Interview with Dave Kittle, PT, DPT

Interview with Dave Kittle

Ray Berardinelli: Finally, going live here with Dave Kittle from the Cash-based Physical Therapy (PT) One-on-one Forum. Dave and I have known each other for about two and a half years.  

Dave Kittle: Yes. Well, thank you for having me. How are you doing today?

RB: Thank you so much for being here. I'm not much man. So how are you doing today?

DK: I'm feeling great. I'm ready to hopefully provide value to your audience, and that is literally the only reason for being here. 

No pitch, no push, nothing other than if you're a guest on a podcast or a show or whatever. I think it's the guest’s duty to try to be helpful and valuable to the audience. So hopefully, I can deliver that for you guys today.

RB: So Dave, the Cash-based PT Forum that you started going with, could you get in on that? How long ago was that you guys started to work together on the Cash-based PT Forum? Could you tell us about what led you to that? What was the step between the initial and moving into that?

DK: Yeah. So if you guys don't know, I'm a physical therapist. I'm in New York City, Brooklyn. I've been a therapist for eight years. I've always been entrepreneurial just like Ray and probably just like a bunch of you that are here in the group. 

I had a software company that was a HIPAA-compliant messaging app. And that's kind of where I really got to know Ray, and we're talking over the past couple years about trying to provide software solutions that help practice owners from around the country - help them, help their patients more, and provide a better patient experience. 

I had some developer issues. After a couple of years doing that, I was doing that full time. I had left my full-time job. On the side, I was seeing some private patients, clients, friends, referrals, people that I knew, or was being referred to, in New York City. And so, I was going to them in Brooklyn, Manhattan.

And that was just to cover the bills. Because it takes a lot of time and effort to ramp up a startup or any business for that matter, so with student loans and other bills, like you have to cover the bills.

My wife, Danny, is a physical therapist as well. I still had to chip in and do my half and do my part to cover the bills and do all that stuff. So that is where I found myself seeing patients on the side, out of pocket, kind of just making stuff up along the way, just really making all the common mistakes and not really knowing what I was doing. 

But it was a good time in terms of just another entrepreneurial path. And once you're kind of in that, the mindset of like trying to make something happen, even if something blows up and falls apart, there will be another way. 

That's in a nutshell of how I got connected with Ron Miller and helping other physical therapists now across the country with their cash-based physical therapy, brick and mortar, and mobile. That was kind of my weaving and navigating of how I went from software and technology to back more into the physical therapy world of treating.

RB: I think I love you guys with this model or kind of doing the concierge thing. Ron is totally doing the brick and mortar correct. So on both sides of the cash-based PT market and concierge market, there's tons of people out there that are doing the crosshairs way. And there's a lot of people doing brick and mortar. I like that you guys have both of those covered. 

Has that given you guys any unique perspectives on the cash pay model? Is there anything that you find that differs from the in-home concierge versus the brick and mortar?

DK: One thing is like the newer graduates that are coming out of school over the last couple years or the last 5 to 10 years, they have a lot of student debt. And so, they don't want to go and open up an office like you have Ray because of the overhead of an office and rent and all that. 

It's super common now in work for physical therapists going into a CrossFit box, and paying much less to have some space or going and seeing patients in their home, their home gyms or their offices or workplaces. So it's super low overhead, and that's where a lot of physical therapists are getting into it. 

In terms of like helping others out there, we cover the brick and mortar side as well as the mobile concierge. And so, we really kind of covering the two biggest possible settings. And that's definitely a big leverage point in terms of helping other PT - the all-in-one roof in terms of one place where they can get help from us.

RB: I love the people like you that are out there, pushing us into new avenues. It's pretty awesome. Giving a lot of people that are old kids that don't want to do that opening a brick and mortar, it's giving them another options. 

Giving people options, a way out and forward into where they want to be. One of the benefits of the cash pay is you get around our nemesis in the documentation. That's one of the things that you and I have talked about.

It's one of the really nice things about what you do is that there's not much in the way of documentation compared to what we were having to deal with being in the network model. And while I do something out of network, but primarily in network, even documentation is the same for both for me. 

DK: Whatever the minimum of your State Practice Act is all you would need to do in terms of writing it up in a simple as a Word or Google document typing it or even writing it. There are other practice owners that are cash-based that just do like a sentence or two for each section of their soap note, and I know Katie Holmes. 

In terms of the cash-based stuff, it is actually still super common because someone might look at a price point of like an EMR and they'll say, “Do I even need that? Do I need that overhead?” That's why a lot of others don't really teach it, but there's a lot of cash-based physical therapy,  marketers and business coaches that talk about using Google Doc. 

I think that's why if you want to grow something bigger and think about something long term, I think you should get an EMR you might be coming out with or something like that. Because if you're thinking small about using Google Docs, it's going to stay small forever. If you're trying to limit your overhead and minimize those types of things.

