through the transition yourself, and obviously I'm, I'm, you didn't have you to help yourself at the time. I, as I discussed the idea of cash to providers, let's say the most common description is part of a walk, what I call a walkaway strategy in an audit where a payer is just sinking their feet the ground and they want a gazillion dollars and the doc doesn't have the money, in which case the doc walks away, converts— has to convert the practice to non-covered services for cash. One of the biggest concerns— there are 2 big concerns. One is, all my patients are gonna quit. They're all gonna go if I don't take their insurance. The second one is, I'm not gonna make any money. How do you deal with those questions? I could tell you how I deal with them, but I'll let you go first because your answer's probably gonna be more professionally oriented and helpful than mine.

I don't know. About that, but I think it all comes down to value, Mike. It's if you are providing a service that the patients are that is high on their value scale, that is going to keep them with you because now versus if you are a commodity, if you're going to just be one of many, then yeah, they're going to shop for the the lowest price option, and that's not what we are. That's not what we choose to be in the marketplace. Our goal is to really be an expert, a specialist. in the marketplace because that allows us to really charge what we want and deal with conditions that patients are really not desperate, but they really want to get fixed and they want to avoid drugs and surgery. That's our whole thing, avoid drugs and surgery.

You don't want to call yourself an expert though. You don't want to call yourself an expert though because we got some licensure board issues that might come into play there.

But yeah, 100%.

But we get your point. You want to create a concentrated area of practice where you have advanced capabilities, let's put it that way, and advanced training in dealing with certain conditions to set yourself above the crowd. And I knew you would say all that.

That's why we have people like you, because you fix that stuff and you keep us from basically stepping on our own toes. But, so that's the first thing is we need to provide a service that is of high value to the patient. We need to move out of commodities. We need to move into a high value service. And then 2, in terms of not making as much money, this is the farthest from the truth. We made enormously much more money going this route because we were able to charge what we felt was a fair market value for that service. And, and so that was never an issue. We, and by the way, all our clients, they're adding, I don't know if we can talk numbers, but $10,000, $20,000, $50,000 a month in cash with these services. So you're not gonna, in my opinion and experience, you're not gonna be losing money. You're gonna basically be making more money with working less.

I think for the providers that are doing minips and therapies and rehab and whatnot, and they may be still banging out $270 charges per visit, they don't see the ability to charge that cash. But I've always looked at it from a profit perspective. There's an insane amount of overhead expense associated with messing around with insurance and EMR systems and documentation. And extra doctor time where your hands are on a keyboard and not on a patient. You have to pay people to bill it. You have to pay clearinghouses to process your claims. Then you have to pay people to chase after the stuff that didn't get paid and figure out why and send notes and run through all those traps, which to me, when you do, let's say even a $50 cash service and the patient comes in, they pay their $50, you do your thing and they leave. You've got documentation to keep your malpractice carrier happy as well as your state licensure board. And that's pretty much it.

Yeah.

out, put the $50 in the drawer, and take it to the bank. So, you know, the amount of overhead associated with a cash practice is significantly less. So then even if your gross number— what I've heard from my clients is that their gross numbers aren't the same as what they were when they were doing insurance, but their net is way higher. Is that your experience, or are you seeing both an increase in gross and net?

It depends on the model that you go after, right? So there's the old saying, it's not how much you make, it's how much you keep. So in a traditional chiropractic model that's going cash, by and large, yeah, you're going to see a little less gross, but the simplicity of the model is going to— not only in, in equipment and staff, etc. Yeah, you're going to have a lower overhead giving you a higher net. But if you decide to essentially do your traditional chiropractic where you're just doing manipulations, but you are also adding in a niche, which is what we do and teach, Then that's when you get—that's when you have the leverage, right? Because our average case fee is three to five thousand dollars. If you just had five of these patients a month, in addition to your chiro practice, it's it's incredibly profitable because you're using the same model that you're talking about in terms of not billing insurance, not having the staff, not having all you know that necessary. The well, you're going to need EMR and all that type of stuff, but it's mainly staff and and some stuff around the office. But the point being with When we add these niches in addition to a traditional chiropractic office, you can boost your revenue while actually not working as much because you are going to do the evaluation, you're going to do the enrollment, and you're going to do your exams. But in terms of the treatment, by and large, that's going to be done by staff, systems, and technology.

Where that is permissible, of course. And there's people listening across the country, so the rules vary relative to the use of unlicensed assistants. Some states, they're required to be certified and whatnot. Now, you mentioned niches and wondering if you would be willing to share which niches get the most riches.

