How to Start a Cash-Based Practice

For many clinicians, the decision to start a cash-based practice or convert their existing payment model feels overwhelming. To glean insight from their personal experiences with the transition, we caught up with Counterstrainers Kyle Kusunose, founder of Counterstrain San Diego, and Holly Christy, founder and medical director of Element 7 Wellness.

Tell us a little about yourself and your practice. 

KK: My name is Kyle Kusunose. I am a physical therapist and have been Counterstraining for seven years. I started my first cash-based practice in Boulder, CO, part time and moved to San Diego, CA, in 2018 where I started my now full time cash-based practice. 

HC: My name is Holly Christy and I have been in practice for 20 years serving Kitsap County and surrounding areas. I am a naturopathic physician, acupuncturist, and Counterstrain practitioner. I’m also clinical adjunct faculty for Bastyr University, as well as a certified instructor for The Jones Institute and Counterstrain Academy. I have a very busy cash-based practice and just hired a resident physician who has the same credentials as I do.

How long have you been cash based? 

KK: Five years in total. Two years part-time and three years full-time.

HC: Two years. Before that, I was credentialed with all major insurance carriers except Kaiser (previously known as Group Health).

What inspired you to switch to a cash-based model? 

KK: My patients! In fact, my first experience happened when a prospective patient requested to not use their insurance. They felt it would be more beneficial and cost effective for them and it was.

HC: After many years of battling getting paid, we finally decided to move to the cash practice model. Over the years, I noticed that insurance companies kept finding reasons not to pay for their members’ care. They shoveled more and more of the responsibility onto the patients while simultaneously raising deductibles and lowering coverage.

Were there any specific resources that helped you prepare? 

KK: The Counterstrain community has been a great resource for better business practices and strategies for opening a clinic. 

LegalZoom was great and easy enough for incorporation and DBAs. A simple EMR, scheduling software, and billing service will save you time with each patient which adds up as you get busier and busier.

What challenges have you faced—expected or unexpected? 

KK: When I first moved back to San Diego, I started my practice in a city where I had zero word of mouth referrals. It took some time to build up a patient population. Sometimes I would have a busy week, sometimes a slow week. Things were variable in the beginning, but I expected it. At first I felt a little guilty when I had a slower week. But I stayed active, socialized, and did things around town. I learned you won’t get any new patients staying at home!

If I could start all over again, I would have utilized an EMR earlier on. Not necessarily for documentation or scheduling, but as a means of communication to continue to educate current and former patients. After D/Cing a patient you are out of sight, out of mind. But if they get a quarterly email from you then you can keep your word of mouth network large and engaged. That was an unexpected challenge that an EMR with client accounts solved.

HC: Fortunately, I haven’t faced many challenges. It has been an easy transition. We lost some patients, but were very busy again quickly.

What has been the biggest benefit of being cash-based for you?

KK: Efficiency, joy, job satisfaction, passion, diversification. Professionally, having a cash-based practice allows me to prioritize the patient. I can treat and schedule the patient in a manner that I think will most benefit them without any restrictions. My documentation time was greatly reduced as I went from seeing 14-16 patients a day to seeing 5-8. This allows me to give each patient my everything. Instead of being restricted to 30 minute visits, I now get to spend a full hour with each patient which allows me to be incredibly productive. My overhead remains low with no billing expenses.

Personally, my quality of life has improved. I am not spending time on insurance verification, billing, and countless hours of documentation. My work days in the clinic are less of a grind and much more enjoyable. My patients are invested in their health and healing which makes them a joy to work with. Most of all they get better! I work fewer hours per week which allows me to also incorporate other ventures into my personal and professional life!

HC: The biggest benefit is knowing how much cash flow is coming in since patients pay at the time of service. With insurance, we’d sometimes wait for several months before getting paid.

What has been the biggest benefit of being cash-based for your patients?

KK: Not only do patients get better faster with this model, I truly believe that with Counterstrain specifically, an out of pocket option is more cost effective to the patient as well. Instead of scheduling patients for 30 minutes twice a week for six weeks or more, I give them a full hour each week for 4-6 weeks. Depending on their co-pay, this model can save them significant time and money! I’ve always felt that I do triple the amount of work in a one hour visit than I do in a 30 minute visit. I typically schedule a patient once then give them a week to heal, progress, and find homeostasis before intervening again.

HC: My patients know what to expect. There are no surprise bills from us months after a visit because their insurance finally decided to deny.

How do you market your practice?

KK: From the moment I decided to start a cash-based practice in San Diego, I’ve operated entirely on word of mouth. To grow through referrals I place a huge emphasis on patient education which leads to patient “buy-in.” This helps you get better results with the patient and open up a plethora of opportunities for them to ask questions like: “Do you work on people with…?” or “Does this technique work on …?” Usually my answer is yes! People who experience pain relief, health, and wellness want their loved ones, friends, neighbors, colleagues, and even strangers to experience it too. My former and current patients are the most important people to me in regards to growing my patient base. 

HC: I also don’t do any marketing. We’re 100% word of mouth!

What advice would you give new clinicians who want to start a cash-based practice? 

HC: Do it! If you’re busy now, you will continue to be once you’re cash based as your patients know you are delivering a service that few others can deliver.

KK: I was going to say wait until you’re ready, but I agree with Holly too! It depends on where you’re at as a practitioner. Skill development in Counterstrain requires hours and hours of practice with patients. If you’re working at a practice that allows for that then stay put while you’re learning. You’ll experience a few major jumps in skill development which occur over a multi-year period. When you look back and assess your progress you’ll see how far you’ve come and how much more effective you are. 

You’ll know when you’re ready to start a cash-based practice. At that point, if you build it, they will come. Find a space, accept credit cards, offer superbills so patients can seek reimbursement, make business cards and a brochure that speaks to prospective patients, and educate your current patients. Lastly, ask for word of mouth referrals! Don’t be shy. Ask within the first 2-3 visits of that patient’s plan of care. This is often when they are most excited about the technique and are telling everyone about it already anyway. 

Say, “Hey if you like what I’m doing with you, please spread the word! I’m taking on new patients right now so if you can think of anyone who would benefit from Counterstrain, please tell them about me and your experience working with me so far.”

The best way to start a cash-based practice is to first improve your skills in the clinic. To begin your Counterstrain journey, check out our free webinar on improving OMT effectiveness.