Maximize Clinic Profit & Drop Low-Paying Insurances

[00:00:00] Adam, Robin and I are hosting a three-day hands-on event for PT, OT, speech, mental health, peds, pelvic floor, and medical practice owners who want to build clinics that are profitable, scalable, and best of all, don't depend on them 24-7. Welcome to the Private Practice Owners Club. Your hosts and coaches, Nathan Shields scaled his

[00:00:25] practice and exited for millions, while Adam Robin went from working 60 hours a week in one clinic to scaling to multiple clinics while working less than four hours per week remotely. This podcast is meant to share with you exactly how they did it and how you can build a business that supports the lifestyle that you truly desire. And don't forget to join the Private Practice Owners Club community on Facebook, where we are obsessed with providing even more resources that help owners just like you

[00:00:52] win the game of private practice. Hey, it's Nathan. Quick heads up for all the Private Practice Owners who are listening. If you've been listening to the podcast for a while, you know that it took me at least 10 years of grinding in my own clinics before I finally figured out how to scale and sell my four practices for seven figures and about three times the national average. The biggest shift

[00:01:21] wasn't some secret marketing hack. It was how I thought about profit systems and actually my role as the owner. That's exactly what we're going to be working on together with you at the High Performance Practice Conference this fall in San Antonio, Texas. From October 15th through 17th, Adam Robin and I are hosting a three-day hands-on event for PT, OT, speech, mental health,

[00:01:46] peds, pelvic floor, and medical practice owners who want to build clinics that are profitable, scalable, and best of all, don't depend on them 24-7. We'll dig into simple profit and KPI frameworks, real leadership and culture work, and practical systems you can take home and plug in with your team. So if you're doing roughly six to seven low figures a year and you want your clinic to feel

[00:02:11] more like a real business and less like a job slash cage, I'd love to see you there. Frankly, I'd love to see you bring your leadership teams as well because we will have breakout sessions for them too. You can get all the details and grab your seat at the link in the show notes. All right, let's get into today's episode. Recording in progress. We're up and going. Very cool. Yeah, so we're talking about dropping low-paying insurances and maximizing revenue. Welcome everybody

[00:02:38] to the Facebook Live and all those who are listening on the podcast is the Private Practice Owners Club with me, Nathan Shields, and Adam Robin. And like I told Adam, I think my presentation at PPS last year was about this. Essentially, I've given this presentation a few times. Not so much like the dropping payers stuff, but the maximizing revenue part of the title of this episode is

[00:03:03] something that I like talking about it because I think there's so many. It's getting to the point nowadays where if you're not doing everything you can to squeeze every penny out of the service you provide, it's just going to be hard, right? To stay in business, frankly, and at least make a decent profit. So that's just the nature of the industry at this point, right? Yeah, I think I had a

[00:03:29] colleague the other day say, it's like you used to be able to be average at private practice and still figure out a way to make 10% margins. And now you have to be really, really good just to make 10% margins. That's true. So as we're talking about it today, the topic being dropping low-paying insurances and maximizing revenue, maybe we focus on the second part first and then talk about dropping

[00:03:57] insurances. Because I don't know about you, like if I'm coaching somebody about a topic regarding this, they're not getting the reimbursements that they want. They're not hitting the profit margins that they want. My first inclination isn't to figure out what insurance is the drop right away, right? Begin the negotiation processes with- Go cash, go cash paying, right? That's not my initial thought because my first thought, and maybe you feel the same way, my first

[00:04:25] thought is, well, have you optimized what you're currently doing? Because you and I both know if you're going to drop an insurance, if you're going to negotiate with an insurance, you've done it a number of times over the past couple of years. How long is it taking for that process to come full circle and finally come to a resolution? Yeah, it's taken a while. It's slow and tedious. Like if you're going to drop an insurance, that's at least 90 days on most contracts.

[00:04:51] For sure. And if you're going to negotiate, I'm assuming it goes beyond 90 days, doesn't it? Yeah. And then they like to ghost you and they don't want to email you back and you got to chase them. And it's like, it's just tough, you know? So if you're drowning, you can't waste that time hoping that a negotiation changes the trajectory of your clinic or dropping an insurance makes a huge difference. So maximizing what you're currently doing

[00:05:19] is my recommendation for this first step, right? And you can get into some of the details, but we've talked about it in recent episodes. The four areas that I personally focus on is number one, know your numbers, know where you're at. Number two, focus on the front desk because there's a lot of easy money that can be garnered there. Number three, focus on your billing collections team and that

[00:05:45] they're collecting every penny that's given to you. And number four, ensuring that the providers are charging and billing optimally with appropriate justification for the services that they provide. And I purposefully go in that order because number one, you got to know your numbers. You got to know where you're starting with, right? Even if you were going to negotiate or drop an insurance, you need to

[00:06:11] know what is my average reimbursement for that payer and how does that compare to my cost per visit? Am I in the negative immediately? So knowing your general profit margins and where you are now and where you want to be, you got to have those baseline measures. But then going from front desk to billing collections company to the working with the providers and changing their charging habits and

[00:06:34] documentation and whatnot, it's kind of easiest to hardest, I would say. Like it's easier and faster to collect more money if you clean things up at the front desk, like collecting over-the-counter payments. I mean, that can change tomorrow. I mean, it can change in your cashflow. And then working with your billing collections team, yeah, that's going to take some time to make sure they're cleaning up the AR aging

