Why You Should Drop Your PT License! (And Why It Matters)

0:01 All right, we are live. I am back. I'm here with Dave Kittle, Tony Maritato. Jimmy may or may not jump on. He's got another meeting this morning. But I was just asking Dave before we started about Mother's Day in New York. So, you know, down here, down here, out here, southwest Ohio area. The tradition is always we mulch, we mulch the flower beds, we mulch the yard, we cut the grass, we edge, we clean it up, make it look pretty for mom. Tell me again what you guys did for, is this her first Mother's Day as a mother? No, second, because the baby was born last March twenty ninth. So the first Mother's Day was pretty quick last year, like in terms of like, you know, got on us quick.

0:45 So this year, probably a little bit more time for her to soak it up and all that. And yeah, it was great. We just went out for an early dinner in the neighborhood here in Brooklyn and had a good time. Awesome. With the baby, of course. Yeah, of course. So lots to talk about. I was in D.C. last week. It was awesome. But you shared this screenshot and I think it resonates probably with every small private practice owner. So I've got it up on the screen. This comes from the physical therapy billing group. It's an awesome group. Shelly, Heidi, if you guys are PT practice owners, OT practice owners, go check out the group on Facebook.

1:30 But it says, love some help. My husband, who's the owner, has been doing his own billing, a five therapist office. That's a boatload. That's a ton. Staying up until two a.m. every night, seeing eighteen patients a day himself, including Saturdays when things went kind of bad two years ago. So had some negative outcomes from a previous billing company. It sounds like says now with my aggressive scheduling, it's just getting to be too much for him. No time to deal with issues. Ideally, he'd love a full time person in the office. They're in South California, I think.

2:12 But, like, maybe we look for a virtual company or in person. Any input or suggestions? So, Dave, you shared that with me. What are your thoughts about that? Yeah, so, I mean... You have to do something. You have to figure out something. And it's either going to be outsource it or you hire a billing person in-house. It depends on the total volume of claims and visits per week and per month and all that. But as an aside, This practice, you got to treat it like a business. I just did a solo episode screen share of Joe Lowe's post on LinkedIn about the physical therapy M&A market for twenty twenty five.

2:55 And you commented on that. And I screen share that as part of my episode. And one of your comments, Tony, was, you know, basically like this will work or X, Y, Z, like with that market report, like the improvement or the ability for practices to grow or maintain profitability and all that. Your your comment said, basically like it'll work or this is possible if you treat the therapy practice like a business. And this screen share is no different. I think it's, respectfully, respectfully, I think it's crazy for a practice owner, a physical therapist practice owner that has five physical therapists to be treating eighteen patients per day and doing the billing.

3:39 You need an intervention, respectfully. You need an intervention. You need Sturdy McKee, Jamie Schrier. You need a coach to help you delegate stuff. The first thing I'm thinking of is you need to just get out. I can't believe that there are small business owners that want to do all the stuff It's crazy. And then how do you have time to work out, go to the gym, go for a jog, I don't know, do leisurely stuff, mow the lawn, mulching, like Tony was just talking about. How do you have time to do any of that? You don't. And your head's spinning all the time. And then if you do some of these things, if you outsource it, or if you hire one or two billion people for the practice, yes, some of your income money goes to their salaries.

4:26 but you have more time for clarity to think about self pay options, to think about hiring and recruiting other therapists to replace yourself. So I have a lot of thoughts obviously about this and I just, I don't know, like Tony, like how, how does this happen? Is this something that you see a lot or you've heard a lot with practice owners that like they want to do all this stuff and then the practice kind of gets bigger over time and they never get out of those initial jobs, roles or responsibilities? Yeah, I think it's one of those things where, like I said, the comment said two years ago they had a negative experience. So, you know, I always share this story. When we started, we hired a biller. We thought a biller was a biller.

5:07 Like we didn't realize, well, there's physical therapy billers and non-physical therapy billers. So we hire this random biller. We we never get any of our claims paid. Thankfully, we still we started as a cash based business. So we had tons of income coming in. We fired that bill or hired a second bill or still no results. We lost about sixty thousand dollars back in two thousand one, two thousand two until we hired the third biller. Now, the third biller was awesome. He specialized in physical therapy billing. He reminds me actually now that I think of it of Heidi and Shelly and some of the billers that are in that Facebook group.

5:48 It was just him and a partner. They were a small, you know, service provider. And he dug us out of a major hole there. But we still had such a negative experience. Now, I think for us, what made the difference because we were in the same boat. We were seeing tons of patients. We were busy. We didn't have five clinicians. We probably had two like myself, my my wife, another two other therapists. So let's say four in total. But we were treating a full caseload and running the business and doing everything. And I think you're just on that hamster wheel. It's going so fast. You don't have time to take a breath and step off. And as clinicians, we tend to think nobody can do it better than us, whatever it is.