Yeah. Yeah, that's good. Interesting. We're actually having a seminar on this coming up in September in Nashville, but, and it's called the Riches and Niches Advanced Seminar. But we've found that, of course, herniated discs with spinal decompression. And this is really, here's what's interesting to me. Doctors say, isn't decompression played out or isn't it essentially saturated? And the answer to that is absolutely not. Because if you look at how many surgeries there are on a yearly basis and how many don't really need to go to surgery, all of those are potential patients. But even if you just took your average new patient flow, say you had 20 new patients a month, we've found that 10 to 20% of those are actually disc patients and can be better served with decompression. So that's the first niche, and you—that's always what I recommend: the first niche that doctors add. But spinal decompression is the first one. Peripheral neuropathy is an excellent niche, but it's a complicated niche. You really need to be super sharp clinically from a neurological standpoint. Chronic knee pain—fantastic niche, right? Because these are your patients that are very similar to your chiropractic patients, right? They want to stay active. It's interfering with their life. They can't a lot of times. Well, not a lot of times, but sometimes they can't work. But A lot of times they can't do the things that they love— golf, exercise, those types of things. So chronic knee pain, save those patients from surgery and the 3 to 6 months of rehab after. And then plantar fasciitis is another really good niche that we have an excellent protocol to treat. And those are the 4 niches that we focus on. And we do that because there's so many of these patients, like so many patients have chronic back pain, tons of patients with knee pain. Neuropathy is Primarily induced by chemo or by diabetes, which is the number 3 chronic condition in the US. And then plantar fasciitis. It, a lot of times you'll, if you're doing neuropathy, you'll see some of each. But those are the niches that we have found that produce the most patients, the most revenue, and the most satisfaction for the doctor.

Now I find it interesting that all of your niches are condition-focused, which I think is awesome, rather than focusing on the treatment. So I would assume that in your marketing, as you try to build out these niches, you're marketing the condition or the problem rather than the treatment. Is that a safe assumption?

It is. It's a very astute observation. And when I was practicing, we had our clinic, we have 2 other sister clinics, and we did cooperative marketing. It's still going on, soundpaintsolutions.com, here in the Northwest. And we focused on those conditions. And it just was— went— because we dumped a lot of money into advertising, a lot. And we did radio, TV, digital, and print. And if you try to market anything other than the condition, your marketing dollars do not go as far because you have to think from the patient's perspective. It's everyone's like, what's in it for me? Everyone— the only— the person that everyone cares about the most is themselves. So you need to— your message needs to talk to them and what they are experiencing. Are you suffering from chronic Back pain? Are you suffering from chronic knee pain? Do you have pain, numbness, and tingling in your hands or feet? When you use a headline like that or a message like that, that's focused on the condition, that's what perks people's ears up and gets them to read further. And then hopefully, you know, click the button and—

Plus it's something that the patient, you know, the patient can understand. They know whether their knees hurt or they have plantar fasciitis. Maybe they don't know it in that term, but, or if they've been told they have peripheral neuropathy or something like that, those are things that patients understand. You, I have to imagine if you throw something out, I'm no marketing stud by any stretch of the imagination. When you market like a treatment, let's say there's these new, like, you know, class 4 laser or the new, what's the new sound thing that they—

Shockwave.

Yeah. They have no clue what that is. I, and I've always favored the condition-based marketing because even if you're doing experimental investigational type treatments, which is why you're cash. You're not marketing the treatment for a condition. You're just marketing the condition. And then you're not gonna get in, in, in Dutch with your licensure board for deceptive advertising. If I were saying, hey, we have this new treatment shockwave for whatever, and it's not cleared for that, you can't say that and you get— it can get you in trouble.

100%.

We're closing in on, on our time. How have— now I've in past presentations, you know, have addressed the issue of bringing Medicare patients in for cash, and it's a very simple construct. Some of the myths that I wanted to debunk are that with the appropriate documentation and depending on what you're doing, if it's a service that's not covered by Medicare, you absolutely have no obligation to bill it. As a chiropractor, if you do manual manipulation of the spine or manipulation with a manually controlled instrument, it's potentially covered. And even in those circumstances, if the purpose of the treatment is not something that's covered, meaning you don't have all the documentation that they want you to have, And most people don't, then they're going to deem that not medically necessary. And if you do an ABN Option 2, you don't have to bill it. So before we leave, I wanted to debunk the myth, wanted to make sure that this is consistent with your experience in the practices that you've worked with and even in your own practice. If you're in the same zip code as a Medicare patient, you don't have to submit a claim. That's just not the law. And people that tell you that and that shy away from accepting Medicare patients into their practice because they want to be cash, you don't need to do that. The Medicare population is a fertile market for a cash Practice, and you don't need to be shy away from it. But you do need to learn how to do it.

And I couldn't agree with you more. And I'm so glad you brought that up because I loved Medicare patients when I was in practice. And I it's so weird when doctors are like, oh, I hate Medicare patients. Why? They show up on time. They have money. They want to get better. They don't want to spend their golden years. How many times have you you know heard someone say, gosh, I thought these were supposed to be golden years. They they don't want to spend that time in pain. They own their home. They have money and investments.

They probably have more money than you do. And they bake you cookies at Christmas time.

Exactly, and they bring you all types of treats and flowers and gift cards. It's ridiculous. So Medicare patients, and I always, that's why I always tell docs, hey, my clients, hey, if you're concerned about this at all, go talk to Mike because he'll set you straight and he'll tell you exactly what you need to do. But Medicare patients are wonderful patients, and it would be a shame to leave them out of your potential market.