RB: They do have value, the free AR for your billing for all that day. It's really nice. Some of the other stuff is just a little commerce on the documentation of it especially those of you who are up in the system. I did when we dictated and I was like 15-20 minutes a day. 

I did have my car on the way home and I was done. Now it's hanging over my head all weekend. I really wanted to ask you on how are you guys serving in your cash and they get the cash flow one-on-one forum? 

You know, the cash is up there be on one-on-one forum. What are you guys doing to serve your audience? I'm trying to serve the people here that are part of my group, and I'm wondering what you guys are doing and how you're doing.

DK: Yeah, I'll definitely describe how we're doing it. Let me do a quick little marketing hook. Here’s what I'm going to do.

I'm going to drop like a little nugget. And it's going to be something that try to keep you longer on this video call. Again, I'm not pitching anything, I'm not selling anything. 

But if you're interested in elevating your Google ranking, which is one thing that we help physical therapist with, and if you're watching this, if you're a physical therapist or working in any type of business, then your Google ranking is really important, right? 

So I said to Ray in the pre-interview, when we were talking about setting up this interview, I would love to just mention to your audience that I would love at the end of this call to describe my cash practice here in New York City called Concierge Pain Relief.

If you guys Google home physical therapy NYC, and you hit the Google Map part on the top and you hit more places, my business listing right now is around eighth on that list on that map page on the first page. Last October, my business was on page 43, less than a year ago.

Now I'm on the first page, there's some things I'd love to just offer and tell you guys for free about how I have done that you got to stay to the end. That's a little marketing hook to try to keep you engaged longer. And obviously, you can come back to watch the replay later if you wanted to. 

That's the teaser and most people who are in marketing will do those teasers but they won't tell you about why they're doing it.

You're asking about how we're serving physical therapists? We have a couple different offerings: we have digital courses about marketing, business and sales, and ethical sales. It's the things that we don't learn in physical therapy school anyway. 

You either learn it from like a business coach or you might have to leave the physical therapy industry and go to some other content or read other books to learn about marketing and sales and business if you're a practice owner that's trying to actually navigate this decline in reimbursement and trying to navigate better revenue and better profits.

We have a semi-private Mastermind that's like a weekly live in a private Facebook group every Wednesday at 8pm Eastern time. We have one-on-one coaching and calls for someone who's even more serious. You guys can check out it. Again, I'm not pitching or selling anything, but you can check this out. You can go to www.cashbasedphysicaltherapy.org

You can check out some of the offering there. My point on jumping on this video and helping out Ray and just catching up with him is to help you guys in the audience. So if anyone is here live, if you want to drop any questions or comments about business, or sales, or marketing, or even technology, maybe we can answer that as well. I'd be happy to help you guys on this call or in the replay in the comments about how we can help physical therapist.

I want to just help you guys provide massive value. And I think that's the way that most physical therapy business owners can succeed. If you just on the front end provide so much massive value, then the income and all that other stuff will follow.

RB: Right. And I explained when we were talking specifically about offering more to people before we got into this and that's kind of it. It's got to be in your leg and it's got to be ingrained in you. It's going to be something that you feel that you want to do and that's what we have to make by doing. 

If we don't make money doing it, we can't continue. That need to want to help these people drives you to do this stuff, like you're talking about the Google reviews and the tool that I've created. 

I think it's funny. You said about the teaser, also I'm thinking about my Webinar, how it's structured, “Hey, stay until the end and we've got some gifts for you.” That's how these things are structured. 

They always are. That's what we do. That's how we get people and you got to do that with your patients. 

You have to work that into your offer with your patients. At the end of our training giveaway, for example, identify that if I give away a free wellness thing, it’s because I have a gym attached to my clinic. 

DK: At the end of my plan of care and discharge?

RB: Yes. I work out another visit one month to make sure that we're still doing well and then naturally, I upsell them to buying a gym membership. It's something that I tease them out with, it's something that I said, “Look, I'm going to help you even beyond this. When we're done, I'm going to help you.” I give them a carrot at the end of the stick to keep them motivated. 

Do you do anything like that with with your patients? I know it's a little bit different being cashed in crosshairs wherever you're seeing them, is there anything like that to do that you work in by chance?

DK: My patients that I go and see, I say busy professionals with orthopedic issues - knee, shoulder, back, neck pain, back pain, knee pain, or shoulder pain, like the normal top orthopedic issues - that's half of the population who is interested in home physical therapy because those are the busy professionals that want a therapist to come to their home before or after work because they're still working or they're busy. 

They want the convenience. They don't want to go to an office and go sweat. Most of the offices don't have showers, so they got to come home and shower, then change, put a suit or dress work attire and then go back out to work. 

That population is part of my niche population. Then the other half is kind of like the geriatric population, that's neuro training and all that. Once we get closer to achieving any of the longer term goals for patients, we don't have a formal discharge process. 

