While building a stable, high retention family practice is easy, it depends on two things.

The first is specific communication strategies (which I covered last month) so patients value chiropractic enough to put you on their health care team for wellness.

The second is great cash plans so patients can afford the care for their entire family. There are specific guidelines for establishing cash plans so they are legal.

I have had a cash practice for 23 years. I brought the cash practice seminar to our profession 15 years ago while practices were still thriving on insurance reimbursement, yet about to enter a new era in cost containment resulting in practice strangulation for those solely dependant on insurance. I had to make sure doctors were getting the best cash plans available to accomplish practice growth, retention and stability.

But most important, the plans had to be affordable to the patient, yield the doctor the most income without creating a "work for nothing" consciousness, and be legal in all states.

Before I give you these guidelines, it is important to mention that many doctors are still using plans that are vulnerable to legal scrutiny. Although there could be gray areas in certain states, my attorney's research resulted in consistent guidelines that are safe for everyone.

The major issue behind having legal prepay cash plans seems to hinge on the question of the assumption of risk (by the doctor for the patient) especially for fortuitous events. In other words, if the plan could be interpreted as providing care for any future injury, accident, exacerbation, pain or even a wellness check, it is construed as providing insurance without a license and is illegal.

Prepay cash plans in themselves are not illegal, but must be structured as "fee for service." You must stay away from unlimited care for a fixed fee, cap fees, year long programs or any programs structured around a specific period of time. Although these plans are attractive plans to build "volume practices," several problems occur.

First, with any "fixed" or "capped" fee, patients are not paying for all the adjustments they are receiving. Even if a preset number of adjustments is listed, the patient is given these adjustments over a specific period of time, most commonly one year.

For instance, take a plan that lists 80 visits for one year at a prepay price of around $2,000. Visits are laid out with a 3-2-1 format. The reality is the majority of the practices using this plan are spinal correction rather than musculoskeletal, symptom- based, so correction stays at 3x/wk. for a long time and 80 visits are used up long before the year is over or total correction is achieved.

The doctor, therefore, continues to treat the patient (for free) until the time frame of one year is up because the plan agreement stated, "additional visits would be included as determined by the doctor for necessary flare-ups, slow healing, etc..." This can be construed as assuming risk. In essence, the capped fee is the same thing as unlimited service for fixed fee. What it says is the fee is being fixed or capped so the patient won't have to pay any more for any service needed. If this was fee for service why would the word "capped" even be necessary?

Second, a volume trap occurs when volume goes up, but many people are not paying. The D.C.'s conscience needs to be okay with this, otherwise a burnout occurs from the doctor feeling under- compensated for the workload he or she is doing. This can become a violation of the "fair exchange principle." Not to mention, as volume goes up more staff is needed, but the doctor's income has not risen in proportion to the volume as expected.

The best -- and perfectly legal -- plans that I have been using and teaching for a number of years provide fee for service, fair exchange, three times the income from other unlimited service or capped fee plans...and families are happy to pay.

Use these guidelines to prepare your own:

*** Decide how many adjustments patients can buy at one time and list the retail and discounted amounts. Example: 25-50-100 visits.

*** Prepare a chart they can easily understand illustrating these amounts.

*** Itemize your adjustments, re-exams, re-x-rays or any other service included within this plan. Example: 50 adjustments at 3x/wk will last about three months. The patient will get two re-exams and one re-x-ray during that period of time. After you show the itemized and accumulated retail fees, show the discounted fees (usually 25-30%) for prepaying.

Note: It is acceptable to prepay for re-exams and re-x-rays for monitoring progress but it is illegal to provide these services occasioned by fortuitous events.

*** Never sell a prepay plan based on time, only a specific number of adjustments. The previous example was to show the approximate time it takes to use up 50 adjustments in a structural corrective program. The adjustments would be sold to the patient in groups of 50 without a time frame restriction, expiration, etc.

*** An understandable refund clause must be written on the plan and given to the patient in the event a patient does not use the prepaid number of adjustments.

*** If you are billing insurance you cannot have a higher adjustment fee for insurance than for cash. Waiving or discounting deductibles or co-pays (NOOPE -- No out of Pocket Expense) is illegal.

*** The retail adjustment fee and the discounted fee must be on the patients receipt and the discounted adjustment fee is put in the total column.

*** Check with your state association, attorney general or insurance commissioner to determine if your state requires prepaid fees are to be kept in escrow.

*** For families, have an increasing discount percentage for each member from the prepaid amount. Example: 10-20% off the second family member, 20-30% off the third etc. Come up with a fee you would be comfortable paying without giving it away.

Stick to these guidelines and regulate your discounts to what you're comfortable with for families. But by all means, do fee for service to protect yourself and our profession.