Private practice owners need to make quick decisions in order to mitigate the negative effects of the COVID-19 pandemic. There isn’t a how-to on this disruption other than to take some logical and quick steps. In this episode, financial planner Eric Miller of Econologics (Private Practice Millionaire) talks about those steps that we need to take now and how to strategically ramp up in the future. Obviously, as the owner, your sole purpose is to keep the business going, so now is the time to take action in order to stay afloat until things turn around, no matter the time frame.
I'm bringing back Eric Miller because we are all worried about money in the middle of the COVID-19 pandemic. I don't know a single owner that hasn't significantly slowed down or shut their doors altogether. The concern immediately goes to not only your employees but also your money and your financials and if you're going to be able to stay afloat when this thing does get back around. Eric, you've been a multiple-time guest. Thanks for joining me again. I appreciate it.
It’s my pleasure.
I've enjoyed the information that you've put out through Econologics, your webinars, the downloads and all that stuff. I figured it'd be great to have a talk with you on the show so we can work this thing out and share some valuable information with the owners.
I know a lot of practice owners have a lot of uncertainties happening. Anything we can do to make them feel a bit more stable in these unstable times.
A lot of times, some guys are more prepared than others financially for an expense like this. It's coming as a shock to all of us. What are some of the first things we need to do right off the bat as we're addressing this as owners?
The first thing you have to do is you have to look at what the condition is that your businesses and your finances are in. The best word is confusion and uncertainty. That is the condition. The way that you handle a confusion is that you have to get rid of all the uncertainties that you have. What I hear most when I'm talking with practice owners is that, “I don't know what I'm going to open. I don't know how I'm going to pay my bills. I don't know how this is going to affect the longevity of my practice.” There are many of those. That's what causes the fear and the anxiety and all the things that you don't want.
One thing I do know about the condition of confusion is that it breeds bad decision making and we don't want that. My advice is let's clear up some of the uncertainties. Get everything out of your head, get it on a piece of paper and try to figure out like, "I need one piece of certainty that I can establish. I know how much I have in my bank accounts. I know how much accounts receivable I have coming. These are my open credit lines." You're trying to get some stability that you can navigate without making bad or rash decisions in this timeframe.
If it's not uncertainty, it's fear, which also can lead to bad decision making. Once you can get your hands on some real data and information that is true, that helps you then make the decision and you've got to start making decisions. You can't wait for the next update. You can't wait for the press briefing. You’ve got to start making some of these sure financial decisions based on the true data that you have to start overcoming the uncertainty and fear and start developing a plan not only for the now but for the future as well.The way that you handle a confusion is by getting rid of all the uncertainties that you have. Click To Tweet
Another point to that too, because there's information coming out fast, it's a mistake to start trying to look 4 or 6 months in the future. That's going to mess with your head when you do that. You have to say, "What do I have in front of me this week?" and plan out that way. Another week comes, "Here's my battle plan for this week." Because there's always going to be new information that's coming, it would be better to navigate that way. Otherwise, your attitude and your emotional tone level is the key. If you're an action and if you're like, "We're going to do this," you'll be imaginative that you can be creative. If you're in fear, anxiety and all those negative things that creep up, that doesn't spark creativity. Now more than ever, you need to be creative.
Keep your horizon to 1 to 3 weeks ahead of you and deal with it when you get there. I don't want to get too off-topic because I want to talk immediately about what things people need to do. After you've handled some of those things, think about maybe how this company to look in the future. If there are some things I want to change, do you allow time for that?
You're doing both. You study history, no great movement or organization ever made strides when everything was hunky-dory and rich and prosperous. You can make some big strides as an organization when times are in distress like this. What you would need to do would be the exact opposite of what everybody is telling you to do, which is a contract, close down, don't see anybody and don't promote. Those are the things that if you can do the exact opposite of that in some form, then you can become a beacon to your community and your patients and be like, "These guys were willing to provide good data and information and provide a safe place we can still get help." Make no mistake, the help that you provide is much needed in terms of what physical therapy can do for the human body.
It's interesting as people were considering shutting down. The information that I provide to my clients was don't stop promoting. Your message might change and probably should, but don't make your promotion and marketing budget one of the things that you cut. You still want to get the message out. You still want to keep in touch with your patients and your physicians and all your marketing vendors. Change the message if you need to. If you have some extra time, take an opportunity to redesign and rebrand a little bit or something like that but don't stop promoting and marketing. Find another way to do it.
You want to make sure that you're over-communicating not under-communicating. I'm having all my advisers, myself, I'm calling everybody, every client that I have because I want to make sure how they're doing and that they know that we're trying to figure out ways that they can navigate this situation. It's not easy for anybody. You can establish a lot of goodwill with your people and enhance that by doing that.
Another thing that came up in a mastermind group we've taken from physicians, we get referrals much from physicians. How many physicians are getting calls of, "What do you guys need? What can we do for you? Can we come over?" If you have a massage therapist on board or can hire a massage therapist to go over and one-on-one, not in a group, but provide massages to an overworked staff or something like that. What can you do for those physician groups who are having to stop all elective surgeries altogether? What are they doing and how can you help in that situation?