We have some folks that they want us to continue to maintain visits with them. You can call it maintenance or wellness. And because we're 75% cash-based, I don't even worry about the definition if we are providing physical therapy or hands on, if it's needed or not, if it’s skilled care or not, or if it’s considered wellness or not.

I don't even worry about that. It's easy that way. There's people that are really busy or they just love the convenient service that they say, “Hey, I would love for you to just come back every week, once a week, or every two weeks,” or we have some clients that we see just once a month.

At this time, I've had around eight independent contractors work for me underneath. We can talk about that in terms of the business model and even compensating them.

I tell my physical therapist the same thing, I say, “Hey, you don't have any productivity goals, like you get paid per visit that you go see them. And if you don't see them, then you don't get paid as a 1099 independent contractor.” But I don't hover over them about you need to see more visits, or you need to schedule.

They do understand my background of some of these. The clientele of some people want a therapist to check in with them every month. I tell them there's some patients that just want this service ongoing, almost like retaining a lawyer like retaining an attorney, some people in New York City, are they starting like a service, and they just want to continue it. 

It doesn't mean we have to stop people and discharge them. You're not making progress, I believe there's always more goals to achieve with someone. If they're getting more active than that, you could have bigger goals like walk farther or travel longer. 

We don't have that traditional physical therapy model of discharging people and cutting them off. Jerry Durham always talks about how physical therapy is like the only industry that likes discharges and cuts off their customers. Why do we do that? I don't know. But I don't do it in my business, that's for sure.

RB: Right. And by and large, we all know the answer. It's the insurance companies to pair people that are paying the bills are cutting it off, they're saying, “Hey, we've got to wrap this up, you're done tonight, there's no more visits.” It is what it is there. 

We're kind of stuck in that model. And like I said, there's people like you that are out there breaking that model that are out there going out and actually creating something different, doing something different, finding a way to serve their people.

You started out in the clinic, whenever you started out of school, right? 

DK: I worked outpatient PT, ortho sports med for years, since 2011.

RB: So can you contrast that to be in the brick and mortar and in a concierge cash business? What was the difference? 

Because a lot of us, like me, were stuck. We are in a model that we've chosen, we choose to stay in so we don't really get to see what that other side is and maybe there's some people out there that are looking to do that one move that way but just don't know how. 

First, contrast the difference between the two so that people can understand what it's like for you.

DK: The differences, and this kind of goes into some of the common questions, originally I thought you actually needed like a treatment table and equipment. And like more of the resources you have in an office. 

Most of the time, it's half like hands-on and it's half like exercise or stability work or whatever, meaning half of it is hands-on therapy. If I'm working in a clinic, I might only have my hands-on a patient for 10 or 15 minutes when I was busy, and I was having three or four patients an hour. You don't provide as much hands-on care for that patient.

Therefore, you cannot provide the amount of one-on-one attention, like adjusting things, tweaking things, or discussing the future plans of moving forward. You just don't have enough time. It was interesting to get into that where it was very stress-free. I had a lot more time to focus on someone.

You have to be good clinically. I've done some Mckenzie stuff, I do some hands-on stuff. You have to be good with moves and manipulate my opinion and joint mobilizations but I do other things like taping and cupping and whatever the patient or client has a perceived notion or understanding about. Sometimes we have to start that way. 

To get them to the long run, you have to kind of meet them where they're at, rather than saying, “Oh, I'm a Doctor of Physical Therapy. We don't do some of these things because there's no research about it.”

RB: I always say the same thing. If somebody comes in, I asked them if they've had therapy in the past and what their favorite thing was, if they offer some. They're getting ultrasound, like I'm giving you all percent. 

Part of what I do is I want you to come back. I want to provide the best possible experience that I can for you. I think you better if you don't shop in the clinic. 

I'm always trying to figure out what it is that they want, I'm going to give that to them. And then I'm going to give them what I really want to give them.

I love that you said that because everybody does run this evidence based. My patients are completing their plans of care. How's that for evidence?

DK: And how you're getting out? People are getting better.

RB: And if they don't show up or if they quit, I'm not getting that outcome. I'm not even better. 

It doesn't matter how much more effective my exercises. If they love that ultrasound and they only come back, I give that to them. We give it to them.

DK: There's a lot of common skeptical questions or how is one-on-one for an hour visits. There's therapists that don't even believe that people need that. Or maybe some people do and some people don't.

But from my clients, my patients, they love the one-on-one hour long, 60-minute long visits, and my therapist like it too. It's hard to hire therapists to only go see someone for 30 minutes. It's hard to prorate however you compensate them. 

It's just a normal structure of an hour. And maybe you don't use the hour, sometimes it's under, sometimes you go over, but it's definitely a different mindset but it's the same hands-on skills. You have the skills and you do it in outpatient ortho or sports med clinics, whether you just bring those same hands-on skills to someone's home. 