[00:06:58] in your AR. And then the providers, you and I both know, trying to get providers to change their billing and charging habits is not an easy task and take some training, right? No, it's not easy at all. So we can get into some of those details, but were you ever at a point in the last few years where you had to kind of go through this process of really cleaning up your operations to maximize what you

[00:07:27] are collecting and what was the impetus behind it? Well, I think, I mean, if you go several months in a row and you're kind of breaking even and not making any money and you know that third payroll cycle is coming up in a couple of months, you got to figure out a way to afford that. Like that'll kind of, that'll spark you up and be like, hmm, we're going to make some changes. You know what I mean? So I'd say that's a pretty clear sign that you gotta, you gotta know your numbers. I think

[00:07:55] I'll kind of back, maybe break it down a little bit to more fundamental level. I think that the first step in this is really the idea of like create, making this a priority like that. I think that's the first step because, you know, it's like figure out the front desk. Okay. When are you going to do it? How are you going to do it? Right. So I feel like the biggest risk is not necessarily like

[00:08:26] not collecting over the counter or having a poor revenue cycle. The biggest risk is you being glued to this treatment floor and keeping your head in the sand and never creating the schedule and the cadence to focus and study this and actually push these initiatives forward. So I think that's where you start, right? Making sure you have your time allocated because there's only, I mean, you have to put time in, you got to put your energy into it and you have to get in there and wrestle with

[00:08:55] what's going on with the money over the counter. What's going on with the revenue cycle? How does that work? What's our denial rate? Start asking questions and learning. But if you do that for a few weeks, you'll start to become more competent and more have greater perspective on how you can start moving the needle at the various touch points. So that's where I usually recommend starting. What you're showing is some owners are just kind of wishing and hoping, like my schedule's full.

[00:09:24] And if I just keep my schedule full, the numbers should look good. Don't ignore it. It's like naivety, it's ignorance, right? And it's running your business on a hope and a prayer. Yeah. And underestimating the amount of time and energy it's actually going to take to make a difference and treating it at like a side project instead of the project that needs to be, you know

[00:09:47] what I mean? I think that's a really bad strategy. And then also underestimating the danger of allowing your company to be barely breaking even for months over months over months. There's so many reasons for you not to do that. But one of the biggest reasons is obviously running out of money, but secondarily,

[00:10:10] like you're building a team and a culture that tolerates finding like breaking even, right? And so like, and the longer you wait, the deeper that pattern just ingrains into the company. And then the bigger the lift it is to kind of like turn the ship around. So I think attacking it with a sense of urgency and is really important. It's always been important, but now considering the climate

[00:10:40] that we're in and the, how hard it is as a private practice owner, it's even like, you have to like, get your finger on the pulse and keep it there. Otherwise it's gonna be tough. It reminds me of a quote that Eric Miller said a number of years ago on the podcast. And that is you have to demand profit from your business. That's the mindset you have to have. You have to

[00:11:03] say, I demand this profit, this business make profit for not only its survivability, but to give me money in exchange for the risk and effort that I put into starting this whole thing up. Right. And having a mindset of demanding that is what is necessary to be more passive is what gets you stuck in some of these situations that you're talking about, right? Totally. Where any hiccup in reimbursements, like if Medicare delays payments for a few weeks,

[00:11:33] you are, you know, SOL. So that's, it's really important to have a mindset of this business needs to generate. I demand this business to generate a profit for me. And this is the profit that I demand it to generate. This is what I need to, in exchange for me to do all the things I need for my business, but also do all the things that I want to do with my household. And frankly, let's talk about it

[00:11:57] to support my retirement, to support my kids going to college. This is why I do this and not be afraid to talk about that and demand it. Right. And so I love that you brought that up. You do have to go in with the right mindset and that mindset then requires you to spend the time, take the admin time, get to know your numbers, get really comfortable with KPIs, get really comfortable reading a profit

[00:12:23] and loss statement, get really comfortable reading the billing and collections reports, your AR aging reports, your know how to find out the denial rate, know how to hold a billing collections team accountable, et cetera, et cetera. I mean, those are the steps you take then to demand profit. And then, you know, if I'm not meeting that, I need to start looking in these areas to make sure operations are running appropriately. Then if they are all running appropriately and hitting their

[00:12:52] metrics, now we can talk about dropping insurances, renegotiating, that kind of stuff. Right. That's my mindset as I'm going into this is that making sure your operations are great. But like you said, you first have to take the time to get to know how to know if your operations are going well. Yeah. You got to be unreasonable. You'd be unreasonable with your actions, right? Like unreasonable. And then if you do it, if you're unreasonable enough, you just might be profitable.

[00:13:20] You know what I mean? Like it's tough. Yeah, exactly. Yeah. I'm glad you brought that up. You do have to take the time. It takes effort and it takes knowledge and it's stuff that doesn't come. I mean, no one taught you this stuff unless you join some kind of program like ours. There's zero, there's not a single thing in the world that is going to like just grant you

[00:13:50] profitability. There's nothing convenient about it. Nothing. It's not a downhill game, right? So it's like, you don't start a business and then just the money flows in. Everything is working against you. Everything, every single, everything, all the people in your business, all the patients, all the everything, all the vendors, they're all trying to get a piece of it. You know what I mean? So it's like, if you don't go in with a mindset of like,

[00:14:19] I can't allow this to happen. Like somebody has got to be the person to be like, no, no, no, no, just keep making money, keep making money. Then it's, it's tough, you know? Yeah. And unfortunately I think we're also in an industry not to belabor this point. And soon after this, we'll definitely get into some details, but I think we're in an industry that puts profit in the backseat. I'm just here for the patients, dude. I just want to provide the best care

[00:14:48] and then the patients are going to come and the money's going to flow and all's going to be good in hunky-dory land. And that's not how it goes. Like you said, there's plenty of forces working against you and your company will spend as much money as you allow it to. And as you continue to generate more revenue, your company will find more ways to create more expenses. Totally. Right. So you have to be the manager of this and it all starts with the owner.