I'm seeing a lot of people that are giving stuff away. You have to do that at this time. We look at profits and revenue. That's important but at this point, you’ve got to be a beacon of help. That means that maybe I'm given a course away or I'm giving something away, a month off, whatever it would be. We want to help you. You have to do that.
When someone comes to you and as you're doing these interviews on shows, what's the first step now to handle things financially?
From a business point of view, the number one responsibility of the owner is to make sure that the organization can stay there. It means that financially speaking, you have to make probably some of the toughest decisions you've ever made in your life. Likely, a lot of practice owners have never been in a situation where you had to furlough and lay off 50%, 60%, 80% of your staff. Unless you have few months of business reserves, there's no way you can carry that payroll when no patient visits are coming in. You have to act fast on that one though. You can't wait because patient visits are dropping percentage-wise, 70%, 60%. They're dropping fast because people are scared. You can't carry that payroll if you don't have the patients coming in. You have to act fast on doing that. It's a tough thing to do, but you’ve got to make sure that you preserve the organization. Work on a skeleton crew. Keep your key people, keep your producers and the people that are going to help you fight your way out of this one.
Keep your billing people because that's your money lines right there. You need to keep those. Keep some good executives and some key producers that you need. Go down to a skeleton crew and try to produce the basics of what you need that you can keep the organization there. I don't know how many patients visit that is. Each practice would be different, what is the minimal amount of patients that we have to have come in here so that we can keep the organization flowing at least in that respect?
Have you recommended the owners get in touch with their CPAs and rework their break-even number? “What are my bare minimum expenses?” It's probably a good exercise for owners who don't have a lot of accounting knowledge and aren't good with QuickBooks and whatnot, but sit down with the CPA and say, "Walk me through it. What are my bare minimum expenses? What is my salary need to be? If I'm open, how many visits do I need to squeak out to break even and stay afloat?"
That's part of the getting rid of the confusion because you would need to do something like that. That is one of the smartest things you can do, it's going to put your attention on your money. In this time, you need to stay connected as far as who you have on your Rolodex, who I'm talking to you. You're talking to colleagues a lot and your associations. Like the show that you're doing, there is good data is coming out this. People in the news media, you go anywhere else I'm not certain that's necessarily good data, but the associations and your other colleagues, good data is coming from there. Your bookkeeper and your accountant because they're going to know your income and your expenses and they'll help you rework that make-break number. You want to get in touch with your banker because you may need to look at credit lines, see what you have available, see if there are different ways that you can access credit that maybe you didn't know about that you could.
Your financial advisors, if you have types of investments that you may not even realize have some liquidity features to them that you can access. They've made some changes with the Stimulus Bill that you can access qualified plans for some time if you need it. It's time to stay in communication with your financial team and your billing department. What do you have coming in? Whatever is in your business checking account, you have whatever accounts receivable that you're going to have coming in. You should know that and whenever your business credit lines would be. Let's get some certainty on what that is. I know what I'm going to have to do because your reserves and your credit lines are gold.
For me, as you're talking through that, I can see that if I knew I have this much cash available to me, even if it's in a line of credit and my accounts receivable and my checking account and then I know what my bare minimum expense level is, I know how many weeks or months I can ride this out. That's where I get some certainty and that's where I start getting more confident and less fearful because people might have more than what they think they have. They might be looking at their bank account and thinking, "This is only going to get me through two weeks." Whereas if they've done some proper planning and gotten a lot of credit ahead of time, they have access to that. Could people tap into IRAs possibly?
The Stimulus Bill came out and there were some provisions in there that if you were affected by the Coronavirus negatively in some way, shape or form, that you can get access to $100,000 of your qualified plans. Everyone's accounts got hit 40% and you're taking money out.
You don't want to sell low.
I'm not sure that's a smart thing to do. They have all the relief loans and grants that are coming out. I'm going to touch on that because my advice is that the devils are in the details on that. Be careful before you sign your name to something because when credit and free money is made accessible, it usually has titanium strings that are attached to it. I don't want people to start getting loans and grants and money and keep people because you think that you're going to get this money or you may be able to hit the stipulations that they're going to have of requirements before they forgive it. I would caution people to not do that. Get your mini make-break done. Know what your expenses are. Try to see enough patients ride this wave through so that way you don't come out the other end with $100,000, $200,000 of what you already have in debt. That's the problem that we're trying to solve. I don't want that for people.The condition of confusion breeds bad decision-making. Click To Tweet
What have you heard about people putting in claims with their general business liability, insurance policies or anything like that? Have you heard anything on that end? Whether that it's going to work out for people's favor?
Unfortunately, I have and insurance companies aren't dumb. If you remember the SARS virus that hit, insurance companies went back and rework that business interruption policy that this thing wouldn't necessarily qualify for business interruption insurance. That doesn't mean that if you did have it, you shouldn't take it to file a claim. You should do that anyway because who knows. From what I'm hearing, most people that have that type of insurance, this necessarily wouldn't qualify because they're saying that there has to be actual property damage for something like that to occur. That's hard to quantify. I wish there was better news on that, but I don't think there is.