And if you can make a meaningful change and get them feeling better on the first visit to a moment or something that changes their symptoms, I do some of the TMR stuff right now, which blows my mind about how well it works. And so, I offer 100% money-back guarantee up to the third visit. I'm seeing someone and they're paying $250 for a visit.

I'm in New York City. I know some of you that listen to this, if you're in other parts of the country, you probably won't even believe that I charge that. I have some patients that are paying to add a visit. We have their credit cards on file securely.

It's not even through insurance. But you have to think differently, I was completely skeptical about this a couple years ago. There's no way someone would ever pay anything like that out of pocket, and turns out that there's people that pay for, go shopping at Whole Foods and spend $200.

RB: I love the fact that there's people out there that are going out and getting exactly what they feel they're worth, setting your price telling people, “This is what I charge. If you want to do business with me, great. If not, that's fine, too. This is what I am, this is how much I cost. Take it or leave it there.”

I don't know how you're looking for time, I'm starting to feel good. I wanted to talk to you about the promise that we made the people to talk about the Google review stuff.

DK: I'll get back to the Google review thing. 

In the pre interview, you were talking about the NPS app that you have. And I want you to tell me more about it. Because that actually results in sending patients the reminder and the link to do Google reviews. And right now, I'm doing a lot of that manually. So I actually need the thing that you were talking about.

RB: It's free iPad app, it's called Aetas NPS app. It's on iStore, you can go get it. It is a review app. You're putting all your information, you hint the patient and we asked them the Net Promoter Score for people who don't know it, “How likely are you to refer a family or friend to us on a scale of zero to 10?”

They select that response. If they select 9 or 10, it automatically sends the email. And then we also ask them question if they're improving or not. We ask them that and then if they give you a 9 or 10, they automatically get their email address and then input their email, that automatically sends them the email.  

When you're above them, then you can talk to them face-to-face and say, “Hey, I saw that you gave me a 9. It means the world to me already relationship means that much. And, I was wondering do you by chance have your cell phone?” The answer is yes, they have their cell phone, do their email on it. 95% of the time, yes.

Or “Actually, I just sent you an email. And if you wouldn't mind, just opening it up and clicking on the link, it literally only takes 30 seconds while we're together because some people don't know me as well as you. And sometimes all the way, they find out about us is from our online revenues. So if you would just take literally 30 seconds and just give us a real quick review with that link. It would mean the world to me and would help a lot of people that just don't know about.”

I've been sharing it out there with everybody, a lot of people are really seeing a lot of benefits, getting 150-200 Google reviews and in a year, depending on your volume. It's incredible.

DK: The patient, they don't need to download the app, right? It just they get an email?

RB: You got the iPad, it's going to send the email to their phone. Because if the review came from your iPad IP address, who's going to drop a flag? Google's not gonna let the review happen.

But when it goes from their phone, Google thinks it's organic. And it really does. 

We're just asking. One of the limitations with Net Promoter Scores: nobody answers them. You send them to people via email or text and you get a 15% or 20% response rate. 

With this app, you get a 99% response rate. Somebody actually has to look you in the face and say no.

DK: You suggest doing that in person? 

RB: Absolutely. Because if you get only get 20% of the information, imagine you're doing any about with somebody and you can only get 20% of the information, how accurate is your diagnosis going to be? Not very good because you only have 20% of the information. 

If I want to look at the health of my practice, I need more than 20% of information. I need 100% of that information. You'll get all of that information.

I'm interested in what you guys are doing, how you guys are working, how did you climb from page one was it 43 or 48 up to the page.

DK: I've only done a few Google ads and then I paused it. It wasn't converting and effective. It’s not like Google ads are effective overall.

I'm for this particular thing that helps me. You don't necessarily need Google ads or Google PPC ads. What I did from about last year in October of 2018, I was around page 43. And then I started to creep up.

One thing is Google reviews. The thing that we just reviewed, the thing we just went over, I think there's a couple opinions about how I went about it in terms of what matches kind of the algorithm and then some of the things that I had done. It's reviews and then like the cadence of reviews, meaning if you got a whole bunch like a snowball of reviews all at once, then Google is going to look at that. 

And they're going to ding you because they're going to think that is something nefarious, something not completely organic or true. If you have reviews that are coming in kind of peppering in throughout your month, meaning every day, one a day or every other day, Google looks at that as it's more organic. If you can get a review, get it whenever right of course. 

But if you have a choice of how to get it, then you actually want to spread them out a little bit. Now that's tough. But if you're using the thing that I need to look at, with Ray’s app is that I could actually control almost like a floodgate. 

I want to control the amount of people doing the reviews because if I got five on one day, I actually got three reviews one day last month, and then I've only had like one or two since then. So that doesn't help my profile in Google's algorithm because it looks like it's less, it's kind of more choppy. And it's not a consistent smooth description of like my business credibility. 