[00:15:17] Someone has to say, no, someone has to push things down. Let's start with the owner. Let's start with a budget. How about that? Let's start with a budget. A budget. Talk to your bookkeeper, your CPA. Let's put together a budget pro forma. How are things going? What do we need to do to generate this profit margin, et cetera, et cetera. That's a good place to start. Great place to start. If you are financially illiterate, start talking to your CPA.

[00:15:47] Start talking to your bookkeeper on a monthly basis on what do I need to do? What can I expect? What is my trend? Ask them, what is my break even if you can't figure it out? How many visits do I need to see a week? How much money do I need to generate per month? Right. And then how much more than that do I need to generate in order to hit the profit margins that I want? Let's start with that. Start there. Start there. It's really simple. From there, you can start gaining some particular metrics.

[00:16:16] What's your average reimbursement rate across all payers? What's your average reimbursement rate per payer? Right. I like to say Connor did a, an audit with me. No, he went through my profits course. And one of the worksheets was what is your average reimbursement per payer? And of course, if you ask anybody, what's your average reimbursement for say a United healthcare, a flat rate payer like that, you know, across the country, it's somewhere around $65, maybe some more

[00:16:44] if you negotiate a little bit, but I think he was assuming it was $65, but when he broke it down, revenue over visits for only United healthcare patients, his average reimbursement rate was like $59 and 14 cents or something like that. Cause there are denials and there are co-pays that don't get paid and that kind of stuff. And he was assuming he was getting 65. Well, 59, 14

[00:17:08] is a little big difference compared to 65. That's a 10% haircut you're taking on every United healthcare patient. And that's not meeting your cost per visit, I'm sure in most places. So having that kind of knowledge puts a different perspective on all the work that you're doing right there. Yeah, I agree. And to add to that, you and I both have talked to owners and you'll ask the question,

[00:17:37] what's your average reimbursement rate? Would you say more often than not, they're pretty confident or pretty clear on what that is? No, I'd say there's two buckets that I'd say 97% of people fall into. And that's including myself at times. It fluctuates. It's either a, they have no idea, right? Like, Oh, I don't, I don't really know.

[00:18:01] Right. Or B they're estimating it based on maybe a few EOBs that they're looking at and blue cross blue shield or whatever paid them and they're estimating it. And typically when we estimate things, we're a little bit more generous with our estimate, just like Connor, Connor did, right? We're a little bit more generous and we don't account for all of the inefficiencies inside the business that take place like denials and miscollections

[00:18:31] and deductibles not being met and AR and all that stuff. So I think the, to answer the question, that was a long winded answer to say like, no, I don't think most people truly know what their average reimbursement per visit is. And I don't think they're measuring it accurately. Or on a regular basis. Or on a regular basis. Correct. Like you said, it could fluctuate, but you should have a general trend over the past six to 12 months

[00:18:57] of this is what it's been. Right. And compare what's happening now against their trend. Totally. To take it further. I don't know. You probably haven't asked this question, but if you have, let me know. I would assume most owners don't know their cost per visit. Well, you know, I'm kind of like in the back of my head, I'm thinking about, as I hear you talking through this and I almost believe like cost per visit is some,

[00:19:22] it's almost more important at times. Right. Because for the reasons that you explained, especially in private practice, like I've never had a lot of success in business, trying to out revenue the expenses. That makes sense. Like if I just, let me figure how to make more. And I always end up just spending more every time I hire more people and I get more, I get more bloated because I got extra cash in the bank. Let me just spend it. Right. Cause we

[00:19:50] are humans. I can grow a business, but creating a profitable business really, in my opinion, it's like optimizing your revenue, but really sometimes even more so like learning how to control your expenses, like control your expense line and learning how to operate with less. Like you've got to figure out how to be more efficient. And that could include, which is

[00:20:18] essentially all of your KPIs, all of your KPIs are being measured. For instance, uh, over the counter collections, which are basically measuring is we have this idea of where we want to be, but we have a S like anything below 99 or 97%. That's our budget. Right. Like that makes sense. And so I think learning how to minimize the inefficiencies across your business will probably make you a lot

[00:20:47] more money in the long run than just focusing on how do I generate as much capital as possible. Does that make sense? Yeah. I think there's a point like you can never cut expenses to wealth. You can only cut so far, but you need to be aware of them. I think that's also another benefit, one of the benefits of meeting with your CPA or bookkeeper monthly. What I learned as I was doing that monthly, not only learning how to read the P and L, but we would look at this month over last

[00:21:16] month, or maybe this month over the last two or three months comparatively. And this month over last year, this time last year. And so you could say, let's look at our expenses by category. And is there a huge variation? And if so, why? Because we had multiple clinics at that time. It's very possible that a clinic director or someone in the office got a wild hair and wanted to buy a bunch of office supplies and didn't know or something like that. And we had to maybe talk to

[00:21:44] them, but you need to, it was important for me to know where we were because once you get a handle on that and you're relatively steady and you're not having a lot of influx of providers and not a lot of transitions and whatnot, the cost per visit should stay pretty consistent. Of course, with each provider, it should bump up a little bit more. And then if you get a few providers, then you know, you have to add more admin staff. So that should bump. I mean, those are all kind of built in. And

[00:22:12] so it does fluctuate month to month, but during steady times, it should be a relatively constant. Right. And so it is super important to learn because then you can break it down by unit. Okay. Now I have this cost per visit number and I have my average reimbursement per payer number. It's really easy to see who am I losing money on, on a regular basis? Who do I need to see more of on a regular basis? It's really easy to make objective decisions at that point.