6:34 So we want to do it all. We're not approaching this like a business. We're approaching this like patient care. I will see more patients. I will build more units. I will do more stuff. And so you just can't do it anymore. For us, we read E-Myth, revisited it. We made the decision that we're going to treat this like a business and not a job. We took our self-worth and value away from having to do everything and being the best at everything. We went through some education, some consulting, and we actually learned how to structure a business and bring people in to put them into those roles that we had defined.

7:17 And for the next, I don't know, probably three years, we outsourced as we continued to grow, outsourced our billing. But even there, we got to the point where like, why are we paying, you know, seven percent on a million in revenue when really we could just bring it in house and probably do it better. But at that point, we had replaced ourselves as clinicians. We were no longer treating every patient every day. So we had the capacity, the bandwidth to build a billing business. And we've actually spun off billing businesses as completely separate entities because Because we had the ability to not spend eight to ten hours treating patients and then try to work on the business afterward.

8:01 Yeah, makes a ton of sense. I feel like for the small business owner, the practice owners out there, it's just, I think, a shame to not... Respectfully, we're not saying it's not a serious business. Obviously, it is. You have five physical therapists outside of the owner. Like you said, that's a meaningful practice, even if they're in network. And so... it's just a shame that I don't know like is it is it some you know small business like uh dna or ethos or something where it's like my generation and and older uh and I like to include myself in in the you know put your head down like just grind it out like it might have stopped a little bit after my age but like kind of like you know your colleagues and your friends and small business owners like Is it just easy for practice owners, business owners that are independent to kind of put their head down, just grind it out until, you know, your wife goes on a Facebook group and says like, hey, we need some help with this or that.

9:06 And it's not even it's not even that individual. It's not even that the practice owner, that's the physical therapist asking for help. So who knows if he or she even wants to help? Yeah. Yeah. Yeah. I think it is. I think it's within our DNA, but then I think there's also a lot of baggage that we bring with us. You know, what did your parents do? What were your parents' mindsets around money? I know I've still got tons of baggage from mom and dad and how they addressed money, how your spouse addresses money, what money is. We were just, I mean, every chance I get with my four boys, I always try to instill in them Who cares? It's just money. It has zero value unless you spend it.

9:49 You decide how you want to spend it. Spend it could be investing it or it could be just wasteful spending. It doesn't matter. But the point is, I want them to understand money can always be created. It can always be generated. There's no scarcity around money ever. You could have zero money and be completely happy. You could have millions of dollars and be completely miserable. So those are the lessons that I try to instill in my kids. But I recognize that I still have a ton of bad money habits from my parents who were successful in their own right. I mean, I'm not taking anything away from them. I'm just saying it's work to change the way we look at it.

10:34 Plus, going back to I think a lot of therapists just tie their value, their identity to I'm a hard worker. I was successful in school. I checked all the boxes and I did the homework. I never saw value in any of that. So I came to therapy from kind of a different perspective. But there's a lot of identity tied to doing what you think you're supposed to do. So and a lot of people still think, well, I got to work hard. If I'm not working hard, I'm being lazy. It's just not true at all. Yeah, I love it. Um, so what are, what are some, I know there's a bunch of comments. I know Joey Albritton commented, a bunch of folks commented, what would be, uh, you know, not, not that they're asking for our unsolicited advice.

11:22 They're asking that whole Facebook group or whatever. What would be like, what would be an idea or like, what would you do if you were that owner? And you know, your wife is going on the Facebook group and, uh, or what's, what suggestion would you have for, uh, for this practice owner? I think this is where you have to bring in a new set of eyes. This is where you have to bring in an outside consultant. And you have to step back and use the logical brain. You have a clinical brain. There's logic in that. It's like, well, wait a minute. If this person is doing eighteen visits a day. So let's say close to two thousand dollars in revenue generation a day, just this person.

12:02 And then there's five, potentially five other people doing comparable. You know, this practice is doing a significant amount of revenue within this, probably upwards, you know, well over half. a five hundred thousand plus close to a million in revenue, you have to sit there and be like, wait a minute, something doesn't add up. We're generating, let's say, seven hundred and fifty thousand a year in revenue. And I'm I'm killing myself doing all this stuff like you have to acknowledge there's a problem. The wife acknowledges it. Other people around you see it. You have to acknowledge it and then you have to get a fresh set of eyes.

12:43 You know, somebody to come in and look at this, give you their perspective from the outside looking in. And then you can decide like, all right, do I agree with their perspective? You know, we get patients and I tie everything back to patient care. Patient walks in the door. He loves smoking. He loves drinking. He loves eating whatever he wants, but his back pain doesn't get better. I can tell them, look, this isn't a mechanical problem. It's a chemical problem. Your body is dealing with chemical issues. If you really want to address this, we need lifestyle change. And then that that patient can make the decision. Yeah, I want to do this. I'm ready. I'm ready to make the change.

