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How to Start a Cash-Based Practice

November 5, 2020
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For many clinicians, the decision to start a cash-based practice or convert their existing payment model feels overwhelming. To glean insight from their personal experiences with the transition, we caught up with Counterstrainers Kyle Kusunose, founder of Counterstrain San Diego, and Holly Christy, founder and medical director of Element 7 Wellness.

Tell us a little about yourself and your practice. 

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

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

How long have you been cash based? 

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

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

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

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

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

Were there any specific resources that helped you prepare? 

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

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

What challenges have you faced—expected or unexpected? 

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

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

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

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

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

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

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

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

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

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

How do you market your practice?

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

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

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

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

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

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

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

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

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      Shannon Arndt, MSPT, JSCC, is a distinguished physical therapist and owner of Soundview Center for Well-being, Lone Lake Physical Therapy, and Sage Counterstrain. She holds an MSPT from the University of Rhode Island, where she graduated at the top of her class, and is a Board Certified Specialist in Strain and Counterstrain. Shannon’s expertise extends to her work with The Bridge Back Project, where she uses counterstrain techniques to support veterans and first responders in their recovery from PTSD. Passionate about patient education, she thrives on uncovering the complex interconnections of physical impairments and empowering individuals to manage their health autonomously.

      Dr. Kim Braun, PT, DPT, brings over 30 years of experience to her practice as a doctor of physical therapy, with a focus on comprehensive pain and dysfunction treatment. She earned her initial PT degree from the University of Iowa and later completed her Doctor of Physical Therapy at St. Scholastica College. Passionate about infant care, Dr. Braun specializes in treating and preventing torticollis and plagiocephaly. Her dedication to patient-centered care is rooted in integrity, efficacy, compassion, and advocacy, utilizing a holistic approach for rehabilitation, prevention, and wellness. Dr. Braun has pursued extensive post-graduate study in the Fascial Counterstrain technique through the Jones Institute and with Brian Tuckey, PT, OCS, JSCCI, and is excited to leverage Counterstrain when other interventions have proven insufficient.

      Michael Wangsness, PT, DPT, ATC, CSC I, holds a Bachelor of Science in Athletic Training from Nova Southeastern University (2007) and earned his Doctorate in Physical Therapy from the University of Minnesota (2010). He began incorporating Fascial Counterstrain (FCS) into his practice in 2011 and has advanced to teaching roles, serving as a Teaching Assistant since 2016 and a Lab Instructor since 2020. In 2022, Michael was among the first to receive his CSC I certification. Passionate about FCS, he has been privileged to train extensively under Brian Tuckey. Michael currently practices at an outpatient clinic for M Health Fairview in Woodbury, MN. Outside of work, he enjoys golfing, coaching hockey, and spending time with his wife, Heather, and their three children: Olivia, Gavin, and Amelia.

      Greg Zadow has been a self-employed physical therapist since 1998. He earned a Bachelor of Applied Science in physiotherapy from the University of South Australia and Doctor of Physical Therapy from the Rocky Mountain University of Health Professionals. Greg is the owner and clinic director of Green Ridge Physical Therapy and Wellness, his Oregon-based private practice. In 2011, he became certified in the Strain Counterstrain (SCS) technique and continued on to complete a mastery program with Counterstrain Academy and become a Jones Strain Counterstrain Certified Instructor (JSCCI) of Fascial Counterstrain (FCS). Greg has been using Counterstrain ever since his first introduction to the technique in 1991 and now holds over 20 years of continuing education experience in the field of manual therapy.

      Kyle graduated from San Diego State University in 2010 with a bachelor’s degree in kinesiology and earned a Doctor of Physical Therapy from the University of Miami in 2014.​ Kyle immediately started his private practice and became certified with The Jones Institute after witnessing the powerful effects of Counterstrain on his patients. Kyle currently lends his expertise to the Doctor of Physical Therapy programs at both San Diego State University and the University of Miami. Since joining The Jones Institute as a lab instructor in 2015, Kyle has taken on additional roles in managing the company’s domestic headquarters, developing the curriculum for a new anatomy program, and teaching Anatomy Dissection as the lead instructor.