[00:22:42] And what would be in the best interest of your business? I agree. When we're talking about the reason I bring up front desk, like I said, is because it's easy to increase cashflow if that's an area that's not optimized immediately. And you tell me the EMRs that you've worked with in the last few years, are they helpful in tracking over the counter collections or is that something you still had to do manually?

[00:23:10] No, I've seen them. Well, I've seen them actually do a pretty good job of that. The good EMRs, you know, go to the Facebook group and you see the ones that we mess with. You know what I mean? They're all good that you should have. They should have some decent reporting. And I totally agree about the front desk. Like it's just a risk, such a revenue driver. And so it's so many ways, over the counter collections is one way.

[00:23:35] In the past couple of years, I know that you've done, I recommend, we recommend is that keep credit cards on file for every patient. And you made that transition a couple of years ago. I'm assuming you saw an increase in cashflow by doing that pretty quickly. We never have, patients don't owe us money. You don't have any patient AR outstanding. It doesn't exist. It's just, we have a positive AR, you know, like we're always reimbursing people every month.

[00:24:05] I would much rather do that than be chasing people for money. Yeah. So yeah, put credit cards on file and make sure that you are collecting your co-pays, but at the time of service also collect the estimated deductibles, right? And estimated co-insurances that might be associated with that payer. Right. And I know some people who have heard that from us before be like, yeah, and there's

[00:24:34] going to be some people who've never really thought about that. They're going to say something like, what happens if you, if, how are we supposed to estimate that? You know, what if they bill a different CPT code? I'm just going to say, figure it out. You know what I mean? Like it's, it's like, figure it out guys. Like go look at all your blue cross patients that you ever billed over the last 12 months. You're probably going to, not a whole lot's going to change. You're going to bill them pretty consistently, pretty, you know, you're gonna have a normal bell curve, just like it's

[00:25:03] statistics. Most of your patients are going to cost this much. You're going to schedule them at the same one hour time block. You're going to build this many units. And so if you look at it, you can kind of get a really close idea of what you're going to get reimbursed. It's assuming you stay normal and you just continue to do what you've been doing. And then you just take a percentage of that, right? Well, it's really easy. Yeah. Let's say you average a hundred dollars, even if you didn't

[00:25:28] want to break it down by pair, what's your average reimbursement? If it's a hundred bucks, well, and if they haven't met their deductible, you collect a hundred bucks that visit. If they have a 20% co-insurance, you're collecting 20 bucks that visit, right? Yeah. You can make it very, very simple, but the idea being don't let anybody walk out those doors owing you money. No way. You lose money that way. No way. It's just not good. It's not a good idea.

[00:25:57] It's just not a good business sense. And I think I shared a quote at PPS that I found last year, but a lot of patients now expect more digitized payment services like that. Nowadays, if I have to cut a check for somebody, I'm like, dude, this is 2026. Why, why am I mailing checks anywhere or even writing checks? I can't remember last time I wrote a check. I'm trying to get some work done

[00:26:25] at my house in Alaska. And the guy's like, yeah, I can get started. Just send me a check. I'm in Arizona. Why don't you have a digital payment service? And so I think about that the same way with, with physical therapists or any private practice owners, you should have credit cards on file and to make it most easy for them. They don't have to bring a physical credit card to subsequent visits. We'll run it when they walk in the door. And when there's a balance left over at the end of the

[00:26:53] months, we'll run it again and let them know that we're going to do it. And they don't have to lift a finger. And I think the patients expect that at this point. Totally. We're going to be doing a little build out downstairs with an outdoor kitchen area. And so I had to call the material, the supply house and buy some lumber. And I said, got the quote and whatnot. And they were like, oh, you're going to have to come in and pay in person. We don't collect cards over the phone. Sorry. I'll call someone else.

[00:27:23] Totally right. Not getting out of my house. No, you're exactly right. Call me when you have a payment processor that you can collect over the phone. That's right. You know, I just don't have time for that. And really quickly, what do you tell, because there's going to be owners who are listening. You're like, but some patients are going to get mad and some people don't want to share their credit card. What do you tell them? Well, you've lived it. Yeah. Yeah. I will tell them, you know, sometimes in life and in business, and when you learn enough

[00:27:52] of the things, the hard way you start to kind of build these principles of success. And I will say that one of the principles that I've learned is that a lot of your success will be found when you learn to stop being consumed by the opinions of other people. And yeah, we love the patients. We love them as people. We want them to get help. But if they're upset with me, I don't have to let that

[00:28:21] consume me. You know what I mean? And if that means they have to choose to do a business in other places, that's fine. That doesn't mean that they're bad people. It doesn't mean that I'm a bad person. It just means that like, I don't have the luxury of absorbing that cost any longer. Yeah, exactly. That's the point right there. Right. And so I care about my family a lot more. And so I want to make sure that they're protected. Yeah. I tend to think there's also a part of me that thinks if someone's not willing to

[00:28:49] share their credit card information, because that's our policy, we don't see patients who don't keep credit card on file. You can pay in other ways when you come to each visit, but we are going to protect ourselves by having a credit card on file. And if they don't want to do that, then that makes me think, well, that's a person that I might have to track down. I'd rather not do that. I choose not to be in that position. Yeah. I would just encourage people to do it anyway. Do it.

