In this monologue Kelly Alhooie outlines why the traditional insurance‑based physical therapy model is unsustainable and provides a concrete roadmap for moving to a fully cash‑based practice. She first details the operational and financial headaches of insurance billing—delayed reimbursements, payroll backlogs, and the need to over‑schedule clinicians, which leads to provider burnout and lower quality care. She argues that partial participation in insurance (e.g., keeping one carrier) creates confusion and undermines the cash model, framing insurers as the “enemy” that prevents one‑on‑one, result‑driven treatment. To make the shift, clinicians must acquire new business competencies—sales, messaging, and value‑communication—to attract cash‑paying patients confidently. Alhooie advises targeting high‑value clients (those with a “rich” mindset about their health problem) to build a sustainable revenue base, then using that success to serve broader populations. She provides a step‑by‑step transition plan: send formal letters to insurers to terminate contracts, notify patients, go out‑of‑network, issue superbills, and consistently communicate the superior outcomes of cash care versus symptom‑management insurance care. The overall message is that a cash‑based practice, when executed with proper skills and client focus, yields better outcomes, higher provider satisfaction, and a more profitable, resilient business.
Chapters
Insurance to Cash Pay, the complete transition guide that's going to help you go from insurance-based practice to an actual cash-based practice. Okay, so the biggest thing here is if you're taking insurance, you need to audit what is the return. And sometimes it's really hard in insurance-based practice because per month you don't get payments potentially until 6 weeks later, if you even get a payment without fighting them. Without having to resubmit. And it's just a hot mess. So number one, it is so hard to keep up with what is coming in in a business when your insurance— it's not a direct transaction when you treat the client. Then you have backroll or backlog of payroll because you have to pay people, you have to pay the therapist. And so that's another problem that occurs is they're demanding their salaries, which is fine, but then you're also waiting on that payment to come through from that patient that they treated 6 weeks ago. So that's another problem in an insurance-based model. Another problem is you're gonna have to stack 2 to 3 clients a day or an hour on the provider schedule to then make up for what a cash rate would be. So when that happens, that equals more burnout from the provider. That equals double the notes that they take home at night, which that means double the time that they spend doing their notes, because of course, how would they ever have time to, to do that during the day, right? So these are all problems that just lead to unsatisfied employees. It's getting harder and harder to find therapists to begin with, and they're all leaving because they know that there's a different way. They are. And they don't want to treat people as well that are just there because their doctor sent them, or they're just there to work out and be treated like a personal trainer. They don't want that. They actually want to solve problems, what they went to school for. And that's what you're going to get in a more insurance-based practice. Or you're going to get someone that's like, hey, give me all the attention, and you got 2 other people you have to attend to during that hour. And then you feel like shit as the provider because you can't provide the highest level of care that you know that you're meant to provide. So what is that going to lead to? Dissatisfaction. Like, literally, the system is broken. So if you are in an insurance-based model, I would advise you to quickly as possible try to get out of all insurances. And so what you do is you have to send them a letter saying, as of this date, I will no longer be, you know, contracted with you, and I will be, you know, at a network. And you have to then alert the patients that you're going to be at a network. Some people try to do this dance of like, well, I'm only going to take Blue Cross and then drop everyone else. I believe you should not do that because basically, to me, I see the insurance company like the enemy. How can you talk about the enemy when you still are part of the enemy and you're also part of the solution? It makes— it doesn't make sense. It's And so in my head, you're confusing the people when you say, I only take this. Okay, well, if they don't have that insurance, they're going to get pissed off at you because you don't take it. And then, oh, by the way, you're then going to try to bring them in on a cash. They're going to say no way because you do take one, so why don't you take mine? And so there's already an X against you. So like, logically, it makes no sense. Um, conversely If you're like, well, we take cash, well, great. Now you can state why you take cash, because the insurance that is the enemy doesn't let us see you one-on-one, doesn't do this, doesn't do this, only, you know, gets the— gets symptom management. It doesn't actually solve your problem. We actually solve your problem. Like, those are the things that I can say. But if I take one insurance, then I'm also on the enemy's side. So I can't say that because now I'm contradicting myself. So like, please don't be those people that are like, I only take this one insurance. You only take that one insurance not because you love