Your Schedule is Full, So Why Are You Still Struggling?

You’re booked solid. Your staff is hustling. Patients are getting results. But at the end of every month, you’re still wondering where the margin went. For many physical therapy leaders, this is the new reality. You’re doing everything right—at least everything the traditional model told you to do—but it’s not enough anymore. Costs are rising. Staff need raises. Rent keeps climbing. And yet your top-line revenue barely moves.

It’s not that you need to work harder. You need to get paid differently.

The Squeeze Is Real

Margins are tighter than ever. Insurance reimbursement isn’t just flat—it’s eroding. Meanwhile, your business costs have grown across the board:

• Labor costs are up, and your team deserves to be paid fairly.
• Rent and real estate aren’t getting cheaper.
• Technology, compliance, and billing all come with added complexity and cost.

And yet, you’re seeing more patients than ever. Many practices are booked out for weeks but still struggling to cover the basics. It’s frustrating. It’s unsustainable. And it’s not your fault.

The traditional insurance-based model of growth—“see more patients, bill more codes”—is broken. If you’re feeling squeezed from both ends, it’s because the system is working exactly as designed: more effort, less reward.

Why More Volume Isn’t the Answer

It’s tempting to think the solution is just more volume. More patients, more visits, more throughput. But most PT practices are already at or near capacity. Adding more patients often means:

• Shorter visits and rushed care
• Burnout for your staff
• A worse experience for patients
• And no guarantee of higher margins

Even if you manage to squeeze in a few more visits, it’s often at the cost of quality—or sanity. And if those visits are low-reimbursing or require complex billing, they might actually lose you money.‍

Here’s the hard truth: more visits aren’t the lever they used to be. You can’t out-volume a broken payment model. What you can do is take control of how—and from whom—you get paid.

What You Can Actually Do About It

If more visits aren’t the answer, what is? Here are a few levers practice leaders are pulling to stabilize margins and build a more sustainable business:

1. Negotiate Better Rates

Some larger groups are pushing back on stagnant payer contracts—but results vary widely. Without leverage (like strong outcomes data, patient volume, or geographic dominance), most negotiations don’t lead to significant increases. 58% of practices review payer contracts review payer contracts annually—if you're not already doing this, now is a good time to do so. Make sure you're prepared with objective outcomes data that highlights your practice's impact. This exercise is often reserved for larger groups with strong reporting and payer relationships—though that doesn't guarantee success in the negotiations.

‍2. Improve Coding and Collections

Many practices leave money on the table due to errors, underbilling, or delays in collections. Improving coding accuracy, reducing denials, and tightening AR processes can stabilize cash flow and eliminate unnecessary losses. In fact, 56% of practices are dealing with extended days in A/R—thankfully, 86% of claim denials appear to be avoidable. While this is a worthwile exercise (and certainly something every practice should do), this merely stops the bleeding—it doesn't unlock new revenue.

3. Refine Your Payer Mix

Not all visits are created equal. Medicare might reimburse $90 for a visit, while a commercial plan pays $65—and some are even lower after deductibles. By analyzing performance by payer and attracting high-value traffic from your best contracts, you can improve revenue per visit without changing volume. You'll want to review your existing visit data to understand your current payer mix, then use a combination of targeted campaigns and schedule optimization to execute this strategy.

‍4. Add Cash Pay or Subscription Offerings

Offering cash-based services—like performance training, injury prevention, or maintenance subscriptions—can unlock new revenue without adding insurance complexity. This is especially appealing to patients with high deductibles or limited PT coverage. Cash pay programs can lead to increased patient satisfaction, lower costs per visit, and higher payment per visit than traditional insurance—all without the headache of chasing insurance reimbursement.

‍5. Explore Employer Contracts

Direct-to-employer (D2E) partnerships allow you to bypass insurance entirely, offering packages that align cost, access, and outcomes. Employers are increasingly frustrated by rising MSK spend—especially from surgeries and injections. A 2023 study from the Business Group on Health found that 76% of employers rank MSK conditions among their top three cost-driving conditions, with over half of the overall spend coming from surgery and other invasive procedures. With cost pressures mounting, 75% of employers are actively having conversations about direct contracting—it's an important time to join the conversation.

6. Automate Where It Matters

Marketing, intake, scheduling, and reactivation are often managed manually—or across disconnected tools. Automating these workflows improves efficiency and reduces cost-per-visit without compromising care. Consider evaluating solutions that allow you to maintain your practice operations under a single product, like an integrated digital front door, lead management, and marketing automation workflow.

Each of these strategies can help. But only a few actually change the model. If you’re going to survive this next chapter in rehab therapy, you can’t just tweak around the edges—you have to rethink how you grow.

Building a Better Future Means Rethinking the Model

If your practice is feeling the squeeze, you’re not alone—and you’re not doing anything wrong. The reality is, the traditional growth model in physical therapy is broken. It was built for a different time, with different economics. Trying to make that model work harder—by seeing more patients, billing more codes, or negotiating with payers—might help around the edges, but it won’t create the margin you need to grow, reward your team, or build long-term sustainability. To move forward, practice leaders have to ask a different question:

Not “how do we get busier?” but “how do we get paid differently?”

There are multiple paths to explore—from optimizing your case mix, to offering consumer programs, to contracting directly with employers in your community. The best solution depends on your goals, your market, and your willingness to challenge the status quo.

Ready to Think Bigger?

If you’re looking for a more sustainable way to grow—without burning out your staff or selling more of your time—Second Door can help. We work with practices across the country to unlock new revenue through employer partnerships, subscriptions, and smart automation tools that put you in control of how you grow. You don’t need to work harder. You need to get paid differently.