What should I charge for a sixty minute pelvic floor visit if I go out of network?

A sixty minute out of network pelvic visit needs to cover your cost per treatment hour, your unbilled hours, and the visits that do not happen. In most solo and two therapist clinics that math lands somewhere between $165 and $250 for a follow up, with the evaluation priced 25 to 50 percent above the follow up. But the range is not the answer. The answer is the number your own worksheet produces, because the two clinics at either end of that range usually have identical skills and completely different overhead.

The reason cash pricing feels uncomfortable is that most of us were trained inside a system where a third party set the number. Going out of network means you now own three variables you never controlled: how many hours you can actually treat, what each of those hours costs to produce, and how much of that hour you lose to cancellations. Get those three right and the price falls out almost automatically.

What follows is a build, not a benchmark. Every figure below is a stated assumption you should replace with your own.

Start with the Medicare physician fee schedule as a floor, not a target

The fee schedule is useful for one thing: it tells you what the largest payer in the country thinks a unit of your work is worth, and it gives you a locality adjusted reference point that your patients' insurers also use when they calculate out of network reimbursement.

Look up the payment amount in your own locality for a typical follow up combination, say two units of therapeutic exercise and one unit of manual therapy. Call that amount M. In most localities M for a three unit visit is well under $120 once the multiple procedure payment reduction has taken its bite out of the second and third units.

That number is your floor because it is what you would net, before any billing cost, if you stayed in network with the least generous major payer. It is not a target, because M assumes volume, and volume is the thing you gave up when you decided to spend a full hour with one patient behind a closed door.

Keep reading: Why do my postpartum patients stop doing their home program after the second week?

Calculating your true cost per treatment hour

This is the section worth doing on paper today. Start with treatable hours, not calendar hours.

Assume a solo clinician working 42 weeks a year after vacation, holidays and continuing education. Assume 26 patient hours a week is the honest ceiling for pelvic work, because internal treatment, documentation and room turnover do not compress. That is 1,092 available treatment hours a year.

Now assume 82 percent of those hours actually get filled once you account for schedule gaps, new patient pipeline lulls and the slow week after every holiday. That leaves roughly 895 billed hours.

Next, annual fixed and semi fixed costs. These figures are illustrative:

Line item	Annual assumption
Rent and utilities, one treatment room plus waiting area	$27,000
Malpractice, general liability, business insurance	$2,400
EMR, scheduling, payments, home program platform	$3,600
Licensure, continuing education, professional dues	$3,000
Supplies, linens, sensors, gloves, laundry	$4,200
Marketing, website, referral outreach	$4,800
Administrative help, 10 hours a week	$18,000
Accounting, legal, banking, card processing	$6,000
Total	$69,000

Divide $69,000 by 895 billed hours and your overhead is about $77 per treatment hour. That is before you have paid yourself a dollar.

Now set your own compensation. If you want $110,000 in owner pay plus roughly $17,000 in self employment tax and benefits you fund yourself, that is $127,000 over 895 hours, or about $142 per hour. Add the $77 and you are at $219 per treatment hour before profit and before losses.

Adding the losses back in

Late cancellations and no shows are not a footnote. If 7 percent of scheduled hours evaporate without a fee collected, your effective yield per booked hour drops by that same 7 percent, so the sticker price has to rise to compensate. Divide $219 by 0.93 and you get about $235.

Then decide on retained profit, the money that funds a second treatment room, a maternity leave or a bad quarter. Five percent on top puts you near $247. Round to $245 for the sixty minute follow up and price the initial evaluation, which runs 75 to 90 minutes of your time including the write up, at $325.

If that number makes you flinch, the flinch is information. It usually means one of three things: your assumed patient hours are unrealistically low, your overhead has a line item that is too big for your current volume, or you have absorbed the belief that your hour is worth what a payer once said it was.

Geographic adjustment and why your locality matters

Medicare adjusts payment by locality using geographic practice cost indices covering work, practice expense and malpractice. Practice expense is the component that varies most, and it varies for exactly the reason your own worksheet varies: commercial rent and wages.