13:24 I'm going to change my diet, change my lifestyle. I'm going to start to exercise. Or they're going to say, no, I don't want that. And they're going to they would rather deal with the pain of back back pain. This guy would rather deal with the pain of burnout than make these changes because they're so fearful of what those changes involve. And a lot of times those changes are more painful. Exercising daily and eating a different diet is more painful than the nuisance back pain he's dealing with. He'd rather just deal with the nuisance back pain. But you need an outside set of eyes, somebody like you or other people that are out there that have been down that road and have seen a hundred other business models.

14:06 That's somebody that I would say, hey, take a look at this and tell me what you see. I love what you mentioned maybe ten or so minutes ago. I don't know how long we had a lot of five or ten minutes ago when you mentioned that you had tried several different billers. And this goes back to remember when we were searching, we were interviewing folks to do home cleaning. And I don't know if I mentioned this, but like the first person like we had her come twice and like it just she was super nice, but it just like took forever. It was like eight hours. Like our place, it's a condo apartment in Brooklyn. place for three hours. Now, were you paying by the hour or by the job? No, by the job. It's like, why would you not hustle to get out of here sooner?

14:51 It was a flat rate for the whole job. And by the way, that was her idea. The reason I'm bringing this up is because we tried her a couple of times and we're like, yeah, we're going to pause and then we continue the search. I think certain business owners can get in the rut of like, well, we tried that, so that didn't work. It's like what you said and what I did, then we look for another cleaner. If that didn't work, we're going to look for another and another. It's the same thing with recruiting for therapists. Some are just not going to be the right fit. They're going to be too experienced, too inexperienced. They're just not going to be the right fit.

15:33 um regardless of the challenges that this practice had with uh billing folks or billing companies or whatever like there absolutely is a great fit out there like you said you might need a coach or a consultant or some practice owner that has been there before that hired five or ten different billing companies over the years, they actually could give you maybe like a cheat sheet or a handout of like, here's the proper questions to ask. Like, here's the savvy questions to ask when you're interviewing business or when you're interviewing billing companies. Like, you know, those types of asking for referrals or asking for references and asking to speak with other business owners that they're already helping on the billing side.

16:14 So I love that. I always want to echo that, which is like there's just always more to assess and check out and never think that just because the first option or two didn't work out, that that's like the whole route doesn't work. Obviously, billing companies work. And you would think this is a lesson we already understand. The patient who comes in and says physical therapy doesn't work because they went down the street and they didn't do, you know, well with that. And that same physical therapist will then go on Facebook and say, I can't believe these patients say, you know, physical therapy won't work. And, you know, get physical therapy first and get PT first or, you know, PT.

16:55 What was your choose PT first? It's hilarious. Yes. What a conundrum. What's interesting about what you shared with the cleaning person is you, and correct me if I'm wrong, you were just at least a little bit more concerned with the amount of time it took than the quality of the job. Now, a lot of people will say- No, no, no. I'm sorry. It was like missing dusty, dirty spots or whatever. So it was both. It was low quality and it took too long. So it's like, how did that happen? Yeah. Okay, let's pivot a little bit.

17:36 You've shared a ton of information about recruitment and hiring and ads that you're running and how to bring in staff. I was listening to Dan Ariely. Are you familiar with him at all? Love him. What is he like a behavioral economics? Yeah, behavioral economics. At Duke or something. He's an author. Excellent books. Predictably Irrational is probably in my top five of like favorite books of all time. So the last time I shared some of his content, maybe it was Joey Rossi or somebody had shared he had some questionable research ethic violations and people were investigating him because maybe he didn't really carry out the research or his findings were manipulated.

18:22 I don't know. I read those opinions. Nonetheless, the idea behind the information is still valuable. Right. So one of the, the like, fifteen year ago, YouTube Ted Talks was why we enjoy the work that we do. And it got me thinking about your situation. So I'm going to share my chat GPT. And what I did. Folks, you got to jump over. You got to jump over to the YouTube. Jump over to Learn Medicare Billing or PT podcast or the Dave Kittle show on YouTube. If you're listening right now on iTunes or Spotify or LinkedIn or wherever you're watching. Yeah. So if you guys don't already do this, this is a cool little hack, but then we'll get into the main content.

19:05 Let me get up here at the top. So basically, let's say you hear a YouTube interview and you're like, yeah, I love that idea. How can I apply that idea to physical therapy? So I put in a simple prompt. I just say, hey, Dan Ariely talks about the importance of meaningful work. This is coming from a TED Talk transcript. I want you to process this and then tell me how this applies to the physical therapy private practice. And on YouTube, you can copy and paste, if you're on a desktop, the full transcript of the interview. So I put it in and then chat GPT, you know, says, OK, here's the framework, the meaningful work magnet.

