In a cash-based practice you set your own prices, but licensure still follows the patient. You need a license or compact privilege in the state where the patient is located during the visit, and that state's practice act governs direct access, consent, documentation and supervision. Medicare beneficiaries raise separate rules worth confirming with your MAC.
Cash-based practice is attractive for a therapist who wants to work across state lines. There are no payer networks to join, no per-state credentialing queues and no claim denials. What remains is the part that was never about insurance: the state where your patient is located still decides whether you may treat them.
Pricing is yours
Without payer contracts, you set your own fees, packages and cancellation terms. Many cash-based therapists use one price schedule regardless of where a patient lives, and that is a business choice, not a licensure one. Be clear and consistent about what a visit includes, what it costs, and when payment is due. Some states have consumer or disclosure rules that touch on how charges are presented, so check before you publish a price list aimed at a new state.
Licensure follows the patient
The legal question for every visit is where the patient is at that moment. A patient who lives in your home state but joins a telehealth session from a vacation rental in another state is, for that session, a patient in the other state. A patient who travels to your clinic is being treated where your clinic is.
That means a cash practice serving people in several states needs authorization in each of them. For a therapist whose home state is issuing compact privileges, a privilege is often the practical route. For patients in states outside the compact, such as California, Florida and New York, a full license is required.
Build the check into intake. Ask where the patient will be during each visit, not only their home address, and have a plan for what happens when the answer is a state where you are not authorized.
Consent, direct access and records
The practice act of the patient's state governs direct access, referral requirements, telehealth consent, documentation and PTA supervision. These differ enough that a single intake form written for your home state may be missing something the other state requires.
Review each state's rules before you accept patients there, and adjust consent language and documentation templates accordingly. Keep records to the standard of the state where care happened.
Payers still reach into cash practice
Leaving insurance does not always leave Medicare behind. Medicare has particular rules about when a physical therapist may collect cash from a beneficiary for services Medicare would cover, and those rules are stricter than many cash practices assume. If any of your patients are Medicare beneficiaries, confirm what applies with CMS or your Medicare Administrative Contractor before you take their payment.
Patients may also ask for paperwork to submit to their own insurers. Decide in advance what you will provide, and make clear that reimbursement is between them and their plan. Your malpractice carrier should also know every state where you treat, cash patients included.
Common questions
- Do I need a license in the patient's state for a cash-pay telehealth visit?
- Yes. Authorization to practice depends on where the patient is located during the visit, not on how the visit is paid for. A license or compact privilege in that state is required.
- Can I charge the same price in every state?
- Pricing is your business decision, and a single price schedule is common. Separate from price, confirm any state consumer or disclosure rules that apply to how you present charges to patients.
- Can I see Medicare patients on a cash basis?
- Medicare has specific rules about when a physical therapist may charge a beneficiary directly for services Medicare covers, and they are narrower than many cash practices expect. Confirm the rules with CMS or your Medicare Administrative Contractor before accepting payment.
- Whose direct access rules apply when a patient in another state books with me?
- The rules of the state where the patient is located. Direct access, referral requirements and any limits on treatment without a referral come from that state's practice act.
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