I have had a very small private practice for many years and never processed insurance. I have also practiced within larger institutions who did process insurance. Since I have formalized my private practice into a limited liability company, I have waivered back and forth regarding whether I should become a provider and process insurance, or not. I began my full-time practice in 2018, and I still do not process insurance. Despite this, my practice continues to grow.
To Process or Not to Process Insurance
Occasionally, something happens that makes me rethink my stance on processing insurance. Clients might ask about insurance or tell me they’d come more often if I took it. They might tell me they have passed my name on to someone who could use my skills, but they won’t come because I don’t take insurance. It may be because they can’t afford it or merely because they think I should take it because I’m an occupational therapist. I have talked with people who are baffled by this choice, some who are irritated by it, and others who applaud me.
On the topic of not being able to afford “out of pocket” services… I know some think that only the elite can afford to pay out of pocket for the services I offer. I was a little concerned about this, too. However, I have found that it is less about income and more about where people place their value. I don’t use a sliding scale or ask about salary when I intake a new client, but I do ask about the type of work they do to get a feel for how they use their body. Their job may or may not tell me about their financial status. I don’t know about their spouse, if they have one, their savings account, or a health savings account. (I make sure to tell them that if they have a health savings account, they can use it since I am an occupational therapist.)
Healthcare is Changing
With high deductible plans becoming common, more clients expect to pay out of pocket. Most of my clients don’t question this arrangement. It is on my website, and I don’t proceed with my evaluation until it is clear that I don’t process insurance. I don’t want any surprises. I also never pressure clients to return. It is up to them if they find value in my services and want to continue. If they do, they decide when and how often. I also volunteer my services to be sure I am helping people who can use my skills but can’t afford them. Giving back to the community is essential, and I am working with a local non-profit to do this regularly.
I continually reflect on how I want to grow my practice and how I want to shape my life. When you own a business, it becomes your life. I crave a simple life, and processing insurance is NOT simple. There are many rules to follow and tasks to complete that extend far beyond client care. I want as much of my energy, creativity, time, and problem-solving to go into client care as possible.
Comparing Costs
Conversely, I could charge more and make more if I took insurance. In Nebraska, if I accepted Medicare, I could make about 40% more per visit. If I accepted other commercial insurance products, that number would go up. However, with others, it may go down. Some pay based on the service description (CPT codes), and others pay a flat rate, often based on their determination of an average treatment time (usually 30 minutes).
I have also compared my hourly rate to that of other practitioners nationwide who have the specialized skills I use in my practice. Some practitioners charge more than triple what I charge. The practitioners are not just on the coasts where the cost of living is higher — many practice in the Midwest. I recently had a client who found a myofascial release practitioner in Oklahoma for her mother. This practitioner has much less experience and charges double my rate. Ultimately, even though I could make more money, I do not want any insurance company dictating how I interact with my clients, provide therapy, and operate my business.
Recently, I had an experience that made me reflect on my decision not to process insurance. Usually, these experiences push me to reconsider my stance. I have often reopened my provider application to Medicare, but something always stops me. This recent experience made me dig in my heels and affirmed why I don’t. I don’t want to share too many details about the situation, but my client and I had a great discussion about insurance, evaluation, and documentation.
Empowering Myself and My Clients
When it comes down to it, not processing insurance allows me to practice how I want to practice. It allows me to spend 100% of my time with clients, addressing their needs exactly how I think is best (in collaboration with them). The insurance company does not dictate how long each visit lasts and how frequently we meet. It cannot cap how many sessions we can work together. It cannot stop therapy if progress is slow or they deem therapy to be medically unnecessary. Many clients begin with several visits, trail off, and then return intermittently as they need help. Each client’s frequency and duration of visits varies widely. Again, the client decides rather than the insurance company.
Pain Is Difficult to Measure
Insurance companies want objective information. They want proof that a person has pain. They demand objective, reproducible, measurable information to prove a person actually has pain and proof that the therapy being provided is making progress toward an objective, measurable goal. There is not always a clear, measurable deficit that accompanies pain. Most of my clients can do all their daily tasks. They go to work every day and take care of their families. They have a normal range of motion and functional strength. Many have had imaging tests that do not show a problem. …and yet they have pain. Sometimes, the pain is mild and intermittent, and sometimes severe and chronic. But they are still functional. They must be. Life won’t allow less. It is the quality of their experience that brings them to therapy. My therapist friends might ask, “Don’t you use a pain scale?” I used to. It just doesn’t work for many of my clients.
A pain rating is a snapshot in time. Sometimes, a client walks in and tells me they are doing great right now, but they had pain during the weekend when working in their garden or while at work lifting boxes, or it wakes them up at night. The nature of fascial pain is that it does change. It is not always in the same place or the same intensity. It can increase and decrease depending on the overall tension in the body. Tension can change with variations in activities and stress. Both activities and stress change every moment of every day. Pain can get a little better, then worse, then better again. The path to healing is NOT always linear. And some of my clients say they don’t really have pain. They describe it as tension or tightness in their bodies. So, the pain scale doesn’t really work in my practice, and I no longer use it.
New Clients
I complete an evaluation with every new client. I get a full history and evaluate their body alignment in great depth. We discuss their activities, work, and wellness habits. This process helps me determine if there may be a connection between their experience of pain and their life habits. When it comes to them telling me about their pain, where it is, when it hurts, and how bad, I simply believe them. I don’t have to have objective evidence (which often doesn’t exist) to prove they need therapy. If they are spending their own money to get help, I don’t need proof. I don’t waste any time collecting information I don’t need to help them. I spend 100% of my time collecting data that will help me help them.
The information I collect is often subjective and part of the person’s lived experience, not a standardized assessment. Each follow-up session is 100% problem-solving and treatment. There are no repetitive assessments to prove change is happening. I simply ask my clients how they are doing, and we go from there.
I am not trying to state that health insurance for therapy services is not a tremendous benefit. It absolutely is. However, it comes with many requirements that shape both the business and the services offered. It is far better suited for diagnoses that come with measurable effects and result in clear functional deficits. I want to offer something different for my clients who don’t always demonstrate clear, measurable impairments or have functional loss. The common thread in both groups is loss of quality of life. That is very difficult to measure.
Where I See Value
Another aspect that sets my practice apart is how involved my clients are in their own care. You are not simply treated and sent away until next time. Even though I am no longer in academics, I love to teach and am constantly sharing information with my clients. How can we improve your posture? How can we make daily tasks more manageable? What kinds of self-treatment would most benefit your specific pain or lifestyle? At Mayer Fascia Wellness, we are a team. This is a new concept for some clients, but I’ve found that most people are eager to take control of their pain and tension.
Overall, I understand that not processing insurance shortens my reach a bit. Over the years, I’ve developed a few ways to combat this and make my fascia-informed™ approach more accessible for everyone. You can join us for a workshop in Omaha, NE. Check out my on-demand courses, where you can go at your own pace and access the information again and again. I also have numerous free resources on my website and YouTube channel.
Updated June 18th, 2024
