How to Provide Cash-Based Telehealth

Adding new cash-pay services to your clinic’s repertoire can be a challenge. Not only do you have to ensure that you have the legal freedom to provide cash-based services (because you might not), but you also have to price and market them in a way that ensures patients will not only pay for those services out of pocket, but also receive value commensurate to the cost.

Whether you’re exploring ways to keep your patients safe amid the current pandemic—or you’re simply looking to add a new revenue source—this might be the ideal time to hunker down and decide whether introducing self-pay services (in this case, telehealth) is the right move for your clinic. Here’s how: 

1. Understand the benefits of cash-pay. 

It’s important to recognize that adding cash-pay services might not be the right move for every clinic. If you work with a low-income population, for instance, then offering pricey cash-based services won’t be the smartest move. But, cash-pay does come with some universal benefits—and there are three you should consider when weighing whether or not to implement this revenue stream in your clinic: 

• You’re not beholden to low payer rates—which could allow you to relax staff productivity requirements. 
• You can provide—and receive payment for—treatments that payers don’t cover.
• You can diversify your clinic’s income sources (which could help you recover from—or reduce the future impact of—economic hardship).

2. Consult your state practice act and professional liability insurance (PLI) policy. 

Because of COVID-19, several states have loosened telehealth restrictions, allowing many PTs, OTs, and SLPs to provide telehealth for the first time. But, not all states have jumped on the telehealth bandwagon (I’m looking at you, Alabama), and even those that have aren’t necessarily planning to stay on the bandwagon. Many states have stipulated that these regulatory relaxations are temporary—and that rehab therapists will only be allowed to provide telehealth for the duration of the COVID-19 health crisis. Some telehealth privileges may even be revoked before the pandemic is officially over.

It’s critical that you consult your state practice act and any applicable new legislation to figure out exactly which telehealth services you can legally provide your patients. Or, you can reach out to your state’s therapy licensing board to ask about your options. 

Additionally, you must ensure that your PLI policy covers telehealth—because it may not. If it doesn’t, then ask if you can add a runner to your policy so you can safely treat your patients. 

3. Check in with payers. 

At the end of the day, the biggest difference between providing cash-pay telehealth services and covered telehealth services (beyond how you get paid) lies in the breadth of remote services you can offer. Even when you’re circumventing payers, you can’t provide any ol’ cash-pay service to any ol’ patient—you must adhere to specific rules, guidelines, and statutes that may prohibit you from collecting out-of-pocket payment from insured patients. 

Commercial Payers

If your practice doesn’t contract with any local or national commercial payers, then providing cash-pay services is a cinch. You don’t have to answer to any carrier contracts or guidelines—you just have to create a fee schedule. Easy as pie!

But if you, like the majority of rehab therapy providers, contract with one or more commercial payers, then you have to do some homework before you start providing cash-pay services. Some payers restrict the out-of-pocket amount contracted providers can charge patients. Others outright forbid providers from offering cash-pay services to covered patients—though some payers hide these restrictions inside individual contracts. So, read your contract carefully, and give your payer (or maybe even a legal expert) a ring to ensure you don’t accidentally cross any boundaries.  

Medicare

As of April 30, 2020, the Centers for Medicare and Medicaid Services (CMS) announced that it will cover telehealth services provided by a PT, OT, or SLP for the duration of the COVID-19 public health emergency, retroactive to March 1, 2020. Essentially, what that means for your cash-pay model is that you can no longer provide cash-based telehealth services to Medicare beneficiaries, because Medicare now covers those services. (For a list of telehealth-eligible rehab therapy CPT codes, check out this article.)  

However, you can still follow normal Medicare cash-pay guidelines when providing any services, in-person or via telehealth, that “are ‘not covered’ by Medicare—either due to statutory exclusion (think wellness and fitness services) or lack of medical necessity.”

4. Decide which remote telehealth services you’re going to provide. 

When picking the telehealth services you’d like to offer in your clinic, keep your patient population in mind, and try to incorporate services that will genuinely help them. If you mostly serve Medicare patients, for example, then you’ll have to stick to a menu of telehealth wellness services (e.g., a posture clinic, a guided stretching class, or a gentle yoga regimen). On the other hand, if the majority of your patients are covered by commercial carriers, then you may be able to provide more traditional treatments through telehealth, like initial evaluations, gait training, neuromuscular re-education, or prosthetic training. You’re only limited by your ingenuity—and distance! (You can’t exactly provide manual therapy over Zoom, after all.)

5. Create a fee schedule. 

After you’ve pinpointed the telehealth services you’re going to offer, you must set your fee schedule. As long as you’re not restricted by any of your payer contracts, you can technically set any price that the market will support (i.e., if your patients will pay for a $200 service, then have at it!). Realistically, though, you’ll want to keep your prices reasonable. Just be sure to account for all of your expenses to ensure you’re getting paid fairly for your work. Consider the cost of everything that goes into a telehealth appointment, including: 

• therapist labor; 
• the telehealth platform; 
• Internet and electricity; 
• rent, mortgage, and other location costs;  
• your EMR and other software; and
• equipment.

For more advice on establishing a rate schedule for your services, check out this blog post. 

6. Launch telehealth in your organization.  

Once you have all your cash-pay ducks in a row, you can launch your telehealth program the same way an in-network provider would. Start by selecting a telehealth platform, making any necessary physical adjustments to your office (i.e., setting up a designated telehealth appointment area), and creating your telehealth processes (e.g., protocols for collecting payment, ensuring safety, and fostering a high-quality patient experience). Then, practice, practice, practice! Telehealth is new for rehab therapists, so you’ll likely need to iron out some kinks. Try running test appointments with other therapists—or even family members. 

Finally, it’s time to market these services directly to your patients. This could be a whole post in and of itself (and in fact, we already wrote one!), but from a process perspective, marketing cash-based telehealth isn’t all that different from marketing your other services. Educate current and prospective patients about the benefits of telehealth—specifically, the benefits of working outside of insurance constraints—and really make an effort to get the word out to:

• your patients (through email, phone calls, and your front office),
• your referral sources (through email, phone calls, or mailers), and
• the general public (through social media, your website, and your Google My Business listing). 

Providing new services can be intimidating—especially if you’re unfamiliar with the world of cash-based care. But with a little bit of legwork, you can create a telehealth program that works for your patients as well as your clinic—and helps everyone stay a little bit safer.