I like your advice though about being wary of the SBA loans and grants that are out there because you can imagine. You're working with the government and the time and effort that it's going to take for this to happen and to get those funds, I can't believe that it's going to be quick and in a timely manner.
You don't have time to wait. You have to act fast. The speed in which you make decisions and doing it with good data, which is why you want to get out of this uncertainty is paramount. Trying to carry all this expense on your back, it's going to force you to potentially have to dip into your personal reserves. A lot of people don't even have that. It's something I would be much wary against doing something like that.
Number one, get some true data. Put some money together or figure out where you're standing financially and what you have access to financially. Stay in communication with all the important people. That includes fellow professionals and peers. I don't know if you can trust Facebook groups because you could get a lot of fear out of those. You pick and choose the right one. Stay in close touch with your vendors. Don't give up the promotions and make fast decisions.
There was one more point I was going to make. A lot of people have loans and leases and such. Get in communication with them. I'm sure you can get some relief, deferral payments or something like that. Don't be afraid to call them up. Everyone's going through the same thing. Most of them are going to be open to it and say, "I may need 2 or 3 months deferral and let's work together on this." If you don't call them, then that's where you're going to get in trouble.
Look at any of your expenses and feel free to call them. I say this because I know that they're forgiving some of the student loan payments at this time and deferring interest and whatnot. As a landlord, my mindset and the other landlords I'm talking to is I'm still going to send out the invoice until you call me. If they do call me, I don't want to lose your business. I don't want you to go under. There are a couple of things I'm willing to do. If you want to decrease your rent payment and then spread that out over the next twelve months, that's fine. If you want to take this month's rent payment and add it to the end of the lease agreement, that's fine. If you want to draw down from your security deposit that you're already put in and pay that back over time. I'm open to all of those things. If you're coming up on a renegotiation of a lease, now is the time to do that renegotiation and see if you can get some of those free months. If your lease is coming due here, it's the time to call your landlord and say, "Here's my situation. I need some help. I need some relief. Let's start negotiating so I can get some immediate relief and I will pay you back if you help me through this."
It's amazing what will happen if you get in communication because nobody wants to lose tenants. As a landlord, especially if you have businesses in your building, you care what happens to them. That's your lifeblood too as a landlord. You're going to be open to any creative methods, but to your point, if no one calls you, you're like, "Rent is due. I need it." That's a good point.
Outside of salary and payroll, some of your bigger expenses are going to be exactly that. It's going to be rent. It's going to be insurance payments, debt payments that stuff. Some of those can be relieved and taken off your plate.
We talked a little bit about this as far as when this thing recovers, how do you handle that point as well?
What would you recommend owners do as they're looking to the future? We've got some of this. I've got a financial plan in place. My idea to throw it in there is that, maybe start reading some books that you hadn't read before about business organization. Getting your mindset right. I'm a big proponent of Think and Grow Rich. Those first four chapters of getting your mind straight and getting an ideal scene in mind. If you've been working in a situation that you haven't truly enjoyed, start creating maybe an ideal scene of, what is this going to look like when I do revamp and how can I make it look the way I want to look in a situation I want to see?
You're getting an opportunity to reset this whole thing.
Take advantage of this pause button.
Right now, it should be, “If I had to do this all over again, what would I do differently?” You're going to have that opportunity, especially if you've had to let people go. You're going to have this opportunity to do good money management if you didn't do that. Now, you see the necessity of having organizational reserves and profits and putting that in as an actual expense. Maybe not having the percentages be out of whack where 80% of all your revenue is going toward staff and benefits. You have an opportunity right here to play the reset button on there. Put in some good business systems that maybe weren't there so that you can grow your organization and expand even more than what it was. Pay attention to that. Wear your owner and executive hat more than being a practitioner.
Our previous interview talked about how you handle things financially as a PT owner. You're talking to the points that we made in the previous show, is making your 10% profit margin and expense line and coming off of the top. Also, make sure that you're getting a decent profit. Some of these guys are working on 8% to 10% profit margins and I'm like, "You can do so much better." Now, is the time. As you started getting into this saying, "How are we going to ramp up and be more productive, profitable and financially sustainable?"
You have to do it on a gradient. You have to make sure that as you're bringing people back slowly that you're not overwhelming the organization with expenses again because that's what got you into trouble in the first place.
You don't open the doors and invite all the employees back in?They can try to bankrupt you or make your business non-existent, but they can't take away the ability for you to create it again. Click To Tweet
I'm sorry, this is going to be wildly unpopular. I know that and I'll probably get beat up from some people, but you can't do that because, in the reimbursement game, the lag on income is 1 or 2 months. You have to make sure that as you bring people on, you work on a skeleton crew even if they're working double-time seeing patients.
Pay them overtime if you have to.