RB: Right. And I've had people actually tell me that exactly. So they started using my app first. They didn't see there, they weren't seeing the SEO getting there, we're getting tons of reviews. 

Once the reviews maintained and they kept coming, then that's when I went through the roof. There was a month or two where they're like, “I don't understand, I'm getting all these reviews. Why? Why is this not improving my SEO?”

I spoke with someone that does this, and they told me basically the same thing that you did. It's all of a sudden, all these reviews out of nowhere from this business that's been there for five or four years, and all of a sudden they only had five or six reviews. Now they're getting 30 to 40 a month and it takes a while. But once you get past that first month, two months, then that SEO starts to really kick in and starts moving up the page.

DK: Another couple things about it. I want to point out and I'm going to mention a couple of names. This is not in terms of a couple of names that I've outranked in terms of physical therapy practices and how maybe. Right now for home physical therapy in New York City, if you click again the more places I should consider as pain relief, my practice is ranked eighth right now.  Last year, I was on page 43. 

Right now, I'm outranking SPEAR Physical Therapy, and they have 168 Google reviews. I only have 26. I'm going to tell you my next point of why I think I'm also doing that.

And then also one of my colleagues and buddies, Karen - awesome physical therapist podcaster - you guys probably know her, Karen has been a home mobile concierge physical therapist for like 10 years. And I just started this Google profile for my business last year. And I'm outranking her and that's like her mobile home concierge physical therapy.

That's her thing and she's awesome. She's one of my colleagues and we're cool. But right now I'm outranking her. How is that possible? 

So the one thing, she only has three Google reviews, I have 26. But I've only been on the block for a year with my Google profile as a business. And she has been in business for 10 years. 

So the next point is Google posts. This is one thing that's super overlooked: the Google posts like Google My Business posts. You may only get a few views or a few clicks here or there but you can add a picture. 

It's basically like a Facebook post but it's a picture and you're adding a description. And the description has to be, in my opinion, we're talking about copywriting and has to be persuasive. And it has to have the keywords of what the people are searching in Google originally to find your practice. 

I'm using keywords like home physical therapy, in-home physical therapy, best physical therapy, or physical therapy near me. I'm using those phrases and those words in my post. If you go to concierge pain relief on Google, you're going to see how many posts that I did there. 

They're long narrative posts. They're ethically trying to get a call to action. My call to action is Call now. I list my website URL, my link, and my phone number, in case they want to just dial it by looking at it. 

And then my call to action button is Call now. I've gotten a few calls from there. And then, Google Analytics tracks those calls and tells me, “Here's how many calls you got based on people clicking on the post the Google My Business listing.”

If you focus 100% on Google, you can possibly do what I did, which is in less than a year go from page 43 or basically the desert like you're dead and you don't even have a business there to page one. Now, I'm ranked eighth on page one, and I've only had this Google business listing for less than a year.

It's because I'm following the things that actually work. And I am wasting zero time on Facebook, Instagram, or Twitter. I have the customers pain relief, my practice, I don't do any posts or any videos. 

I know that it's super popular to do Facebook posts, videos, and lives. For my business, I don't do any Facebook, Instagram, or Twitter. It's 100% Google because my patient, my prospective patient, my ideal customer is searching Google. 

And I'm also not going to doctors, I don't kiss a** and go to doctors, I'm not getting referrals from physicians. I have some patients who tell their doctors about me and then they send patients my way. 

My ideal patient is someone who is on Google and they are searching for a solution for today or tomorrow, meaning they want it fixed or they want their pain ease right now or tomorrow. 

I'm in New York City and some people will just pay for whatever today or tomorrow and maybe elsewhere. And if you're in other states, maybe the behavior is different. But you have to understand and you have to know your ideal client and your ideal patient, whoever that customer might be. 

I'm 100% focused on Google. Just that was like a spout. So I'll take a pause and jump in, what do you got?

RB: Well, I don't know what. There were a couple of things. Number one, I'd love to joke. I'm sure everybody's heard it, “What's the best place to hide a dead body?” On page two of a Google search, nobody goes there.

It's very important when you're saying you need to be on page one, nobody's clicking through your page. And then the other thing that I noticed, you respond to reviews that improve your SEO. 

Responding to reviews really improved SEO because they want to see that you're engaging on Google, that you're using the platform because they want to show people that are searching for things.

That's going to keep them on Google. They want to show people that this is where you should come. This is where you can get a lot of information. This is where you can interact. 

Their entire goal is to get people using Google, to keep using Google, and to get people to use Google more. So people that are doing what you're talking about. They're getting reviews, they're following up with reviews. 

They're posting, they're making sure all their hours, all of everything is there. They are going to move you up the page because you're checking all of the boxes. 

DK: Definitely reply to every single review. “Thank you. Thank you for sharing. Thanks for your testimonial. Thank you for your review. We really appreciate the words.” Whatever it might be, it takes two seconds.