      Eryn Milian earned a Bachelor of Science in chemistry and environmental science from William Smith College along with a Doctor of Physical Therapy and PhD from the University of Miami. Her doctoral work focused on anatomical sciences and measurable outcomes which inform her current clinical expertise in orthopedics and sport physical therapy. Since joining the University of Miami’s faculty in 2013, Eryn has expanded her role as assistant professor to become a course master for neuroanatomy and instructor for both pelvic anatomy and the university’s orthopedic, sport, and neuroscience residency programs. Her research interests lie primarily in knee injuries and the development of reliable and valid measures of assessing ACL risk in adolescent athletes via musculoskeletal ultrasound.

      Tim Hodges has worked in the field of physical rehabilitation since 1996. Since joining The Jones Institute in 2004, he’s assisted Brian Tuckey, PT, OCS, JSCCI, in the development of several Fascial Counterstrain techniques and taught numerous Fascial Counterstrain courses as a certified instructor. Tim continues to apply his knowledge and expertise through Counterstrain Academy—a mastery program designed for licensed Counterstrainers throughout the country. In addition to developing the program’s curriculum and overseeing its mentorships, Tim is currently practicing at Counterstrain Portland, his Oregon-based private practice.

      Larry Ham graduated from the University of Southern California in 1978 with a Master of Science in physical therapy. He took his first Counterstrain course in 1986 after Lawrence Jones, D.O., treated him and successfully eliminated all back and sciatica pain. He’s now certified to teach Strain and Fascial Counterstrain courses for the spine and extremities and the viscera, respectively. In addition to teaching Counterstrain in the U.S. and Australia, Larry has served on the sidelines of over one thousand sporting events as a Certified Athletic Trainer. Though nearing retirement, Larry still practices in Spokane, Washington, and enjoys spending his free time with his wife, sons, and grandchildren. You can catch him scuba diving with sharks, remodeling his home, or hydrofoiling on the lake.

      Robert Dowd holds a Bachelor of Science in medicine with a certificate in physical therapy, Master of Healthcare Administration, and Doctor of Physical Therapy. Robert is now a Jones Strain Counterstrain Certified Instructor (JSCCI) who’s dedicated to presenting Counterstrain the way Lawrence Jones, D.O., advised his students to do at his final course offering. Robert applies the philosophy of Counterstrain to all clinical settings from the outpatient orthopedic clinic, acute care hospital, and ICU to the nursing home and hospice industry. When he’s not practicing in the Black Hills of South Dakota, Robert can be found writing, fishing, hunting, or riding his motorcycle.

      Holly Christy earned a Bachelor of Science from the University of Washington, Master of Acupuncture from Northwest Institute of Acupuncture and Oriental Medicine, and Doctor of Naturopathic Medicine from Bastyr University where she currently teaches as an adjunct clinical faculty member. Holly started her practice in 2000 and became a lead instructor for Counterstrain Academy in 2014 after a mastery-level internship with Tim Hodges, LMT, JSCCI. In 2019, she became a Jones Strain Counterstrain Certified Instructor (JSCCI) of Fascial Counterstrain (FCS) for the nervous system. Though Counterstrain is her primary modality, Holly also offers primary care, acupuncture, prolotherapy, custom orthotics, and intravenous nutrient therapy.

      Brian Tuckey, a magna cum laude graduate of the University of Maryland School of Physical Therapy, became board certified in orthopedics in 1995. Under the tutelage of Lawrence Jones, D.O., Brian became one of only four physical therapists in the world to be certified in the Strain Counterstrain (SCS) technique. He was also the first practitioner to recognize Counterstrain’s impact on the fascial system which led to his development of Fascial Counterstrain (FCS) with over 800 anatomically-specific techniques in addition to the FCS Cranial Scan—a proprietary assessment that identifies dysfunction in all systems and regions of the body. When he’s not teaching, Brian is treating complex patients at Tuckey and Associates Physical Therapy in Frederick, Maryland.

      Randall Kusunose founded The Jones Institute in 1988 with Lawrence Jones, D.O., the original developer of Counterstrain. He was the first therapist to be board certified in orthopedics by the American Board of Physical Therapy Specialties in California. Randall has trained all Jones Strain Counterstrain Certified Instructors (JSCCI) in the U.S., France, Italy, and Australia, and developed over 60 Jones Strain Counterstrain techniques along with the Facilitated Counterstrain curriculum. When he’s not practicing, you can find Randall skiing, scuba diving, and relaxing on the sand in the beautiful beach town of Encinitas, California.