Don't bring on all the staff too quickly. That way, as your patient load increases, because it's not going to go from, you're doing 500 patients a week and then it goes down to 50. It's not going to go right back up the 500 in a matter of months. It's going to take a little bit of time. You’ve got to make sure you can navigate that. Now is a good time to hit that reset button and say, "We're going to put in 10% for reserves, 5% for a tax fund, another 5% for a business reserve account. I'm going to put these things in right now." That way as I bring people on and I'm going to stick to those percentages and I'm not going to deviate from them because I understand how important my profit is. That's going to do a couple of things. Number one, it's going to put good control of money back in. It's going to allow you to expand the organization and it's going to make the business more valuable down the line because you'll have a profit margin, which as you know when you sell your business, that's largely what it's based upon.
That's the value of your company.
You have an opportunity right here to do that. If you overwhelm the organization with expenses again and bring all your stuff back right away, then you're going to be right back in the same boat that you were.
If any owners are reading out there, if there are people that you didn't like or didn't produce in your company beforehand, take advantage of it and bring back the people that you're excited to see. Not the ones that you're like, "We’ve got to bring so-and-so back because we need to fill that hole." No. There are going to be plenty of people out there looking for work. Find the good ones. If you have an amazing employee, one of the skeleton crew that is live and die with you, ask them about their friends and their network and how you can find more and more A-players because they're going to be there. Find your A-players, let go of the ones that you weren't excited to bring back, to begin with, and you're having issues with. Take advantage of this time. It's a time to not only strategize financially, but it's also a time to strategize with your human resources as well.
This became an employer economy. It was an employee economy because everyone was demanding higher pay, time off, benefits and all of that and it flipped like that. The business owners are back in control here a little bit where they can be. This is not a competition. It's not me against them. It's finding out who is part of your team, who wants to be there and who's there to get a paycheck. To your point, that's key to do that.
This is an opportunity. There are opportunities that abound. Financially, restructuring and reorganizing your financials, but looking at the structure of your company and the people that are in it, your team members and create your dream team. It's time to create a dream team. If you're sitting on your butt and waiting this out, then you're going to be behind the curve. You need to start reaching out to people who you might've wanted to reach out to in the past that weren't available, more than likely they might've been let go at. It's time to start making those connections again. Even if they might be committed to going back to the place they were before, it is not a bad time to reach out.
You can get rid of the negative people without having to get in there and fire them.
All the stuff that you've talked about, you shared a lot of this on webinars. You have those things on YouTube. You've got a PDF download for people to manage this. I hope they take advantage of the information that you're sharing because it's hugely valuable.
We're trying to put good financial data out there and if I can talk a little bit about the financial plan aspect of this thing going forward. What you're going to do going forward from this because you do have an opportunity to do something different. When there's a crisis, when there's blood in the water, there is an opportunity there for you to take advantage of. When you look at the several years, you look at the things that people have done with their money and what's happened, interest rates and checking and money market accounts have been 0% to 1%. Nobody saved any money because there was no purpose to save money. They made debt accessible and easy to get, "Buy this big house. Buy this car. You can afford the payment. That's all you need." They made the Tax Code confusing, ambiguous for practice owners because it's four million words. How can you confront that? Your accountants don't help you as well.
They made it seem like the stock market was the only place that you could put your money to earn any return against the inflation rate. We call that the default plan. If you didn't have your financial plan, that was your default plan right there. It worked well because if you look at the situation for most business owners, they don't have much liquidity. They have loads of debt. They overpay in their taxes and likely all their 401(k)s and IRAs were in the stock market where they took a 30%, 40% hit. Not only did your business value evaporate overnight, but all of your personal reserves at the same time went down 30% to 40% in value. There has got to be a better way to handle your finances than that. That's why I'm like, "Get a plan that does the exact opposite of that." It's fine having $100,000 sitting in a checking account, earning zero, as long as you have some liquidity there. It's fine to have some money in protected assets that may not make huge returns, but at least you know it is going to be there at some point. It's fine to take advantage of the Tax Code and save yourself $20,000 to $40,000 in taxes a year by being proactive and looking at it. It's time to get a plan that does that.
You're the man that can help us. If people want to get in touch with you, where do they go?
They can go to EconologicsFinancialAdvisors.com. They can hook me up on LinkedIn at Eric Miller and Facebook. They can go to our page. We do have that Financial Disaster Guide. For your readers too, if they want 15 to 30 minutes appointment or consultation, then I'll certainly extend that offer. Please take advantage of it, in any way we can help even if it's helping you navigate through this time. We'll be willing to do that to talk with you for 15 to 30 minutes with no strings attached.
It would help people for sure. Give them some certainty at least. I'm sure you'll give them a battle plan that they can go off and start working it so they can go from a place of surety and a little bit of faith.
Thanks for your time as always. It's awesome to have your information, your knowledge and wisdom. I appreciate it.
I'm glad to help. For those owners again that are having the feeling like their businesses because some of your guys are shut down completely. I've been telling a lot of people this is that they can try to shut you down. They can try to bankrupt you, they can try to make it that your business is non-existent there, but they can't take away the ability for you to create it again. That's a key point for those guys that are shut down. They only lose something if you don't think that you can create it again.