insurance, because you're freaking scared to go all in on cash because you don't have skill sets yet that can actually get you cash-paying clients. Maybe your messaging's off. Maybe you suck at sales. Maybe you don't know how to talk to people. Maybe you don't know how to convey of why you're different than actual insurance-based companies. Like, this could all be a factor of why you still feel that you need to hold on to an insurance. It's all a mindset and belief thing. And when I hear that, I'm basically just saying, okay, though that provider isn't confident, so they need new business skills to make them confident to be able to drop all insurances. And that's what you have to do. You have to learn a new business skill to do that. So guys, the question is, instead of like, well, should I take this insurance or should I stay in network with this? No, the question is, do you believe in yourself and do you believe that you can actually get results for people? If you believe that you can actually get results for people, Then you need to drop all insurances. Because I always say, if you're a cash-based practice, you have to be good and better than everyone else. Because the insurance people, they get fed the clients. They just get them fed. So why the hell do you have to be good when you're an insurance base? They have sucky practitioners. I'm not going to lie. They do. Because I never go to an in-network clinic because I already know those are going to be for kind of the lazy practitioners because Those people don't have to learn new skills. They do not have to learn new skills. Comparatively, if you're in a cash-based model, you have to learn new skills so that people are like, damn, she's different. Like she actually gets the result. How can you get the results with people when you're seeing 3 patients an hour, burned out on notes, working after hours, you know, for 3 to 4 hours doing your notes at night? How can you get results? You can't. You're so over them. They're gonna ask you a question, you're gonna be so annoyed. Comparatively, you have 7 patients max a day. You can specifically look up their case because you've got— for me, I put 50-minute treatment sessions, not an hour, so you can pee, poop, eat, look up something for the next client if you need to, and come prepared. Who's— who do you think is going to get the better outcome? The 2 to 3 people that you split your time between Or the one person that you're hyper-focused on that you can actually drive a result. It's a no-brainer. So like, it's the cash. That's it. So if we all say we want every— we want to do what's best for the patient and, and we want the best for what the patient wants, okay, well guess what that is? The insurance-based model or the cash? It's the cash model. So stop being afraid to step out. You just need to learn new skills. That's all you got to say is, I got to learn new skills, so I have to invest. And when you invest, then you learn those new skills. You have to invest in a program. You have to invest in you. You have to invest in coaching, someone coaching you to teach you how to actually learn that new skill. And once you— it doesn't take long. Once you learn that new skill, then whoop, wipe out all the people that take insurance. Now I know I'm going to get pushback here. Some of y'all gonna be like, but Kelly, I like treating the poor people, or I like treating the people that take insurance. Guess what I always say? Treat the rich people to help the poor people. When I say poor, I don't mean they're physically poor. What I mean is the people that have the poor money mindset and they don't have as big of a problem. That's what I mean by poor, meaning they don't think that their problem is big enough to then it be worth them paying you $3,000. Some other people that are actually poor but have a big problem, I call those the rich people. Those people will pay you any amount of money, even if they have to finance it, take out a loan on their house, whatever, because they have a big problem. They want the problem solved. That's huge. Those are the rich people. You want to go after those people. And then when you make a crap ton of money, sure, you can do whatever you want for free. You can see, you know, give out all your stuff for free, whatever you want to do. But you can't do that at first because you have to build a business that actually is sustainable, that lasts. So when we're talking about guiding you through from insurance-based clinic to a cash-based practice, you have to learn new skills. That's honestly, that's it. And basically you literally just call them up, you say, I'm, you know, I'm Dropping who as of this date, and I'm gonna go out of network. Thank you so much, bye-bye. And then they're gonna try to convince you to stay on with it. That's how this works, okay? And then from there you say no thank you, and then you literally just start giving people super bills and say we're out of network, even if your insurance company still has this in network. We're not in network because that will happen. They will try to drag their feet on it, and that's not it. And so, yeah, then you just and then you have to learn new skills on how to communicate your value and that you're actually gonna get their problem solved. And it's not symptom management like they would get with insurance. Again, this is why you cannot take some insurances and then also take cash. It literally makes no sense. You're confusing everyone, including yourself. And that's why you're not growing because you're not confident. That's it.