Yeah, as we finish up, I hope that for those that have Thought about cash practice, and Vince, you can do a conclusion to tell your experience and what your clients are telling you, but I have yet to meet a client. I've been converting people to cash for probably the last 10 or 15 years, and it's really not in my business interest to do that since I make my living off of defending doctors in postpayment cases. But I think it's the right call for the practice that you either want to deal with all that compliance stuff and dig into all those rules and spend all that time. Or you don't. And because most docs I recognize went to doctor school to become doctors, not compliance geeks like me and coders, it's just— as my dad used to say, it's just not my cup of tea. And so for those docs that have made that transition, I have never had one say, that was the dumbest thing I ever did. Every— to a person, they all say, I wish I would have done that 10 years— I should have been audited 10 years ago and made that transition because I love practice again. I feel like I'm in control of my practice again. I'm financially fine. I'm in better shape than I ever was. My stress curve is like substantially reduced. And to say a little bit different what you said so eloquently about value, for the docs that are concerned about all their patients going away, my response is a little bit more, you have to really be terrible at what you do in terms of how you use your hands if that, for that to be true. Because if you're good with your hands, my dad used to say, when I was planning on becoming a chiropractor, he said, look, if you got good hands, you're gonna be fine. If you don't have good hands, you're gonna be using 'em to bus tables. So the point being is if you're good at what you do, patients will pay for it. They always have and they always will. And putting yourself at the pinnacle of that value curve in the marketplace, because you do something that they can't get somewhere else, or you're delivering results that they can't get somewhere else, you will always be in demand. And to a person, every single client that's converted to cash has not regretted the journey and the transition. And I'd like you to share your experience with your clients. You ever had one that said, boy, that was a big mistake?

No, not when they did it correctly. So the only caveat to this is when, that I found, is doctors try to do it on their own. They try to figure it out. And it's, in other words, they want to try to figure out how to treat neuropathy or chronic knee pain without following a proven protocol. And so what happens is they invest a bunch of money in equipment, but they don't invest in themselves and the training. Which is just ludicrous to me. And I'm not trying— I know this is a self-serving statement, but you wouldn't open a chiropractic practice without being trained as a chiropractor. So why would you start a niche, whether it's decompression or neuropathy, knee pain, or plantar fasciitis? Why would you start a niche without getting the proper training? Why would you want to try to run through a forest with a blindfold on? That's how I felt when I started out, although I did also have coaches. But the point being is, if you're going to do this, and you should do it, you've got to get training. You have to follow a proven model and a protocol. And the equipment that we already know that works. Like, why would you try and figure this out on your own? That's the only caveat, or that's the only pitfall, or one of the major pitfalls I've seen doctors where they regret it because they don't get the results. So if you can't deliver clinical results, just like you said, you're going to be busing tables. So you need to deliver clinical results. If you're going to ask cash and you're going to have them write a check, it's 3 to 5 grand or whatever the number is, you better deliver the results. That's our number one principle at my company is deliver clinical outcomes, right? So that's the only pitfalls. If you're interested in this, don't try to figure it out on your own because you will be, you'll struggle. That's, that's my experience.

Well, I think, I think the difference when I'm showing them the, the administrative side of it in terms of how to do it correctly so that you're not creating new potential risk areas for yourself. And it sounds like what you're doing with these guys is walking them through the process of how to you know, make that transition, staff training, patient education, whatever, such that it actually works out that you're delivering a great clinical result, but making sure that you're bringing the patient along so that they understand what's happening and why they have to pay for it and all of that stuff. I think that is critical. I agree that there's probably some people that have tried to make the jump to cash without any help, and it turned out badly for a variety of reasons, whether It caused licensure board complaints or marketing issues or something like that. But by and large, I have never had a practice that switched that regretted it. I think if you're out there, you're thinking about this model, certainly get help in terms of how to do it the right way with your paperwork and all the admin stuff. And then if you need assistance from somebody like Vince to help build out your niches, so to speak, and to improve the profitability of your cash practice, I'm pretty sure you're not gonna regret the transition. And it will definitely put you back in control of your practice and it'll put all of the decisions about the treatment between you and the patient without this third-party insurance company getting involved saying, hey, we're gonna cover this, we're not gonna cover that. And I think that that level of freedom has gotta be enticing to many of you. Vince, I certainly wanna thank you for coming on. Tell folks how to get in touch with you if you could.

Yeah, absolutely. And I just would love to, uh, Thank you guys, both you, Mike, and ChiroSecure for having me. It's really an honor to jump on the livestream with you guys. A couple ways, if you want to go watch a webinar, it's the 4 Steps to How to Add a High-Value Cash Service to Your Practice. That's where I recommend a lot of doctors start. It's going to teach you a ton. drvinceleone.com. Or if you said, hey, I'm ready to chat, I want to set up a consultation, you can always go to drvincecalendar.com. Either one and whatever suits your needs the best. And once again, thanks so much for having me.

Oh, my pleasure. And I really appreciate you taking the time to be on. I wanna remind everybody next week, Dr. Sam Collins is gonna be with you and I will see you guys next month. Thanks for being with us.