It's going to take some work, but you know how to do it. You've done it before. If you're an entrepreneur, you've been through crises. This isn't the first time. Thanks.
Eric Miller has been in the financial planning industry for over 20 years. He’s a co-owner of Econologics Financial Advisors – awarded an Inc. 5000 honoree for 2019. As the Chief Financial Advisor for the firm, Eric has had the good fortune to have over 10,000 financial conversations with private practice owners in various healthcare industry and helped guide them into a more optimum financial condition using a proven system.
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The Coronavirus pandemic has become a great test for the healthcare systems we have in place. Facing it head on, the time is here for Telehealth in Physical Therapy. In this episode, Nathan Shields speaks with Daniel Seidler, PT of TelePT Solutions about the benefits of the remote provision of healthcare through technology, especially in this time of the outbreak. A relative expert when it comes to providing TelePT services, Daniel has the answers about what you can do to adapt your PT services online. This is a great episode worth listening for any PT owner, to take advantage of the services you can provide, helping those in need in this most pressing time.
This interview is scheduled with Daniel Seidler of TelePT Solutions to talk about Telehealth PT services and how we can use it during this Coronavirus outbreak. There's plenty of information to help you get started at least in providing telehealth PT services. Daniel provides those services through his company, TelePT Solutions. I wanted to rush this episode out considering the current nature of what we're dealing with on this outbreak. Let's get to the interview.
I have Daniel Seidler, Founder, and Owner of TelePT Solutions, a consulting firm to provide telehealth services for physical therapists. He also is a telehealth Physical Therapist himself. He's got a great story that I want to share with everybody. The topic that we're going to cover is rather timely. First off, Daniel, thanks for coming on. I appreciate it.
Thank you, Nathan. I appreciate you having me. We talked and realized that we should record this podcast as soon as possible. You made it happen, so thanks for that.
Thanks for coming on. We want to talk about telehealth services in regards to PT, especially as it's going to affect our services here by the Coronavirus and what's happening. It’s considered a pandemic. Before we get into that a little bit for the benefit of the readers, if you can share a little bit of your professional story and what got you to where you're at this point.
I've been a PT since 1996. I owned a practice in the Bronx in New York for fifteen years. We were acquired by a larger group and I worked for them for three years, MOTION Physical Therapy and helped develop their telehealth practice, the division of telehealth at MOTION. I decided to go out and start my telehealth practice and help other groups to get telehealth off the ground. I never imagined this scenario would arise but either way, the time is here for telehealth for medicine and physical therapy.
I'm sure you couldn't have predicted that a flu pandemic like this would break out and soon after, the need for your services would be almost immediate. It was great to hear that you've gotten established quickly for people who want to get to your website ASAP. What is the website and how can they get in contact with you?
It's TelePTSolutions.com. That's the best way to reach us. All the other information is on there.
Thanks for sharing your story. Tell us a little bit about Telehealth PT services. Let's start answering some of the general questions that you get from PT owners and providers on a regular basis.
The first question I usually get is, “Can I do this on my phone? Can I FaceTime or Skype?” The answer to that is no, you need a secure platform. There are plenty of platforms out there that look a lot like Zoom or FaceTime but they secure the communication on both ends to and from the practitioner and the patient. The audio and video can't be stolen and intercepted. It's secure in both directions.
Do providers need to find something that's going to be shown to be HIPAA-compliant?
HIPAA-compliant and the platform will require a BAA, which is a Business Associate Agreement.
Between the PT company and the software provider as well, that's pretty easy to get that at Zoom?
There are a bunch of software programs. The ones that are most adapted to PT are Doxy.me, BlueJay and Physitrack, and some of them have exercises built-in. A couple of them were built as home exercise programs. Some of the home exercise programs are adding telehealth to their platforms as well making it easy for PTs to do telehealth.
Do you have to have the patient sign anything different or can you use your typical intake paperwork for this?
It’s very similar. You would have them do your typical intake. Any information that you can get in advance is easiest. The answer to a lot of questions about telehealth is different from every state. Different states have different rules about consent. Consent can be verbal, digital or on a sign on paper, and every state is a little bit different. New York State requires only verbal consent. I'm not sure about Alaska and other States but that information is out there.
Do you get patient consent to do telehealth services?
If people wanted to find out those regulations as it pertains to their state, is there a website that has accumulated that information into one website or do you simply have to go through your own state by-laws.
That's always the best idea to go to your State Practice Act and most States at this point have some verbiage about telehealth. One central resource is CCHPCA, which is the Center for Connected Health Policy. They're based in California. They've done the research and plenty of documentation about the changing telehealth laws and they keep it up-to-date.Telehealth is an opportunity to spread practitioners’ geographic reach so they can treat patients in other counties and states. Click To Tweet
Are there some states that simply don't allow telehealth services?
In some capacity, every state allows it, not necessarily for PT though. It's CCHPCA.org.