19:45 The goal, create a job ad that's emotion that emotionally resonates with clinicians who crave more than just a paycheck. Therapists want their work to matter. And I'll just give you the headlines, you know, stop, start with the mission, not the money. So instead of saying we're hiring five thousand dollar sign on bonus, which we see everywhere, start with something like your work should mean something. Ours does every visit, every patient, every life we touch. And I was thinking about you because one of your main ads is talking about how much a therapist could make relative to how few visits they need to do to make that money. But anyway, tell a micro story of impact, acknowledge the trade-off transparently.

20:31 I do that. I'm like, look, guys, you're not going to make as much money working for me as you would make working in home health or a skilled nursing. But it's because... The difference in the population we treat, you know, nothing will burn you out, chew you up, spit you out more than seeing the same person in a different body every single day and knowing that you're not really helping anybody. You know, somebody shared a post about a I don't know if this is the right word, a catatonic person on hospice who a physical therapist is supposed to be helping. Like there's just there's no meaning in that kind of work.

21:12 A lot of times describe the challenge as a source of pride. Right. Why do we climb a mountain? Because it feels good to get to the top, even though it's hard. Give them ownership language, not ownership equity, just ownership language. Show that their work will be seen. Use emotional, resonant call to action. And then it gives a little sample ad. So first, what are some of your thoughts on this? Just a joke because I burst out in laughter. Give them ownership. Not of equity, though. Definitely not. That's so funny. It's the feeling of ownership, not actual ownership.

21:52 Hey, I need to do better at that, man. If I can best or better convey the staff role that they get to take ownership of. Well, I, and my therapist somewhat do like they get to make their own schedule. They get to, they get to make like what time they're going to start and end, uh, per day. They get to fit in people, you know, clients, whatever they want, they can work weekends or not. Um, I mean, I have one therapist that's averaging like two point eight patients per day and he's making just two point eight. Now, of course, I know you got to travel in between the patients and all that. And you got to travel to the first patient. You got to travel to home from the last patient. So sometimes it might come out to like a more of a workday, but two point eight patients on average.

22:38 And they're making like. They're on pace for like ninety K by treating two point eight patients per day. So it's pretty good deal. But I need to give them ownership of. Yeah, like like I don't know, like more of the is that like the touchy feely stuff? Would you say, Tony, like more ownership around that or what? Yeah. Own your schedule. You know, you, you have control. Autonomy. Yeah. Who you can treat, how you want to treat them. Like we all went to school to be professionals. I want to come into a position where I'm a professional. I think too many of us as business owners think, well, they want equity in the business. I don't think they want it. I don't think they care.

23:18 Even me as an example of, I wouldn't want to come in as an equity partner because I don't want the liability associated with your problems, your baggage, you know, and we are as a profession so risk averse. I think of a therapist. It thinks that they're on the hook for mistakes that the bigger entity makes that freaks them out. So it's like as business owners, we think, oh, they want ownership in that respect. I don't think they do. I think they just they want the independency, autonomy. They want to feel good about the work that they're doing. And yours is a great example. Like you are working with a clientele that you can make real impact with.

24:01 You can change that person's life fundamentally. You can keep them in their home or their apartment longer. You can improve their quality of life versus others. some of the other places that it's just that treadmill of CPT code, CPT code, CPT code. Nobody is going to get better anyway. If they do get better, you're going to get penalized because they're going to want to discharge early. The conventional system is designed to reward the most basic mediocre outcome. Don't get better quicker. Don't invest in innovation. Don't improve your education. That is what the system right now is designed to encourage.

24:45 And so, yeah, you give them the opportunity to step out of that negative cycle. And I do think like those emotional triggers resonate deeply. Anything else for this topic or you want to move on? No, we can move on. I sent you a link for Instagram in Facebook Messenger, unless you have some other topics. I know Jimmy's not here, but we were joking last week that I know you were at your DC, your son's class trip, but you sent us a picture. I don't have it right now, but it did look like you were at the Vatican. Jimmy, he'll mention this the next time he comes back, but we had a good laugh as if you were at the Vatican and that you were actually becoming the next Pope.

25:32 And you know what? You and the new Pope, you don't look that different. You got the same haircut and there's some similarities there. So we had a good laugh. All right, let me see if I can get this one up on the screen. Tell me what's going on with this. Okay. Okay. All right. So Jimmy McKay is not here. He's got an awesome new segment here on the show called steal the strategy. Jimmy, I hope I don't want to steal your strategy because you're not here. I just want to highlight this. I came up with this. I came across this guy's Instagram a couple of weeks ago, maybe a month ago. He had like fifteen thousand followers. Now he's got, I don't know, like twenty or thirty thousand followers. Thirty eight thousand.