[00:29:17] Just do it anyway. Just do it anyway. Yeah. When it comes to managing your billing collections team, and I know you've dealt a lot with this, especially over the past year, I think there's two. Number one, I will say just like you're a CPA or a bookkeeper, same thing with the billing collections team, meet with them monthly, review your, the collections for the month. We've talked about projecting out what they should have collected for this month in previous episodes. You should know what they should have collected this past month.

[00:29:46] You also should know what their denial rates, and you should have the report of their AR aging. I think with those three tools, you can pretty handily manage your billing collections team. Don't you think? Yeah. I think I like those three. I like those three stats, but I think even more than that, for me personally, like my standards have kind of grown as I've learned more. I think that's entry level. Yes.

[00:30:12] That's entry level. That's not like you found that hit the jackpot because somebody knows how to measure a statistic, but I think I want to work with somebody who has business acumen. You know what I mean? Like I want somebody, like if I want to run a report that says, Hey, show me a report that shows me what hours of the day we make the most money. I want a builder that can pull that. Or if I want a report that says, I want to know which payers I should be considering going on a network. I want

[00:30:39] a builder who can pull that data. They should be able to like help me make business decisions without me having to micromanage all the data. Yeah. That reminds me. And that's a good point you bring up. Like when we're talking about initially about knowing your, some of these metrics, like your average reimbursement per visit, your average reimbursement per payer, those are numbers that you shouldn't have to get by your own on your own. You could, you should know how, but that's an email to my billing company. Like, Hey,

[00:31:07] I want to know my average reimbursement over the past six months, not for clinic wide and for the, for all these payers, these five payers, I want to know what's happening with them. Yep. They should be able to boom, 24 hours, get you that. Right. Yep. Totally. I would say that is so important. I thought for a long time that we were supposed to be the people tracking every stat across all the businesses for everything. It was a bad idea. That got, that's kind of a pain in the butt. You know what I mean? Instead I'm like, if it's coming

[00:31:35] up on my quarterly meeting, I would send an email and say, Hey, these are the decisions we're trying to make as a company. This is the data that I want to look at. And our meetings on Tuesday. Can you have it to me by Monday? So I can review it before the meeting. Yeah. Boom. And then we can go, I can go in there with knowing that I've got a billing or revenue cycle team. That's like, we're on board with you. Like we know how to support you through this decision. Yeah. I think that's a really important, important piece of it. Yeah. Just in the last few episodes, I know we talked about how to manage a billing

[00:32:04] collections team. So I highly recommend you go back a few episodes and see what we say about that. It was probably one of the high performance practice episodes that we did. So we don't have to spend too much time on that, but I think, like you said, I'm sharing those three reports or those three statistics as entry level. Once you get into it, yeah, you're going to want to know who, what payer has the greatest balance that's greater than 120 days right now. And totally,

[00:32:30] yeah. You know, give me an update on all of my lean or motor vehicle accident patients or no fault insurance patients. Give me an update your communications with each lawyer that you've talked to and what's the status of their case. And so it could get much deeper, but to start off, to measure their efficacy, I think those are some standard ones you should go by. And they should be communicative like you're talking about.

[00:32:54] Totally. The other, another good one is show me the provider that has the highest revenue generation in the company. And I want you to see, tell me like how I want to model the way that they bill. Show me what that looks like. Show me the differences. And so like, you can help me make more money. You know, help me make more money. Yeah. I think that's a good lead into the next session is

[00:33:19] like, how do we optimize billing? How do we optimize charges amongst our providers? And I think what you're asking the billing collections team there is what's their CPT code utilization rate? Like how often are they billing the 97530s? How often are they billing the neuro re-eds? Are they doing re-evaluation billing and how are they justifying in their documentation? That's not a biller's job right there,

[00:33:48] but I think that's what you're looking for, right? If they're generating a lot, is it purely because they're just seeing a ton more visits or are they actually generating more revenue per visit on average compared to the other providers in the clinic, right? And yeah, are they making, that's one thing I'll ask frequently and I'm getting more appropriate answers, but are they billing with AMA when they're supposed to be billing with AMA and are they billing with Medicare eight minute rules when

[00:34:15] they're supposed to be billing with Medicare eight minute rules because it's vastly different and the reimbursement can be significantly different. And so you should be using either one appropriately. And so all those things go into it when you're looking at individual provider productivity. Yeah. I would say I've got some general ideas on that too. Obviously it's like, you want to try to, just to kind of like agree on the terms, like our goal is to bill as much as legally and ethically

[00:34:39] possible for every visit, right? We're not going to do anything illegal or unethical, but we're not going to leave units on the table either. Right. Okay. That's the sweet spot. Yes. And so a few ways to do that is to number one, train your team, right? Like have a training. It doesn't have to be complicated, but just have some type of formal training to help them understand how to generate revenue for the business, which units pay the most, which ones pay the least and how to just

[00:35:08] per payer, right? And how to justify that treatment, that coding consistent with the way that you'd like to treat patients. So, I mean, that'll go a long way, but that's not going to get you all the way there. Another really important hack or tip is to like measure units per visit and have it reported to you every week, right? Just create an accountability rhythm. They're reporting that metric to you every week. Just have them put it on a piece of paper and see it and measure it because that will improve.