RB: Just the fact that you're doing it and Google sees it. They're like, “Oh, there's a review to that.” Also, I've been hearing from some people that I talked to, how fast you respond to that is also affecting it. 

They're looking at the time in response to the reviews going away. And I even heard if you get a negative review that if you respond to and respond quickly, that it doesn't ding you as much. You have to respond, you've got to be out there. 

Anything else you'd like to share with everyone?

DK: I wanted to provide a ton of valuable content for your audience. So guys, in my opinion, Facebook is good. But for our business and for our patients, if someone's scrolling through Facebook and you happen to get in front of them with a Facebook Live or an ad, in my opinion, you are getting in front of that person or human being when they are not interested in solving or addressing their issue, their pain, their back pain, their knee pain, their incontinence, their falls and balance, whatever is the issue.

If they're scrolling on Facebook and you get in front of them, great that you got in front of them, but they aren't even in the mindset to do business. So in my opinion, if you don't have a marketing budget, if you don't have a marketing team, if you're solo, if you're just ramping up, or if you're only at 5 or 10 grand a month, in my opinion, focus more on Google.

I am focusing 100% on Google because someone who finds me on Google is interested in solving the issue or at least addressing the issue today, like right now. And that's the difference in the behavior of Google, someone on Google searching for something, they're looking for something they want help, they want an answer. 

If they're on Facebook, they're in entertainment land, they're in like La La Land. They're just looking, unplugging, and just mindlessly scroll. Google, Google ads, Google reviews, or Google post, look into that. 

I think Facebook is just always new for a bunch of different things. And there are Facebook ad trainings from every person in the world. It's a different mindset of the prospective patient and customer that you're getting in front of on Facebook versus Google.

RB: I couldn't agree with you more like I'm of the theory. If there’s a ton of traffic somewhere, if it's getting worn out, if it's getting worn down, then there's a lot of traffic and probably shouldn't be there. You're not going to get seen as much because it's going to blend in with the rest of the traffic. 

If there's somewhere that there's not as much traffic, that you can get more views, that you can get more people booking you, more people seeing you, all whether they're in the mood or they're not in the mood that definitely affects it. All that aside, if you're somewhere that what people are going to see, that the traffic is going to notice your work, you should probably be spending more time there and less time somewhere really, really crowded.

That's like baseball people coming, probably physical therapy groups out there on Facebook, there's just get John's now. And the people that got in early like that cash shop, and the cash-based PT forum or one-on-one forum. 

You know, you guys have a lot more people within your group. And also there's a number of reasons for that. But also, it was just being there, when it was in its infancy when they're watching right track. 

Now there's tons of traffic. There was so much traffic here.

DK: I'll answer a question earlier, “Dave, how do you manage the people underneath you since you're not brick and mortar with them? And how do you know if they are carrying out what you ask of them?” Okay, so good question. 

If you're just jumping on now or if you don't know me, I'm a home concierge mobile physical therapist, meaning I go to patients homes, gyms, their office workplaces, I do it like remotely.

And I have currently six independent contractors seeing patients where my biller and I are doing the billing, charging of the credit cards, all the processing and the receipts, and everything. And my independent contractors are going and seeing the patients in their homes. I obviously can't even see what they do. 

I don't know what occurs and that is the biggest risk and liability of this business. So the question is, how do I manage this experience? And how do I manage the therapist and the patient care and the experience? 

Well, part of the answer is I cannot completely ever know. But the other part of the answer is, I have to already have a good connection with the point of contact. The point of contact might actually be the patient, it might be a parent, or it might be a son or daughter if the client is older. 

So whoever the point of contact is, and or the patient or maybe it's a home health aide or whatever, I need to have phone number, texting ability, email address, whatever, it's specifically phone numbers and communicate with the patient.

Like “Hey, Ray Berardinelli here. My physical therapist came and he's been working with you for the last three, four visits in your home. How are things going?” And 99.9% of the time patients are happy, they love Ray, they love whichever therapist is coming and seeing them, they're feeling better. 

They love the convenient service. They love that they can roll out of bed and a therapist is at their door and then they can go on with their day. So the answer is, it's tough because I cannot see the independent contractors.

I also get a question often times, “Aren't you nervous about the risk and liability and you don't have full control over your brand, and your company and all of that?”

The answer is that is the trade off. I don't have to pay brick and mortar rents. What I do with my independent contractors, we're charging an average of $250 a visit. And I'm only paying my physical therapist $80 to $100 per visit. 

But the patient is being charged $250. The margins are ridiculous. And I don't have to pay for an office. So the business is great, the therapists are getting paid really well, they love being paid with that for an hour. 