Use it as a sanity check. If your locality's practice expense index sits meaningfully above the national average, your rent line and your admin line should be above the illustrative figures above, and your price should be too. If you practice in a lower cost locality and your worksheet still produces $245, look hard at the utilization assumption before you look at the market.

What the index will not tell you is willingness to pay, which is driven by household income, insurance design in your area and how many pelvic providers a patient can reach in a thirty minute drive. A rural clinic with no competitor within sixty miles can hold a price a dense suburban market will resist.

Keep reading: How do I run a first pelvic floor internal exam so the patient feels genuinely in control?

Bundled packages versus single visit pricing

Packages solve a real problem, which is that pelvic care is a course of treatment and single visit pricing invites the patient to re-decide every week. They create a different problem, which is that prepaid clinical care can be read as an inducement to receive services, and unused balances may fall under your state's unclaimed property rules.

A safer structure is a plan of care commitment with a stated schedule and a modest administrative discount, billed per visit as delivered.

Structure	Patient pays	Effective per visit	Main risk
Single visit	$245 each	$245	Weekly re-decision, higher drop off
Six visit commitment, 8 percent off, billed per visit	$225 each	$225	Requires cancellation terms in writing
Six visits prepaid up front	$1,320	$220	Refund policy, state prepayment rules

Whatever you choose, put the cancellation window, the refund terms and the expiration in the financial agreement the patient signs at intake. Verbal terms are not terms.

Superbills, out of network benefits and what patients recover

Your superbill is not a bill for the insurer to pay you. It is documentation the patient submits to her own plan for reimbursement against her out of network benefit. It must carry your NPI, your tax ID, the date of service, the diagnosis codes, the CPT codes with units, the amount charged and the amount paid.

Teach patients three questions to ask their plan before the first visit: is there an out of network deductible and how much of it is met, what percentage of the allowed amount is reimbursed after the deductible, and is the allowed amount based on the Medicare rate or on a usual and customary schedule. That third question is the one that determines whether a $245 visit reimburses at $130 or at $45.

One important limit: if you have opted out of Medicare or are not enrolled, you generally cannot issue a superbill to a Medicare beneficiary for covered therapy services in a way that lets her seek reimbursement. Get specific advice on your enrollment status before you promise a Medicare patient anything, because this rule catches new cash practices constantly.

See how PelvicPath handles this for pelvic floor physical therapy

Raising rates on an existing caseload without churn

Use a sequence, not an announcement.

1. Set the new rate for new patients only, effective immediately. Nothing changes for anyone currently on your schedule.
2. Give existing patients 60 days written notice with a specific date, and honor the old rate for any visit already booked before that date.
3. Offer current patients within an active plan of care the option to complete that plan at the old rate. Most courses of care finish inside 90 days, so the concession is smaller than it feels.
4. Raise the evaluation price first and the follow up price second, a quarter apart. Evaluations are chosen by people who have no reference point.
5. Move in one step of 8 to 12 percent rather than annual increments of 3 percent, which cost the same goodwill and buy far less.

Expect to lose a few patients. If you lose none, you were too cheap. If a 10 percent increase costs you 6 percent of your visits, revenue still rises, and the hours freed up go to new patients at the higher rate.

The variable most worksheets ignore

Every number above assumes patients finish their plan of care. They do not always, and the most common reason is not price. It is that the work between visits quietly stops, symptoms plateau, and the patient concludes the care is not helping.

That makes home program follow through a pricing input, not a clinical afterthought. Each patient who completes eight visits instead of four doubles the return on the marketing dollars that brought her in, which is the fastest way to make a higher rate feel justified to both of you.

PelvicPath is the practical piece here: it sends the home program, records what the patient actually completed each day, captures symptom flags between visits, and gives you a short summary before she arrives. You walk into the visit already knowing whether the plan was followed, which means fewer wasted sessions, cleaner progress notes and a caseload that finishes what it starts. Build your rate on your own worksheet, then protect it by protecting the days between visits.