26:13 Thirty. This guy is. it's kind of weird he's adding like five thousand followers per week here's this so this guy does a joke right he he holds up his phone it's him and his wife shopping at walmart or they're getting pedicures at the nail salon wherever they're at at a restaurant nice restaurant he holds up his phone and he goes what up gang hey what's going on I'm here with tina we're checking out the deals today at walmart so he acts like a fake social media influencer And obviously his wife gets embarrassed. So like, that's the funny part is she gets like, she's like, no. And like, she like runs away. And then you could see like, yeah, like there, right there, that clip of him at the nail salon. And like the wife puts her hand in front of her face and all the women that are, that are working there, all the women that are in the nail salon, they're all covering their face.

27:01 It's funny. It's funny. Here's the thing. This guy owns one or two different restaurants in Chicago. He links to the, the, uh, the restaurant on his profile. And I think the, the URL in the Instagram, the entire Instagram is a joke. He does, he just does jokes. He just, he just is a funny guy. He likes to do jokes. He goes up to the Starbucks line and he, you know, he does fake voices from different movies. Like when he goes up to the Starbucks line in the drive-through and he's like, you know, yeah, can I get a, can I get a large, you know, can I get a medium pike in a large venti cup? And then they asked for his name and he does like, you know, like an Al Pacino voice or he just does stupid, like, right.

27:45 The point of sharing this is that he's adding like five thousand followers per week. Now, of course, many of them are not in the Chicago area, but he's got Johnny's heroes and subs or whatever his like restaurant is. And he's getting more eyeballs for his restaurant that is linked here in his bio. None of his posts are about the restaurant, about his business. And so that was part that was part one. And then part two was one of the recent posts while I was following him is he was featured on the news in Chicago. And then the news anchor is mentioning, you know, oh, Johnny Anastopoulos has this funny Instagram account and he's the owner of whatever it is, whatever the restaurant is.

28:34 We don't we don't know. Johnny's beef, Johnny's gyros. Beef and Gyros in, you know, Lincoln Park, Chicago or whatever it is. So the local news anchors have featured him and his Instagram account a couple times, which then gets more exposure locally. And they even had him in the news, like a week or two ago, they brought him and invited him and his wife into the news station. And he was like on the live news. Yeah. Okay. This was, this is long winded. I'm going to cut to the chase. The question for Tony Meritato is could physical therapists steal the strategy? Could private practice owners steal the strategy where they make a, whether it's a personal account, a different account, whatever.

29:17 And they, you do an amazing strategy of video inside your clinic. And maybe some therapists don't want to do that or they can't do it or they're afraid to do it or whatever. You also have to be kind of outgoing to even do this. I think to do like the selfie video, the way he's doing it, but maybe there's other ways to do it. Could or should physical therapy practice owners steal this strategy, create kind of like a humorous account that they capture funny, stupid, laughable things in their local area, then just link to their physical therapy profile at the top of the profile. But all the content has nothing to do with the actual business. What are your thoughts? Good, bad, indifferent? Yes, a hundred percent. Yes, you can do it.

29:57 Yes, you should do it. What I think is interesting about that scenario though, and I don't know anything besides what you just shared, His personal profile on Instagram has thirty eight thousand followers. His business profile only has like thirty six hundred followers. The personal and that's what I do. You know, I grow my personal way more than I grow like branded business profiles. But the whole idea here is looking past just is this going to put more patients in my my physical therapy clinic? Because with a thirty eight thousand follower account, he can move into true influencing.

30:40 He can get brand deals. He can do product endorsements. He can do so much more with that account, even if he never sells an extra sandwich because of it. So there's huge value in capturing attention. We know we're in an attention based economy. I still get pretty much two to three emails a week of product companies that want me to do videos and endorsements for them. I don't have to do them for free anymore unless I really want the product and it's a high ticket product. But a therapist who wants to build a brand, a personal brand, absolutely, this is a great strategy. And if you want to monetize that with patient care, you probably could.

31:23 You could put out a product like Kelly Starrett has digital products for people that have physical conditions. He's never going to treat them as a physical therapy patient, but he sells these products. You could do product endorsements like, man, there's just so much you can do. And you don't have to be outgoing. Like, that's the funniest part. I hate I am an introvert through and through. I hate socializing. I love being silent. I love being by myself. But if I'm in front of the camera and I've got a job to do, I will do the job. You know, it's it's a different and I hear this a lot from a lot of influencers. It's like a switch that flips.

