Interview with Cash Based Physical Therapist & Pelvic Guru Tracy Sher

Cash Pay Physical Therapist Tracy Sher MPT, CSCS

Tracy Sher aka The Pelvic Guru

Today I have the pleasure to share with you an interview with Tracy Sher, MPT, CSCS aka The Pelvic Guru. I’ve followed and interacted with Tracy on Twitter and Linkedin and thought her story of starting a cash based physical therapy practice would provide some awesome tips and inspiration for you.

Tracy has specialized in women’s health and pelvic floor dysfunction since her first job as a physical therapist 14 years ago.  She is the owner of Sher Pelvic Health and Healing in Orlando, Fl, and the proprietress and author of The Pelvic Guru blog and associated Pelvic Guru Facebook page. She was recently elected to the Board of Directors of the International Pelvic Pain Society, is an instructor of Pelvic Floor Level 1 and an advanced Pudendal Neuralgia and Pelvic Pain course with the Herman and Wallace Pelvic Rehabilitation Institute and is currently working on her sexual counseling certification through AASECT.

When not treating, or teaching about complex pelvic health conditions, she enjoys yoga, paddle boarding, Zumba, gym activities, sprint triathlons and reading lots of “nerdy medical articles.”

 

Aaron LeBauer: Tracy, at what point did you decide to start your own physical therapy practice?  How or what helped you decide to start a cash based practice?

Tracy Sher: I’m an out-of-the-box thinker, fiercely independent and an entrepreneur at heart. So, I always had a dream of starting my own practice and other business ventures for a long time. Even during my first years as a PT, I had an online business venture with someone in Scotland, selling heart rate monitors worldwide.

I started my private practice in the most nontraditional (and likely riskiest way). During Thanksgiving of 2012, I decided to open a practice in January of 2013. I didn’t have a space or a plan; and my goal was to move away from the limitations of health insurance with regard to proving the best care and least amount of limitations. This was also an opportunity for me to continue to teach CEU courses throughout the year; and create my own schedule (more flexibility, but don’t we always work harder when we own our own business!?). The one thing I was sure of is that I am not afraid to work hard and I absolutely love what I do and truly want to help patients get better. This has been very important over the past year.

My goal was to keep my business overhead as low as possible and start out as a solo practitioner without other staff expenses. This is the start-up story where I was initially bringing small tables and light bulbs from my house. (ha). In keeping with this goal, I knew I would not have the time and resources to handle the work of getting insurance authorizations, submitting claims, and waiting for the lag time in reimbursement. I also wanted to set up a different care model with longer evaluation times, for example, because this is so essential to establishing good rapport and the right treatment plan. So, all signs pointed to cash practice. I was going to give myself 6 months before I would re-evaluate if I would need to sign on with some insurance plans. Thankfully, I’ve been able to keep this model! Phew.

Aaron: Please give us an overview of your Cash Based Physical Therapy Practice.  What are your treatment sessions like? How long do you spend with each patient? How often do you see your patients/clients?  Does anyone else work with or for you?

Tracy: I’ve set up my practice so that the environment has a spa-like feeling to it. I have a waiting area and 2 private treatment rooms. My evaluations are quite extensive, with a purposeful long history-taking part (I’ve found this to be so beneficial for critical thinking and planning) and full evaluation that usually 1.5 hours. I see patients that are local as well as complex cases that are referred to me or find me from across the state of Florida, out of state, and even from other countries. So, sometimes I set up even longer, extended evaluations with follow-up treatments for the next 2 days.

My treatment appointments are typically up to 55-75 minutes, but for complex cases I move that up to 85-95 minutes. I realized that most of my patients were benefitting from the increased time for visits (rather than the standard 45-55 minute treatment in most settings) so, I increased my fees to cover that time.

In an ideal world, I see my patients 1 time a week to at least every other week and provide them with various self-management tools, guidelines and exercises for home. However, I also see patients 2-3 x week and some that visit every few months from other states. We figure out a plan together that will still help them meet their outcome and satisfaction goals while considering their time and finances.

As the first year closes, I’m hiring a part-time office manager and possibly some college interns on stipends for special projects. I honestly should have done this 6 months ago.