You find the software program that you're going to use, you sign the BAA, you have the patient's consent to do telehealth services. Your treatment is like any other except you can't touch them.
That's the simplest form. If you're an independent PT and let's say you treat a patient in their home or at the gym on a regular basis and you have an ongoing relationship with them as a patient-client relationship but they can't make it to one of their visits. It's as simple as that. You have communication. Say, "I'm going to send you a ping. You click on this link, it will take us both to this conference to this BlueJay page and we'll do a telehealth session." That type of session is going to be you much like when you start most PT visits, "How are you? What's going on in your life? What's happened since the last time I saw you? What feels good and what doesn't?"
The subjective stuff, the conversational, comfortable things that you're going to talk about with a patient. That guides your visit like any other visit. If they need to, they can do a warm-up on their own. Someone who you're seeing on a regular basis via telehealth, may heat up a heating pad and sit with it for fifteen minutes before your telehealth session so that they're ready for you going in. Warm-up depending on if they have some exercise equipment at home, they might ride a bike or do whatever warm-up they might do at the beginning of the session. You can guide them through that or have them prepare to do that before you get on the phone with them or visit them.
What are some of your limitations outside of the manual when you can't get yours on them? What do you find is the most difficult thing in treating patients over the phone or through the software?
It depends on the patient and their set-up. I've found that most patients are doing their sessions with a phone. They have to have a good place to put that phone. When you're in front of somebody, you can see their whole body like three feet away from you. With a phone, it's a little bit different. Different accommodations work. You can use speakerphone with some patients in some situations. I always find that wireless earbuds are the best thing for the patient to be wearing so that they can move without a wire. They can hear you, you can hear them.
AirPods are ideal or something similar to that. That one challenge is having a visual and see the patient. The patient might think, "You have to see my arm move." You want to see their whole torso move. You might want to see how the trunk is moving well or even if they're bending their knees as they try to reach overhead or whatever it may be. That can be a challenge. Technology is always a challenge. It seems, for us, as the practitioner who's become used to using the software and it's very simple for me. On the other side, it takes some understanding from the patient.
Especially for those who are not technologically competent, I'm sure that's got to be difficult sometimes.
You've been on the phone with somebody who can't quite figure out how to use their phone. A phone conversation sometimes can be tough.
Do you usually share some of these things with them ahead of time like, “Here’s what is going to make our telehealth visits most successful? Make sure you have wireless earbuds, have your phone set up at a distance where I can see your whole body or you have a telephone stand if you're using one.” Do you list some of those things out for them?
I have a checklist for the patient and practitioners. The other complication or challenge can always be the Wi-Fi or the connection. That depends, sometimes it's perfect. Other times, it's all over the place. You do have to have a contingency plan. You have to have a backup, “If we get disconnected, we're going to reconnect like this, I'll call you, I'll ping you back,” or whatever is going to work for that situation.
You treat as much as you can over the software program. Do you bill as if you had seen them in person with the same CPT codes and time services and all that kind of stuff?
That’s right. Typically, Medicare does not pay for telehealth services for PT.
We can't expect to get anything from our Medicare patients, unfortunately. These are the people that might be home down more than the others during this outbreak.
I have reached out to people I know who were in Washington who might have the ear of the government to get some accommodations on that. At this point, we all know someone in their 60s, 70s or 80s who is reluctant to go outside and probably is not attending PT right now even if they need it. It's important that those services get covered.
There are lobbyists out there that are pushing for it. If there was a way for physical therapists to do some footwork at the grassroots level to push a little bit, is there any way they can do that?
I wish I had a solid answer. The best thing to do is to speak with the APTA and to your local representatives, whether it's local reps or federal government. It's the federal government because it's Medicare. I don't know if it's on their radar right now or not but I would think it has to be.
If some of these PT owners could flood the APTA who have lobbyists set already too, "We need to push Medicare somehow to continue to provide these services to the patients that are home-bound during the pandemic." That would be huge, I would imagine.
You would ask about billing and coding.
The billing and coding and then to follow up, since we're talking about Medicare, after you're talking about CPT codes and what insurances do pay for and who can we focus on?
It's different by state. I have found in New York that most of the commercial payers are paying, most Medicaid does cover all teleservices and managed Medicaid. I'm not sure that every state has the same arrangement but administrators of Medicaid.
It’s a matter of the owners simply need to sit down and start calling.
Speak with your payers and make sure you speak with the right person. Sometimes that first rep that you get on the call has no idea what telehealth is. They don't know. They don't see it right in front of them and they're not sure. A supervisor is your best bet.
With your consulting firm, have you made some of those calls on the behalf of some of your clients in different States or do you have some of that footwork already prepared?
I've only covered New York as far as that goes with the clients, but I've gotten some feedback from people in some other states that are telling me mixed things. Some payers are paying, some are not.
It's up to the individual PT owners to get someone to start making those calls.
As you alluded to, that is part of what we do. If someone does need assistance for that, we're definitely on board. I can be very helpful. I assisted in a lot of calls in New York so I know the conversation.