[00:35:37] That will help it improve. For sure. The other thing is it's really helpful to have somebody else on the team who's responsible for pushing billing production with the providers and not the owner. Yes. Somebody who's a little bit more detached from the financial gain of that initiative because you kind of remove emotion and the conversations could be more direct and less weird. Just don't make

[00:36:04] it weird. Just find somebody who's good at having those conversations and like you can bonus them a little bit if it's tied to it, right? So that's another one. And then the last one is going to be align incentives, right? So like finding ways to create compensation plans for your providers that allow them to earn more when they generate more. That can help create aligned incentives and then all of a sudden people know how to bill. Do a little bit of those that pick up, take those strategies, pick

[00:36:34] which ones you like, pick one or two that you like, and just like go for it. And you'll start to see revenue per visit climb that way. Yeah. There's a huge benefit to, like you said, using a third party, even if, whether it's someone on your team or even like a Goenda or something on Medbridge that teaches you how to bill appropriately, maximize billing for the services you provide is super helpful. But most importantly is that the owner and the clinic directors are all on the same page.

[00:37:02] Totally. That's how we do things, right? And you're also well-versed. So you're not finding the course and then making the providers go listen to it. You're listening and watching it first and getting to know the ins and outs. So you become expert at it as do your clinic directors and you create policy and procedure behind it based on your trainings, right? And so they can

[00:37:27] not only train, but also hold accountable as necessary. Yeah. I love all those things. And if you do all that well, we've kind of basically kind of went through the entire baseline fundamentals on how to make money in a private practice, right? Right. But there's one really important one that we didn't discuss, which is meeting with your

[00:37:52] accountant and bookkeeping team on a regular cadence. Like maybe we kind of loosely discussed it, but have a financial team and have a financial plan, like create a financial plan for the quarter. This is where we're at. This is our burn rate every month over month. This is our break-even, our break-even metrics that we have to be at. Like know that, make sure your team is aligned behind

[00:38:18] it and create budgets around how you spend and what the expectations need to be across all of those financial touch points. That's so important. That's so, so important. Cause if not, you're just going to be like, let's get more patients in the door and you're just going to grow and you're going to spend all your money. That happens a lot. Yeah. It became easier as we became more intentional about that. I started giving credit cards to my clinic directors or my marketing director.

[00:38:48] And I just said, listen, anything under a hundred bucks, don't bother talking to me. It doesn't need approval. I trust you. If it's under a hundred bucks, just go and buy it, right? Anything over a hundred bucks, you need to submit for approval, review, review it and tell me why you need it. That's an email or a form to fill out that kind of thing. Same thing with a marketer. If you're going to do a lunch at a doctor's office, you have a budget of, I don't know, 250, 300 bucks, anything less than

[00:39:15] that. Don't talk to me. Just tell me when to show up and where. And then that made things a lot easier. And it's a simple process, right? And like that, I knew by doing that, I gave them budgets essentially, right? By doing things like that and more so to say, this is what you need to run the clinic. This is your budget for it. Go and do the work. And that made things a lot easier. So a little hack that I'll give, if you're still listening, guess what? You're going to get a hack.

[00:39:44] Don't tell anybody. So ever heard of this thing called AI? It's this new thing. You got to check it out. Tell me about this. Oh man, it's just new. I know you've never heard of this. So like a few simple documents, like get you a KPI dashboard where you're tracking, like track your AR, track your visits, track your email, track your, grab another tab and make, put your average reimbursement per visit per payer on there. All the information that we're talking

[00:40:09] about, your over-the-counter collections. And if you use QuickBooks, you can use like Claude or ChatGPT and you can integrate those into a Claude, a cohort tool, right? And you can just be like, tell me what I got to do to make money. Like, you know what I mean? Like literally you have a financial advisor for your practice sitting in AI right there. And how cool would that be to like equip your directors with pieces of that as well? Right. It's like, Hey, can I hire this person?

[00:40:39] What are our budgets? Well, ask AI, let's see where we're at. Right. So there's somebody like me, I get a little overwhelmed when I start talking about like trying to figure out money. It scares me, but like just having that control, I know it's right there at the tip of my fingers, gives me a lot of peace. Yes. Gives me a lot of peace, you know, that I'm making good sound financial decisions. So that's a, that's an idea for you guys. I love it. I'm glad you brought it up.