I now have a wait list of patients of about 3-4 weeks and anticipate hiring on another specialized PT in the next few months to train and mentor. Due to business start-up costs, it would be ideal to hire a contract PRN PT or part-time until I can build a full case-load for the therapist. This is one of those business dilemmas because many therapists want full-time immediately. To be continued…

 

Aaron: How do you market your services?  Where do most of your patients find out about you?

Tracy: Marketing is an interesting thing! I haven’t really started much marketing and already have a waiting list. I was pleased to have local and out-of-state physicians who know about my work and referred patients to me, even when my business structure changed. I very much appreciate their continued trust in my work with their patients. I’ve also made a point of sending patients to other pelvic PTs in the area if I could not see the patient (due to insurance issues, location, etc.).  This has, in turn, created a reciprocal referral base, where they know they can also send patients to me for additional consults, complex cases, or location preference. Another interesting and unexpected referral pattern emerged: I started getting more referrals and word-of-mouth PR from local massage therapists, chiropractors, counselors, etc. They already have clients who are used to paying for top-notch services rather than just relying on health insurance coverage. My website and Pelvic Guru social media sites also generate organic leads for my practice. Most importantly, my patients are the best marketers. They have provided great feedback to their physicians, other healthcare providers and, friends. This is priceless!

 

Aaron: What do you say to patients when their first question is “Do you take my insurance?”

Tracy: Great question. I have developed a script over time that provides honesty and openness without turning people away immediately. Someone will call and say “I really want to get in to see you as soon as possible”. I say something along the lines of “thank you very much for calling. I look forward to seeing how I can help you. I will be upfront with you and share that I set up a specialized private practice that allows me to spend more time with patients and I’m considered out of network. If you want to use insurance and you have out of network benefits, you may be eligible for some reimbursement”. I also explain to them that sometimes my fees are less expensive if they have to meet high deductibles first.

What’s fascinating to me is that often when I share other places they can go that may take their insurance plans, the patient still requests to come to me for services. They can tell that this experience will be excellent.

I’m always very appreciative that they took time to call and tell them “this is such a great opportunity for you to get care for this condition. Even if I’m not the one to help you ultimately, I’m happy to help you find the right person for you”. And I try to direct them to the best options.

 

Aaron: What was the action you took that made the biggest difference in the success of your cash based practice?

Tracy:

  1. I set up my patient schedule in a way that was manageable for me. It’s not the traditional patient-on-the-hour. I also did not want patients to feel rushed knowing another patient was sitting right outside the door.  I built in time for documentation, payment, scheduling. Once my office manager is up and running fully, I can decrease some of that time and have more efficiency and profitability (even with the extra labor cost).
  2. Also, I have a scheduling system that provides a confirmation at the time of making the appointment and then sends an email reminder 24 hours before their appointment that has a link to the business phone and directions via Google maps. My patients can also schedule online themselves (though may move away from this due to prioritizing issues with a wait list). Patients regularly make a point of saying that they love this scheduling system. I also had only 1 “no-show” all year and all very few cancels less than 24 hours before the appointment. This is a major component of a successful business.
  3. I was responsive and flexible to the feedback from current patients and the needs of the community and physicians. I made changes to forms and reimbursement receipts so that the “system” runs better and is more efficient (and this is still a work in progress)
  4. I analyzed what I do best and verbally shared this; and then showed this loud and clear with actions. You must stand out and show your worth in a cash based practice. Each and every visit counts.
  5. I really try to keep costs low. I am in a great area of town, but was able to find a lease that was within my budget. I buy certain items in bulk at discount. I did not spend money on expensive, fancy PT equipment. I bought necessary items – treatment table, supplies, a cheaper biofeedback unit, etc. I even set up and maintain my own website.
  6. The change I just made that will lead to better success is that I adjusted my prices up to account for the extra time I spend dealing with the business, the communication with physicians and so forth. I actually had two patients tell me something along the lines of, “You aren’t charging enough for the level of service you are providing”

 

Aaron: Is there anything you would have done differently, something that you tried, but that did not work for you?

Tracy: Where do I start? It’s humbling to learn from mistakes, but I value that! I could share many things here, but I’ll just give some highlights.