And that's how I managed them. And there's actually a built-in compensation structure, there's a built-in raise. So any new therapist, if you're watching this and you're in New York City, Brooklyn or whatever, if you're interested in coming on to my practice, this is what we say, “You get paid $80 per visit for the first 15 visits at my practice, or you know, seeing mobile patients that can be one patient can be multiple, however, you get to 15 visits, you're compensated $80 per visit, oftentimes, you get paid the same day or within the next week, faster than other jobs where you got to wait two weeks.”

“You get paid faster and you get paid $80 per hour, the next 15 minutes, you get paid $90 an hour, once you get to 30 total visits, you're at $100 an hour, $100 per visit.” The documentation is very minimal that we talked about in the beginning here. And then there is negotiation power for you.

And there's room because we're charging patients $250 a visit for me to even no one has gotten to that higher level of past $100 per visit. But I would be open to paying a therapist $110 to $130 a visit because there's still a 50% or more margin on the top line of what I'm charging patients and the compensation of therapists.

Independent contractors going and seeing patients, I have not heard of any practice anywhere in the country, in a 1099 situation that's mobile, paying their therapist anywhere close to $100 a visit if not more. PT is like an out-will employment authority.

And the other risk of like this is that they build a better relationship with that patient than I can. And yes, it's possible that they might steal that patient in the future or undercut me and charge the patient $100 a visit. That's possible. And I'll live with that. 

I'm the one with the marketing machine that we just talked about Google and everything along with the marketing machine. So if you want to go steal one patient, or a few here and there, that's fine. I can never, unless I hire a private investigator to follow every physical therapist which would be ridiculous, there's no way for me to ever know.

So that's the downside. But the upside is that I don't want to pay for a brick and mortar office. If I want to pay for a physical therapy office in Brooklyn or New York City and rent an office, it's going to be like 10 or 20 grand a month.

RB: Yeah, right. I love some of the stuff you're talking about. And one, this is all systems, like this is my jam, this is what I do. 

The systems for tracking systems for the engagement. So you can you can control the patient experience some with your systems knowing these Net Promoter Scores, knowing what they are by therapists, being able to look at them by therapist, to segment them out to see exactly how people are performing in relation to other people seeing their number of Google reviews, how many they're getting. 

I don't know if you're using like any email marketing, your email welcome systems, making sure that those systems are all there that they're tight, that every patient is getting every email that the therapists know, when the emails are going and they're saying, “Hey, did you get my email?” Because you're going to improve their open rates.

And I know sometimes in the business a little bit different, there might be a son or daughter or somebody else that's getting my email. But as much as you control it, you cannot make sure that people are doing getting your email, getting text messages, or opening everything. 

All of your follow up there, you can even see a patient potentially might have been lost in various ways through your outreach to them. You know that's automated because you're sending them a voicemail saying, “Hey, we wanted to thank you so much now,” and it's coming from their therapist saying, “Hey, we want to thank you so much for using our services. I know it's been about a month since we last saw you. I just want to make sure you're doing well.” 

So if that ringless voicemail goes out and the patient calls and says, “Hey, I don't know why I got this, and I'm still being seen one. It doesn't stop.”

DK: I definitely want to work more on those systems and here with the webinar that you have coming up about the ringless voicemail, I had heard that on like a Neil Patel, the marketing school podcast that Neil Patel and Erick Sue has on iTunes, and the ringless voicemail is genius. 

You can make it like, “Hey, this is Dave, your physical therapist…” and it sounds like they just called you. And for some reason, like it just knew that it left a voicemail and you missed the call or whatever. 

RB: The place that has been testing this but customer testing this for your place that it's incredible is for people to drop off, right? 

DK: I want to hear what's actually in the voicemail for drop offs?

RB: For the drop offs, I don't say it's me. I say, “Hey, I was just reviewing and I saw you haven't been in the past week, I hope everything's okay. Whenever we discussed during initial visit, how important it is the plan of care is in order to, for you to be able to get your life back. So and if you get a minute, just please give me a call. Let me know what's going on so that we can get you back and get your life back. Sorry, I missed you.”

So that automatically was out like when they hit the drop off list for office reviews. And then there's text and there's email. That works incredible, works amazing. 

And a prospect visits people that in my practice, I wasn't even paying attention to be perfectly honest. Like somebody spoke coming to dance and we were busy. 

They're showing up. I don't notice that it's only twice the system spits it out says, “Hey, they've only been here two times a week.” And then, the automated system calls, sends text messages and emails, then we engage. 

The big thing is on the app, when you get the notification. So you say to the patient, “Did you get my call?” You know, so now they have no idea. Now they think it's really real because not only did they get it, you're asking them about it on the next visit because the system is kicking it out, put it in your app and telling you right from this call, you sent them this email.

DK: Interesting. We got a question: “Do you allow a patient with Medicare?”

If you're asking if I see Medicare patients or private insurance or clarify the question for me if you can adjust and post another comment for your question, but for us, no. We do not see Medicare, we did not build Medicare. Medicare in New York City I think reimburses about $100 per visit. So if I'm paying my therapist $89 or $100 a visit, there's no real margin there for my business.