[00:41:04] Sometimes we get into this and I think we just lean on our past experience and not how we can leverage modern tools to meet some of those same objectives. It's great. Absolutely. Yeah. Yeah. And so let's just talk lastly about negotiating or dropping insurances. And I will say this, I have a, an insurance scorecard that I've had owners fill out in the past and half of it is numbers

[00:41:32] left hand side of the spreadsheet is, you know, who's the payer? What's your average reimbursement rate over the past 12 months? What's your cost per visit? Then the other half is on a scale of one to five. How easy is it to get paid from them? How quickly do they pay? How often do they deny? What is the authorization process like? Are they, so it's the administrative burden of dealing with that payer. And I think sometimes we just look at the number portion of it without thinking there

[00:42:01] could be a serious drain on our resources. Totally. If these insurance companies aren't paying us in a quick and easy manner, if we have to fight tooth and nail just to get a typical reimbursement for an average visit and they're not authorizing stuff in a timely manner, then that expends resources of your team to collect that same money. So dollar for dollar,

[00:42:26] all the insurances aren't paying the same. One could be paying $85 and another one could be paying $85, but one has unlimited visits. They can come as often as they want and they don't require a lot of audits or anything like that, or requesting notes. Whereas another $85 insurance company is giving you six authorized visits and then they want a progress report. And then they give you two authorized visits and they want a progress report. And then they give you one authorized visit and

[00:42:54] they give you a progress report and their denial rates are high and they're always asking for notes. So you can't compare them as apples to apples and you have to consider the administrative burden. Right? So that's one thing to consider as you're looking at either situation. If I'm talking to an insurance company to either negotiate with them or to drop them, I want to know which ones to focus on, not just based on numbers, but also on the administrative headache that they're involved. Considering those two factors, have you dropped any recently?

[00:43:24] Yeah. Yeah. Yeah. Yeah. We did. Have you? How many? We've dropped two, like some smaller ones that I don't really know. And then we dropped Cigna. And these were lower payers and did they also have an administrative headache or were they simply low payers? Yeah. So like the way that we looked at it was like, the answer is yes. Answer is yes. So it's like we were at a place where it was like, Hey, we want to hire another therapist. Well, if we hire another therapist, then we have to hire another front office person because they're already

[00:43:53] drowning in authorizations. And I was like, okay, well that's 40 grand a year. Why don't we just drop them and spend 40 grand a year on marketing? You know what I mean? Like I'd rather do that. Yeah. So we did that. Not 40 grand a year, but you see what I'm saying? Let's like, no, I totally get it. You could be like, okay, we'll hire the therapist, drop them and just spend the extra money on spend a couple thousand bucks a month on marketing, fill your schedule back up.

[00:44:19] Right. So was that a big hiccup for you? Just going through the process of dropping and were you scared? Yeah, I was scared. But again, like just, I think I like to operationalize my fears. And a lot of the fears that I have are related to answers that I don't have the answers to these problems. Like, should I drop them? Should I not? And it's like, what data do I need

[00:44:46] to make this decision? And I mean, now that you got AI, it's like plug your whole business inside the AI bot and you just, Hey, this is what I'm thinking about. And they're like, yeah, that's a great idea. Perfect business move. You know what I mean? Like here's the math and why you should do it. Here's what, you know what I mean? Like you have that level of control of those numbers. You just operate with a different pep in your step. You know what I mean? Cause you kind of know.

[00:45:10] And also when you have a really great team that you trust, then that just makes it like, just take a bet on it. And I'm assuming as you, as you just asking for some real world numbers, like dropping some of those insurance, I'm assuming your average reimbursement went up a certain percentage. Are you willing to share? Yeah, it probably went up. I don't have the data in front of me, but it was probably around

[00:45:35] not a big percentage might've been 1%. Okay. Cause it wasn't a large population. No, it wasn't a large population, but it also saved me a payroll, saved me on payroll that I didn't have to buy another admin. Correct. And that's why I think managing those expenses is so important, man. In my opinion, I feel like the practices that are going to make it are the ones that are able to filter more money to the clinicians. And in order to do that, you got to find ways to save

[00:46:02] money on the admin side. You know what I mean? You've got to implement AI. You've got to work with VAs. You got to get, got to learn how to bill. You got to learn how to do those things efficiently. Got to use AI because you got to pay those clinicians like 60 plus percent of your revenue. Yeah. So you don't want to just keep adminning everything. I mean, you can't just hire more front desk people, hire more billers, hire more credentialers. You can't do that. Like you got to find a way to be more efficient. Yeah. So if you want to know some, like the tactical steps to

[00:46:31] dropping an insurance, feel free to reach out to me on Facebook, send me a messenger note. Like I've got an SOP all about dropping low paying insurances, how you should do it optimally. Cause I've done a number of episodes with people that have done it. I will say this. I haven't met an owner yet that has dropped an insurance and has regretted it. Been around for a few years and everyone to a T has dropped an insurance and wish they did it earlier.

[00:47:02] And never turned it out, turned out poorly for them. Like you have so many fears. Like what you're talking about is the fear of the unknown. You haven't experienced this. Local physicians aren't going to appreciate that I'm dropping this insurance. I haven't found those fears to be founded yet. And quite the opposite. Like they are typically unfounded. They figure out a way to do it the right way. They handle those patients the appropriate way, give them plenty of notice and things work out.

[00:47:31] And then what tends to happen is they go through that experience. It becomes a relatively positive experience. And now they're looking for the next insurance to drop. Who's next on the chopping block? Who's the next one? Yeah. I see it all the time. All the time. What I heard there was the fear of the unknown. It's like, what you really fear is like, you're going to be a pro. You're going to confront new problems that you've never really

[00:47:58] had to confront yet because your schedule was full. And now that you might have a little bit more of a demand problem, which is scary because we feel like if we don't have full schedules, we're going to go broke. And there's some truth to that. But there's also, you'd be surprised at what you're capable of whenever you place that kind of that healthy pressure on you and your team. Like you find ways to be

[00:48:22] resourceful. You find ways to attract the right people to your business, the ones that I'll actually pay you. And I think that like, what I've mostly heard you say is like, most practice owners are capable. They're capable, hardworking, good, hardworking business owners that are able to solve hard problems. That's what I heard. You bet on yourself a little bit and like, you're probably going to rise you and your team.