  1. I started as a sole proprietor just to get things going. I remember a patient telling me a story about how they sued 2 physicians and I immediately went into a panic thinking I don’t have the right business structure or liability coverage. I switched to an LLC and now plan to change my business structure again. Each time you do this, there are fees, changes to bank accounts, changes to leases and business licenses. I’d recommend setting up the business the way you want it from the first day if possible (but, in business, that can still change and evolve).
  2. To keep costs low, I started by using Gmail accounts and my cell phone number. I am now finalizing my new business line, which means sharing a new phone number; and I’m changing my email structure. Again, if you can start out with a phone number and email that is professional right away, that is better than doing it in the middle. It’s more professional and easier, but I did the best I could at the beginning (and am still working on this transition)
  3. I didn’t have an accountant or set up my accounting software until a few months into the business starting. It was quite a daunting task to work on that with an accountant months later. Now that I have my accounting system up, it’s easy to do on a regular basis (and I actually enjoy seeing the cash flow).
  4. I added a fantastic private yoga session option for patients. The issue was that the yoga instructor could only work certain hours and they weren’t always when my patients were available. I also didn’t have time to invest in looking for other yoga instructors and setting up that full line. So, I put it on hold until I finish the full business planning for this upcoming year.
  5. I also co-created a full CEU course, had obligations to teach other courses, and was determined to keep up the Pelvic Guru site (and move forward with projects for the future). This is setting up for great diversification and options for the future, but was likely way too much to do all at one time when starting a brand new business (and raising an adorable 6 year-old).  In an ideal world, don’t have 2 other business projects starting at the same time as your main business.

 

Aaron: What advice do you have for a physical therapist that is thinking about starting cash based practice?

Tracy:

  1. Find a mentor or colleagues who are doing a similar type of business. I thank you, Aaron, for answering some of my questions along the way with regards to HIPAA and other logistics. I should have reached out more, but it’s tough to ask for help. I also found Jarod’s blog and the cash practice LinkedIn group helpful. You’ll also find me reading business books regularly. Join the APTA Private Practice Section. I did not do that initially and lost out on valuable resources that I still have not utilized since joining more recently.
  2. If you charge $80 an hour, you don’t make $80 an hour. So, you will likely need to charge double or triple what you think in order to keep your business numbers in the positive. However, you also have to have prices that are in line with what your patients in that “market” can pay. For example, I charge more because of my specialty than an orthopedic therapist in a rural town, but I would likely lose patients if I charged what they do in NYC.
  3. I highly recommend having at least $10,000-20,000 for start-up costs if you can at a minimum and money for living expenses when the money is slow rolling in at first. This will be very dependent on the type of practice, location, and equipment you plan to purchase. Due to ramp-up time for patients and initial set-up costs (and mistakes made along the way), the first 1-2 years will be lean. It’s tough to make a profit immediately. Plan on that! If you have the ability to start scheduling patients a month or two before you open doors, that’s ideal.
  4. You will work many more hours the first 1-2 years than a regular PT job and you are always “on” because there are so many things to take care of (more than I realized). I just wanted a room with a treatment table, but there’s much more to it.  Make sure your family and friends understand this ahead of time. And don’t try to start a new relationship at the same time (ha).
  5. Make sure you are very confident and comfortable with your clinical skills. I’m very surprised when I see therapists opening up private practices just a year or two out of school. When someone pays cash for services and you are in charge of your own place, you need to be on the top of your game. It’s also great to set up a network of other PTs and healthcare professionals so that you can help each other with tough cases and get cross-referrals.

 

Aaron: Finally, how did you go from being a physical therapy student to a Pelvic Guru? 😉

Tracy: This is a funny question and a play on words. I would prefer to humbly say, I have a passion for Pelvic PT and am vehemently interested in staying on top of the latest research, teaching to students all over world, and promoting the profession. Over the past 14 years, I took numerous courses (sometimes 5-6 a year) on pelvic health issues, attended any conference I could, mentored students, and hired and trained other therapists. My goal has always been to know the most I can about specific pelvic health conditions and then use critical thinking, manual skills and exercise to apply a “whole body” connection to improved health.