So, no, we do not. And if someone has Medicare, there's a whole other conversation we could have. If someone on Medicare has exhausted all their funds, their visits for the year, arguably they can be seen or if they don't have severe pain or any acute injury, then there's a way to kind of there's some loopholes around wellness and if it just like exercise and it's not skilled care. 

Now, if someone has Medicare as a secondary insurance, they are not considered Medicare. They still have that primary, whatever commercial insurance is their primary.

I am definitely not par with Medicare. I am definitely par with collecting a credit card. That's how we operate. 

We're providing a valuable experience for patients and clients that want to retain us ongoing, I have a couple patients that are like neuro base, and I see them once a week for the past two years to three years because it's a chronic condition. It's an ongoing condition. 

I've had patients where I see them in their homes and then they're busy. And they're like, “Hey, if you're nearby in my office in Manhattan, would you be able to stop by my office later in the week around these times?” And so either myself or my teammates are flexible enough to like, “Actually, yeah. I'm going to be in that area.”

I can see you in your office there or I can see you in your home. I've treated a patient for elbow surgery, post up elbow surgery, who is a top sushi chef here in New York City, and I was with him working on his elbow in his restaurant before the restaurant opened on a random day. 

I've been in hotel rooms for people that come into Manhattan and into New York City to get surgeries. And they're from Dubai, England, and all different countries and they stay in a hotel room for two weeks, and then they fly out. So it's a really unique, flexible, adaptable situation. 

High margin. It's high touch in terms of like the interaction and the night you spend with patients. It's high touch but it's also high margin. And it can be really profitable even for the teammates, that the physical therapists who are 1099 is because they're getting compensated pretty well. They love that and they don't have to deal with billing and any significant documentation.

I can see how that's attractive to people from someone that's been in the system a long time and Noah who just hopped on easy candidate in the same boat being in network with the majority of people not having to deal with that stuff especially as a business owner, is very attractive because that significant amount of your time and word but don't worry about on it. It just goes on. 

RB: Anything else you want to share, Dave?

DK: You can ask a question later. Anything about charging patients out of pocket, setting your own rates, raising your rates, or if you're in network like Ray, you're trying to do more out of network, you're probably going to have some trouble and some challenge overcoming objections to paying out of pocket. 

I'd written some notes about that type of stuff, which is like you have to know your ideal patient, your ideal client, and everyone is just going to assume that they can use their health insurance and their $20 to pay and they have no idea what a deductible is most of the time. And you have to get ready for all of the common objections because they don't really know you like you or trust you yet. 

They don't even know who you are and all that unless it's a warm referral. So you have to be ready for all of those things. You have to be ready for the common objections about price. They want to think about it, they need to speak with their spouse, they want to sleep on it, they want to think it over, they want to pray about it, they want to stall, they want to have an excuse to slow the process down. So you have to be smooth and professional with all these responses. 

And because of how much we've seen patients and had these conversations about charging out of pocket, and we provide a receipt, they can maybe get reimbursement from their insurance, but it's just a different approach. And the more experience you have with that, the more confidence you have with that speaking to prospective patients, then you get a lot more comfortable. 

But you have to know all the things that they're going to say before they say it. So for me, for example, on a prospective new patient, first phone call, I like to mention the word insurance before they say the word insurance. Now, if I say the word cost insurance and logistics, because we go to the patient. 

If I say the cost insurance and logistics or I say the word insurance first, that means I'm in control of the insurance conversation, not the prospective patient who's calling me up. And oftentimes, it's tough because people’s the first sentence after you answering the phone is, “Hey, do you take United Healthcare?” And then you got to say, “Okay, I'm sorry. I didn't catch your name. What's your name?” and try to build some rapport. 

If you want to control the cadence of the conversation, you have to know exactly what people are going to say - all the common objections, all the questions, all the uncertainties. And so that just you know, that comes with practice and time. But that was just another thing I wanted to mention.

You have to initiate the conversation about it, steer the conversation where you want to overcome their objection before your voice.

RB: Thank you so much for dropping a whole bunch of knowledge on everybody here. Really kind of helped some people in the group out. 

DK: Thank you very much. I just wanted to provide you guys with a bunch of value and if you wanted to connect with more, feel free to shoot me a private message or friend me on Facebook. 

And now, it's like physical therapy colleagues that I've never even met. You can check out www.cashbasedphysicaltherapy.org if you want to connect. We have free resources there. You guys can download and check out and videos. You can check cash-based physical therapy on YouTube. We have a bunch of free content and a bunch of free videos there.

Thank you.

RB: Sounds great, Dave. Thanks again for your time. And thank you so much for sharing with everybody. I appreciate being willing to come on here and help everybody in the group out.

DK: You're welcome.

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