It’s good to hear that people can reach out to you. It's the person that you talked to, the verbiage that you use, don't take the first answer as the truth as these people are making the call and looking through your contracts and getting that figured out. In terms of billing and coding then, it's the same CPT codes, but there's a modifier.
Most are asking for the modified GT for telehealth and many require that you change the place of service to 02. For outpatient PT or outpatient services, typically is eleven. It's one of those things that's defaulted in most CMRs. Most practitioners have no idea that it even goes in. When you submit a claim, the number eleven goes to the payer. That field needs to be filled with a 02 to indicate that it’s telehealth.
As you've done some of the billing, are you getting denials initially and there have to appeals or are they easy and good about paying considering the modifier and the place of service?
I haven't seen any denials. I and my clients haven't taken too many chances yet. We've gone for the ones that we know will pay. I'm at that point right now where there's more and more demand. Patients want services and we’re going to give you a shot with other payers.
What do you find as you're doing some of this consulting? What are some of the hurdles that you have to prepare the owners for and those coming up against that you have to address?
Part of it is practitioner buy-in. For some PTs, it's completely something new. People don't love change but this environment changes that a little bit. It changes people's mindset a little bit. People are in survival mode and realize that they want to work, they want to reach out to their patients, that patients need the care. They're not going to get it otherwise. It's been a challenge but I suspect that might change. If a PT is sitting around with no patients, they would want to make contact with that patient.
They’ll get some buy-in pretty quick then.
It’s similar on the other side where some patients are very eager to do telehealth because it's so convenient. It's easy but others are not. I always say it's not for every patient, not for every visit but situations change things.
Can PTAs do these in calls?
It depends on the state. In New York, the best answer I've gotten is no. I'm unsure, to be honest with you. I'm hedging a little bit, but we're going with no in New York right now.
That would be up to the owners to call the insurance companies and ask that specific question, I'm assuming.
It's based on the contract. Its two different things. You do have to follow the state law and your State Practice Act and you do have to follow the reimbursement rules or laws from your insurance company if you expect to get paid. We do have clients who do all cash so they only have to follow the state law that they're in. There is no concern for what the payors at. We haven't talked about it yet but another thing to follow is a lot of practitioners now in telehealth recognize it. It's an opportunity to spread their geographic reach so they can treat patients in other counties and states. You do have to be licensed in the state that the patient lives in order to treat there.
You could live in Washington and do a telehealth call to Alaska if you have an Alaska PT license. You can't do a telehealth call to Alaska if you only have a Washington license.
To add to that, there is what's called the PT Compact. The compact is an agreement with, I believe it's eighteen states at this point where if you're licensed in one of those eighteen states, you can get the right to treat in one of the other compact states. Without getting a full-blown license, you can still treat those other states.
Do you have to go through a process in order to get that right?
Each state in the compact has its own process, whether it pays a fee or pass the jurisprudence tests or get approval from your state. Every state is different.
How can we find out about the PT compact from the states involved?
Is that PT compact only for telehealth services?
I don't think so. I believe it's the right to treat in any state in the compact.
If you live near the border, you could cross state lines and do a home health visit in another state?
I'm sure that's how it started and telehealth got the ball rolling in further.
To back up a little bit, if someone's billing for some of these services, it's the CPT code and the GT modifier on top of the other modifiers that they're using. Whether you go 1st, 2nd or 3rd, it doesn’t matter.
I haven't heard that it matters. You're going to be billing and my experience thus far has been billing for an evaluation, if you do one or re-evaluation, it’s 97161. If you are billing for therapeutic exercise, that's 97110. Neuromuscular re-ed, it’s 97112. Therapeutic activity, that's in 97530. It's limited to that. You could get into 97535 or 97537, I believe it is. It's a functional activity like home activities. Reorient the community, that's community reorientation.
What are some of the difficulties than from the patient side? What are some of their complaints as they're going through this? Is it either they like it or they don't or do you hear some of the same concerns?
I don't know if they can't stand the sound of my voice in their ears. They don't like how they look on camera. That is one. Some people are very uncomfortable doing video calls which I get it. You get past that quickly. The biggest thing is you're not getting that physical touch. I encourage people to use foam rollers, physio balls, get some of their own home equipment because as we know as PTs, they should be doing home exercises anyway. They should be managing their chronic pain. This is a great way to get them off on the right foot.
How is compliance? Do you have a cancel rate or a no-show rate?
I'm pretty persistent. My patient's schedule is not that packed. I'll find a time for most patients to get in on that day. That is a good thing, meaning flexibility. If someone can't do their 10:00, you don't want to make an open schedule then you'll have that. If someone can’t make their 10:00, they can see you at 2:00 and make that work because you're there and it's at their convenience. I try to make it that way.
Your documentation is no different than when you see them in-house?
That's true. You want to document that you're doing a visit by telehealth secure remote video call.
Where do you put that? Somewhere in the objective?
It doesn't matter, as long as it's on there.
You use the same EMR system. You use this software program with a BAA and it’s HIPAA-compliant. You do the same therapy that you would without the manual. Your billing is the same CPT codes with an additional modifier and a place of service is changed. Make sure you're dealing with the right insurance companies.