Less than two years ago, I started a blog and social media presence known as “Pelvic Guru”. I never intended to call myself a pelvic “guru”. I picked that name in a matter of seconds just for fun. The power of social media!  This started out as an experiment and hobby (doesn’t everyone say that?) to learn more about the social media experience in relation to sharing and promoting healthcare advice. I was asked to speak at APTA’s Combined Sections meeting on social media and I thought this would be a fun way to share statistics (and it was). I had no idea I’d still maintain the Pelvic Guru blog and that there would be thousands of followers and views from 164 countries. It’s now growing into another business due to advertiser and affiliate interest.

 

If you have any questions or thoughts please write them in the comment section below.

Follow Tracy:

@pelvicguru1

Linkedin

The Pelvic Guru Blog  & Facebook page

About The Author

Aaron LeBauer

Aaron LeBauer PT, DPT, LMBT started a 100% cash based physical therapy practice right after graduation. He enjoys sharing his experiences in private practice and helping other therapists find freedom in practice.

Leave A Comment

9 Comments

  • Tracy Sher

    Reply Reply March 2, 2014

    Thanks for your comment, Susan. If you have pearls of wisdom, we’d love to see them! One thing that I have learned along the way is that most small business owners do best when they learn from mistakes and embrace them. Everyone expects us to say that I started out and everything went perfectly; and “it is so great to be my own boss”. The truth is that it can be lonely and scary at times – personally and financially. But, if you push through and are willing to adapt, great things are possible!

  • Stephanie Morgan

    Reply Reply September 6, 2014

    Hi Tracy and Aaron,
    Great interview!! I just found this web site and have been enjoying it and feeling so inspired. Tracy, I noticed you have a CSCS certification. When in your career did you go after this certification and how have you found it to be useful in your passion and career for pelvic health ?

  • Aaron LeBauer

    Reply Reply September 7, 2014

    Stephanie,
    Thanks so much for your comment and compliments!

  • Tracy Sher

    Reply Reply September 8, 2014

    Stephanie,
    Thanks for your interest and question. I actually did my first personal training certification with American Council on Exercise (ACE) while still in PT school. In my first few years as a PT, I taught continuing education courses for ACE. I was also doing personal training as part of my job as a an orthopedic and women’s health PT. During that time period, I pursued my CSCS because of that dual role and desire to apply more exercise science. I wanted more knowledge about program design and NSCA had good resources for this. I read every article on periodization, program variability, resistance/load, progressions, etc. This was an excellent addition to my knowledge base and I still utilize this knowledge (as it has evolved).
    Back to your question- Pelvic health is actually total body health. So, I apply many exercise/load principles on a global level and more specific “pelvic” level (including the pelvic floor). I’m happy to share more details if you have additional questions. Thanks. Tracy

  • Stephanie Morgan

    Reply Reply September 9, 2014

    Thanks, Tracy. I did have a few other questions come to mind…
    You mentioned that you use a scheduling system that sends reminders to patients and a system that allows patients to schedule themselves. I was wondering what those systems were and what you liked/disliked about them? Do you use EMR?
    Thanks,
    Stephanie

  • Tracy Sher

    Reply Reply September 19, 2014

    Hi Stephanie,

    You ask great questions. There are so many variables to consider. I have been playing around with various options for scheduling and EMR and will likely keep evolving. At this time, I made a conscious decision to use a separate, more versatile scheduling system than relying on my EMR. I use schedulicity for ease of use, relatively low cost, and ability to schedule groups/classes. If you are starting out small, you can likely get away with paper or some sort of online document system. I decided to go a more secure route with WebPT, but admittedly, it is likely too much in cost and bells and whistles for what I really need. I can’t customize either. However, the notes look professional and everything is stored securely. I have started some other programs where we will utilize paper charts. It will be interesting to see where this evolves in the next 6 months to a year… Stay tuned! I’m also open to suggestions from others.
    Regards,
    Tracy
    http://www.sherpelvic.com

  • Thanks again Tracy for your insightful answers!

  • Aaron LeBauer

    Reply Reply February 24, 2014

    Susan,
    Thanks for your comment! Yes, even as experienced therapists and business owners we always need to be open to learning something neww and ways to improve our practices. Even a Master should always maintain a Beginner’s mind and be open for anything.

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