32:04 You're a different person on camera than you are off camera. So it's something that we should be building for all of us. And we'll have to get Jimmy's feedback on this because I did want to share this at a time when both of you were here on the show. But yeah, so that's why I wanted to show it. Hopefully, Jimmy doesn't get upset that I'm stealing his segment on steal this strategy. I think his segment was steal the strategy. So I just wanted to share that. And you're right. Also, people want to follow more of the personal accounts. They don't want to follow like corporate and business accounts. Right. So that's, that's another reason why his personal one also it's, it's funny, right?

32:45 Like it's, it's funny. Like you don't know what's going to happen. So you watch more and then you're more likely to like watch a second and a third video. Cause you don't know, like when he drives up to the drive-through at Starbucks or he, he walked into Starbucks and he ordered, um, With some Brad Pitt character from some movie, you know, any any order with the character's name and the accent or whatever. So you don't know what he's going to do. But yeah, more people want to follow the personal accounts and they don't want to follow like the corporate, you know, business accounts. And I guess, you know, I guess that's OK. That's just the way the attention economy is. There is a, I can't say the name because Jim, Jimmy's doing this interview. I don't know if he's done it already or it's on the books.

33:26 It's part of the PT pint cast series, but I think this is a, it's a home health therapist who's doing funny videos. He is on par. He's on par with So medical doctors that are out there that have, you know, million subscriber accounts. Like, I think it's just a matter of time before this account blows up. If he doesn't quit before he hits that inflection point. He is awesome. I can't wait for that, that interview to go live and go public. And so. I wanted to talk about pivoting just a little bit. I shared a post that gains traction is gaining traction.

34:08 You're not in this world, but in case you didn't know, so as a Medicare contractor provider, when I treat a Medicare beneficiary, my plan of care has to be certified. That means signed by the physician or non-physician practitioner. So it could be a physician assistant. It could be a nurse practitioner. There's a couple other options. providers who can certify a plan of care. In two thousand twenty five, Congress or whoever updated the laws made some changes that said as long as I have a referral and I have proof that I sent the plan of care for signature, I don't need a signature on the initial plan of care.

34:51 But if I extend the plan of care, change the plan of care, do anything, then I do need a signature. I can't believe the comments that I'm seeing from physical therapists who think a physician should be obligated to sign my plan of care. I've said it repeatedly. I'm like, if I'm a doctor, if I have MD after my name, I am not referring patients to physical therapy simply because... I'm expected to sign plans of care. I don't have the time for it. I don't have the desire for it. I don't have the interest in it. Like, I'm sorry, but there is no way.

35:31 Now, these docs aren't getting paid extra. There is no like benefit or bonus system for them. And think about how many patients in a day a doctor sees, how many patients on caseload a doctor manages, thousands of patients. That's hundreds of plans of care. When you sign that plan of care, you're saying effectively, yes, I agree with this plan of care. When they've never met me, they have no idea who I am. They have no idea what I'm doing. Most of the time, they don't understand what the plan of care even entails. I think this is a major issue that I've never seen discussed or addressed. And it's absurd that actual licensed therapists think doctors should be obligated to sign plans of care.

36:18 What are your thoughts on this? Well, the one comment I saw from Joey Rossi was he said there's some physicians he's spoken with that are no longer referring to physical therapy because of this specifically. That's crazy. I think so. We're licensed physical therapists. We have to have, you know, licensure. We have to do continuing education. We're CPR certified. The fact that this is still even a part of CMS is ridiculous. I don't know. You might think it's a good, I don't know. I don't know. But I think, Tony, I think it's absolutely ridiculous that a plan of care even needs to be signed. So you're saying the first initial, so the first, what, nine days or what is it?

37:00 Thirty days or what's the? So the way the law was developed, if you have a referral, because a lot of us have direct access. So I've got a guy coming in today. He's been a patient of mine for a decade. He travels back and forth to Florida. He just texted me this morning. He's like, hey, I got a muscle issue. I want to come in and see you. He's a Medicare beneficiary. He doesn't he's not coming in with a referral. Now I can see him. Medicare doesn't require a referral and my state allows direct access. But because I don't have a referral, I would still need even in twenty twenty five a signature on the plan of care if this is going to be paid for by Medicare.

37:41 If I have a referral, I don't need a signature, but I do have to prove that I at least sent the plan of care to the physician. That's the new change. I don't need the signature, but I need proof that I sent it for the initial plan of care. If I make a plan of care for three weeks, two times a week, six visits, that's the initial plan of care. If I decide to extend it... then I need a signature. It can be the duration you prescribe or up to ninety days. So if I prescribe a six month plan of care, my initial is limited to ninety days. But if I do it shorter than ninety days, then that's my initial.