I like to take advantage of the fact that we work in the patient's home or at their office. There's the opportunity to do an ergonomic assessment of their desk. There's an opportunity to have them put some plates into a cabinet, do some functional activities, how difficult to open a door or go to a window or something like that. I haven't done any of these treatments of patients with vestibular issues, but I had a very long conversation with someone who does. She makes sure that the patient is in a very safe environment. For her vestibular patients, she does their sessions with them standing in a corner. Nothing else around. They put the phone on a nice platform where it can video them while they're doing their program while they're standing in the corner so that they have something to grab onto at all times.Back pain heals because patients understand what's going on with them better. Click To Tweet
How does marketing go? Are the doctors receptive to some of this especially now, I'd assume they are more receptive? What is your response from the physicians?
The real answer is everybody's first response is how you can do physical therapy if you can't touch the person. I've always believed that that's a perception of what PT is a problem. Many people still think it's massage and hamstring stretching. That's a problem within our profession. I've addressed that forever and I continue to address it. This is another opportunity for us to speak for our profession and say we do so much more about education. Back pain heals because patients understand what's going on with them better. That's how people get better. That's a lot of it. Once that conversation happens in the right tone and manner, most people tend to be a lot more receptive.
You get referrals directly from physicians to specifically provide telehealth PT services.
I have not marketed it in that way. I haven't pushed it hard in that way but I suspect that it will start happening very soon and not just for me but across the board.
Have you marketed directly to a consumer and gotten patients? How do you get most of your patients this time? You have direct access in marketing your telehealth services directly to the consumer and they're calling you up and starting the therapy.
They either hit on the website or calling. I have some other online referral sources that refer directly to me. I have not made a big push on social media yet. There are regulations.
Advertising for pain relief and that kind of stuff.
Particularly in New York is tough about that. My methodology has always been when I had a brick and mortar practice was we'd put information out there. It's about being a source of information showing you professional knowledge, people respect that and want to learn more from you.
What is your website? How can people reach out to you?
What I'm getting from this is number one, it's not as hard as people might expect it to be. The ins and outs and intricacies are a place where someone like you could help out quite a bit as a consultant and getting this branch or this section of their PT practice off the ground. I'm thinking, not for this pandemic but also snow days. Like here in Alaska, I'm thinking it would be great if you could offer this service to people who live out in the bush that simply don't want to live near other people and don't want to drive two hours for PT three times a week. There are opportunities there for sure, for people to provide those services. It's time that you established your business to help people out like this.
Thank you and I'm looking at this. This is an impetus to get telehealth into the mainstream. I don't think it's a fad or it's something that's going to go away when this pandemic is gone. It might be the thing that makes people comfortable with it. Look at where demographics are going and how people are working now. A lot more people are working from home and recognizing that they can access stores and food via the internet right from the comfort of their homes. It's not every patient or visit, but if you have a total knee replacement and you're expected to go to physical therapy three times a week, maybe you’d go into the office twice a week and the third visit, you do via telehealth. It's convenient.
Even more simply, what about the mother or father that has a child sick at home and they can't leave? Instead of canceling that visit to the out-patient facility, they do their services over the internet. It can be so great. If a patient cancels, no shows or if there's a drop in a provider's schedule, they can make some of those calls to people who couldn't make it and say, “Let's do it right now if you've got time.” There's an opportunity.
Different groups are looking to do exactly what you said in different ways. Some will have the same PT treat that patient later in the day. If that patient doesn't have so much flexibility in their schedule, they might have someone who only does telehealth visits. They might even outsource to a particular group or PT that never comes into their office and just does their coverage work for those next visits. There are plenty of opportunities out there and plenty of ways for us to reach out to patients and our patients to reach us. That's what this is about.
At this point, the important thing is to make sure providers recognize that this is an option, that there are people like you out there that can help them. Lastly, they need to push at the federal level to make sure these telehealth services are covered. Is there anything else you want to share, Daniel?
Be safe out there. It's crazy times. We'll all get through this. Telehealth and other services like this are ways for us to be smart and handle a challenging situation. Going forward, it will be something a lot more fun for us to do.Telehealth and other services like this are ways for us to be smart and handle a challenging situation. Click To Tweet
Out of every challenge comes an opportunity. Thanks for your time, Daniel. I appreciate you reaching out.
Thank you, Nathan.
It was timely that you did so. I'm glad that we're putting this out.
I appreciate it. I'll be in touch again soon.
Daniel Seidler, PT, MS
Daniel is an experienced Physical Therapist, healthcare innovator, entrepreneur and executive. He grew his practice in the Bronx, NY to three successful locations before being acquired by a regional multi-site group. Daniel developed and launched the company's telehealth program in early 2019.
Daniel's passion for PT and desire to dramatically improve care delivery models inspired him to formalize his telehealth PT education programs and offer them through TelePT Solutions.
Daniel now treats remotely, coaches PTs to be telehealth specialists and consults owners on building successful telehealth practices.
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