[00:48:52] Yeah, for sure. Yeah. And then to switch tables a little bit to the negotiating part, I haven't done negotiating, but I've coached enough people that have done a few episodes about people who have negotiated contracts. And like you said, it's not easy. They'll tend to ghost you. Sometimes it's hard. I remember interviewing Trace and I think it took him like 60 or 90 days

[00:49:15] to find the right person to talk to. Like they're not easy to come by, right? And so talking, finding the right person to negotiate with, do you tend, is that a phone call or is that typically emails back and forth? It's an email. And I think that, man, I can share some stories on negotiation. It's an email. And I would just say the first time you do it. So typically most insurances will

[00:49:45] allow you to consider renegotiating every two years. The first time you do it, you're probably going to be coming to the negotiation with a little less leverage because you're still only two years in the business. You don't know what the heck you're doing. By year four, you know a little bit more. By year six, you know a little bit more. By year eight, you're like, okay, let's negotiate. You know what I mean? And you come to like, listen, I've been around the block. I know

[00:50:13] how to hire people. This is what we need. And we're going to have to either figure out how to get here or we just decide that it's no longer a good fit. And something shifts whenever you approach it with a little bit more backbone, something shifts. So I would say have some courage, be professional, but know your worth and bring data, bring data to the negotiation. And if you want to

[00:50:41] take a screenshot of how much their company profited last year and add that to the bottom of the email, you could do that too. That might give you a few extra bucks. Yeah. Exactly. Especially when you consider UnitedHealthcare makes tens of millions of profit. Billion. I'm sorry. Tens of billions. Billion. With a B. Per quarter. Per quarter. Not annually. Per quarter. Billion. That should make you think, oh, maybe there is some money for this poor struggling private practice.

[00:51:11] It's there. It's there. And don't believe what they tell you. Don't believe what they tell you. Yeah. So good advice. Good advice, man. You can do it. It's possible. There are some resources out there that will help you say I'm talking to a brace health right now, and they're able to help you come up with, like you said, you want to come with numbers. They'll help you come up with numbers. And if you're in the right places, they might even help you find the right people to talk to

[00:51:40] because they have experience in different states, right? But if you need some help, if you are one of those people that's struggling seeing patients the entire time and don't know how to find these people, there are resources out there in which you can leverage to help you fill out those emails and get to the right people with the numbers that you're hoping for and that kind of stuff. Reach out to me again, independently, Nathan at ppoclub.com, or send me a Facebook messenger request and I can connect you with people who can help you negotiate on your behalf.

[00:52:10] Well, not on your behalf. They'll give you the email content you need to send on to the right people. Yeah. Right. It has to come through the owner. Otherwise there's going to have to be some kind of proof of that person negotiating on your behalf. You could do that. You don't have to. Say how many times out of 10 have they come back and given you an increase?

[00:52:36] Eight or nine. Oh, really? That's awesome. Yeah. That's cool. Yeah. They need you. They need you more than you think. Some of them won't budge, but then you just drop them. That's true. Yeah. It's possible. And that's where you, that's really the only power you have is like, especially if you have a specialty, if you have a needed specialty and you have some teeds that helps a ton.

[00:53:01] Bring the data, bring the data, bring your data, bring your cost per visit, bring your average median household income in your area, bring the data, bring the data, bring the average salary, the debt to income ratio for physical therapists when they graduate school. It's all free. Like add that, make this a data driven position. Numbers don't lie. And then listen. I like that you shared some of those metrics. Those are, those are important. I wouldn't have come up

[00:53:28] with those, but they're important to know the surrounding demographics, your people, right? And what you're having to pay people on your team nowadays compared to five years ago, when you signed to the contract and that kind of stuff. Yep. Tell a huge story and back you up as to why you're approaching them. Totally. Totally. Very cool. Cool. Well, dude, we spent a long, a lot of time on this. We did. We're passionate. We wanted you guys to make some money.

[00:53:57] That's why we're here. It's how people make some money. We know that's a path to freedom. What else do you want to add? Anything in particular on top of that? Because I think I've exhausted a lot of the stuff that we covered or I don't have much more to add. I would say make sure you check out the conference in San Antonio, October 15th through 17th. Yep. Is that the right dates? PPoclubevents.com. It's in the, if you're watching this live, it's in the comments. It's the first comment below.

[00:54:27] Check out the landing page. We tried our best to help you see what we're building for you. And, um, and we want to try to give you a place where you can elevate yourself as an owner, as a leader, and also elevate your team so that you can stay in the game with us because we need you. Right. So consider coming to San Antonio. Love it, man. And I'll add to it. Like I said, from Eric Miller, demand profit from your company,

[00:54:55] man, demand the profit, put the energy, put the effort into it. It is the lifeblood. It's the reason why you got into this. That's the American dream, yada, yada, but demand that profit. And these are some of the ways that you can do it. Cool, man. Good talk. All right, brother. We'll see you on the next one. Yeah. See everyone in San Antonio as well. Adios. Thanks for listening to the private practice owners club. If you enjoyed this episode,

[00:55:25] would you mind doing us a huge favor and leaving a review? This helps us get the podcast out to more clinic owners to help them create greater freedom and profits so they can own their future. And visit our website, ppoclub.com to find more resources and connect with us.