38:24 And, you know, we joked about this across the country that most physical therapists are going to say, you know, three times a week for, you know, sixteen weeks or whatever. I'm joking. But like I oftentimes it's going to be like a really it's never going to be three weeks. It's going to be a bigger number. So, OK, so maximum ninety days. And at that point. What is a therapist's option? They have to send that patient to a different physician to get it signed. Say, hey, do you have your primary won't sign it, so I have to send you to a specialist. Or can they, through Medicare, can they then go visit an urgent care or some other primary care physician that's not their PCP on record?

39:06 What are you going to do? If the main doctor refuses, then yeah, you start playing the game. You start saying, okay, do you have an oncologist? Do you have a nephrologist? Do you have a orthopedic that, you know, can I sneak it through someone else and try it? Someone that's not going to read it and just sign it. And this is where my frustration comes back in where I'm like, what's the whole intent of the law anyway? When was the law generated? When was the guideline created? it was probably created before we were, I'm not, but others were DPTs. It was created back when therapists were really glorified AIDS technicians.

39:48 The doctor used to say, get this patient out of bed, walk this patient, you know, and ironically in the Medicare guideline, it specifically says if the referral is, contains all of the required elements for the plan of care. You don't need a separate plan of care and you don't need a separate signature. So back in the day when the doctor said, I want this patient to get a three, is it megahertz, whatever, ultrasound for seven minutes on left elbow, you know, we come from technicians. Like, guys, we are not the same therapists that we were thirty years ago.

40:29 but the laws never change. The laws don't keep up. The laws don't advance as quickly as we believe we're advancing. That goes back to my argument. I think most of us have left physical therapy behind. We are no longer operating as the way the world perceives a physical therapist. We are no longer operating in that capacity. So you can fight to drag the credential with you Or you can just let the credential go. The letters are meaningless. They don't help us in virtually any way because we don't get compensation for the letters that are worth what we're doing. Just let them go. Like, forget it.

41:09 What are your thoughts? Man, I always like to push back with this, because you're not letting them go, right? So a listener, a follower, someone who's watching or listening now or on the replay, they're going to say, well, Tony, are you doing that? And you're going to say no, because you guys are still licensing credential and billing Medicare and billing all the network insurances, right? So I had one guy and I can't remember his name. I wish I could give him credit. He gave me a great response. He said I was basically he said I was crazy, that I was completely wrong. He said that, you know, the credentialing allows them to do dry needling legally. The credentialing allows them to do all of these services within the law that he wouldn't be able to do if he let his license go.

41:55 It dawned on me. I was like, yeah, you're right. He's a hundred percent right. I'm a hundred percent wrong relative to his situation. He wants to do those things. I don't want to do those things. I have zero interest in dry needling. I have zero interest in Pretty much any of the things that require my licensure. So to your point, Dave, well, why haven't I let it go? Why haven't I followed my own advice? Well, it's because I still have a successful business that runs on a thirty year old model. A new therapist coming into business today doesn't have the advantages that I have. And you hear this stuff in popular media when they talk about boomers versus younger generations.

42:39 It's true, guys. I have zero, zero debt to any university. I have, you know, the history with the referral sources. So I have zero marketing expense. I have the history with my systems. I can operationally deliver services for a fraction of the cost of somebody new coming in and trying to build the business that I have. I have legacy experience. that nobody else in my area has. I have low overhead because I signed a lease and I've got a lease that hasn't gone up in monthly rate for like ten years. You can't do what I do. So I'm not going to.

43:20 It's like the guy, me, who has a thirty year mortgage at a three percent interest rate. I'm not going to sell my house because of the interest rate on my mortgage. I'm not going to get rid of those credentials because those credentials are still profitable for me in the model that I have. But if I was a big time influencer, if I had hundreds of thousands of subscribers, that's where the original context came from. If I wanted to treat and I wanted to treat across state lines, man, the first thing I'd do is I'd get rid of the letters after my name and I would just go independence for true, full autonomy. That if you're doing virtual and you're doing, you know, the triaging we talked about before or the, you know, remote programming or you're kind of doing some telehealth or whatever across state lines.

44:07 That is that that is I have to agree with you there. That is the easiest way to go because of the whole compact thing. And you got to, you know, get licensure in all these different states. And there's some states now that are what is it, fifteen or maybe twenty at the most. That's a compact you get. licensed in one of those states and now you have uh licensed reciprocity or whatever in the compact across all those states but not every state and if you're yeah if you have a social media following and you're going to be doing some of the triaging and some of the borderline therapy medical type questions and you know coaching or treatment or whatever you want to call it virtual care then yeah it does make sense to drop the license I a hundred percent agree with that And I think we've seen proven models from non-licensed PTs or clinicians that are working.

44:56 In the finance world, we should get Will Butler back on. It's been forever since I've talked to him. Definitely. But every time I've pushed him to get on social media, he always says he can't because there's so much restriction on what he can say and what he can share. And when you look at Dave Ramsey and you look at the big social media influencers in the finance space, they've all let go of their their licensing. because they can't say the things that they want to say and still be compliant with the regulations. And I think the same applies to healthcare. There's a bunch of medical doctors and healthcare influencers that had to let go of their licensure But they're making ten million a year because of the social media reach that they've built and the businesses and the tools around that.

45:51 So I just – With Dave Ramsey, was he a CPA or was he like a financial – what do you call it – CFA or whatever. Or yeah. Yeah. I think he had all of those licenses. He, I don't even know that world, but I had read interviews and looked into it. But a lot of the newer ones, too, same thing. They're attorneys, you know, attorneys that had their they passed the bar. They were licensed and then they let it go so they can go on to social media because that was the direction that they wanted to go.

46:31 And they couldn't do it, but they still had their knowledge. And that's the same thing with us. Like, you're never going to take away my knowledge of physical therapy. I just I can't deliver one on one physical therapy advice, but I can basically provide education, information, influence, you know, all of those kinds of things, not practicing physical therapy. not having liability insurance for physical therapy, not having to do ridiculous waste of time continuing education for the twenty four hour credit hours that are virtually meaningless. Because, you know, we know so many people that just go there, check the box and they get the credit.

47:14 Like none of this stuff has any impact. Agreed. Agreed. yeah I uh there's a there's a ton of therapists that just what is there's different websites that are like ninety nine dollars a year or something and you just the physical therapist I won't mention any names but go on there like the day before their ceus or uh you know your your license is about to be renewed or whatever they go on like the night before and they you know do a bunch of like whatever courses and just to just to get the amount of courses done for license renewal. And then I think I don't know about your state, but like our license renewal is like it's like the honor system. It's like, yes, I just click a box like, yes, I certify or I don't even know if it says certify. I agree or yes, I I don't know if it is.

47:58 It doesn't say a test like I attest that I have or whatever that I have completed all the continuing education courses. And maybe if there's a random audit, I guess you have to show your content certificates or whatever to the board or the licensing body or whatever of your state. But yeah, I agree that whole thing is a joke too. Yeah, I mean, I use physicaltherapy.com. It's ninety nine dollars for twelve months. But if you do it, you know, like four months before they're due, you can get your twenty four credit hours and then you can do another twenty four credit hours in the next calendar year for the next two year period. So theoretically, it's forty nine dollars or whatever for each one.

48:45 Now, look, I'm not against education. I work every single day to learn new stuff and I want to learn new stuff. My point in this is the person who doesn't care about learning new stuff isn't going to learn new stuff. You can't mandate it. You can't force it. And there's nothing worse than a law that has no real impact and no real effect. And the law just burdens the people who want to do a good job more because the people who don't care, they're not following the laws anyway. So it's just a waste of time, money, effort, compliance. Uh, that was great. I know we're a little bit early, but let's wrap up the episode.

49:25 So what do you think? I want your, I'm going to give you your parting shot. What do you think is the most like emotional impact of finding a new therapist to join your organization? What is, what is the thing that's the most rewarding? That is the most meaningful in what you do, the way you do it. And I don't know if I'm going to get this right. I mean, it's not even for anybody else for you. Okay. No, I thought you were saying, Oh, for me, the emotional part of me finding a new staff, physical therapist. What? No, in your business, you as a therapist in your business, what's the most meaningful part of you doing your job for you?

50:08 Uh, having the patient or client voice that they were able to do XYZ emotional thing like travel to their son's college in St. Louis or being able to walk confidently in public with less of a tremor or with better balance so that they are able to walk their dog in the park so that they can do something in the world better than they could without me, like before they met me. I think, I mean, that's one for sure. And I think you would say you would take a little less money a year to have that kind of meaningful impact on somebody's life versus maybe making a thousand or two more a year, but knowing that nothing you did all year had any benefit or any real impact on the patients you were working with.

51:07 Don't you agree? I agree. Yeah. Same for me. Like my at this stage of my life, especially fifty years old, I am I am working for the meaningful impact more than I am working for the money, you know, and so I will do hard things. I will sacrifice more if I know the sacrifice has meaning on the other side, as opposed to just working harder daily. doing meaningless jobs, meaningless tasks for a little extra money. The extra money just isn't worth sacrificing the importance of having an impact on someone.

51:48 So guys, we're done. And I think today is Tuesday. It is Tuesday, May thirteenth. Come back Thursday. Jimmy McKay will be back with us. Eight thirty a.m. Tuesday, Thursday morning. Dave Kittle show. Go check it out on iTunes and YouTube. And we will catch you guys next time. Thanks, Dave. Thanks, Tony.