build-cash-and-wellness-plan-model

name

build-cash-and-wellness-plan-model

description

Price a compliant cash / membership / wellness-plan model for a chiropractic practice: a supportive-care membership priced to the clinical cadence and above delivery cost, the covered-active-care vs cash-maintenance boundary drawn cleanly, and the ABN/discount-compliance guardrails so a plan isn't an illegal inducement or a way to bill maintenance as active. Reach for it when designing memberships or a cash model. Used by `chiropractic-practice-lead` (primary).

Skill: build-cash-and-wellness-plan-model

Invoked by: chiropractic-practice-lead (primary). Compliance boundary co-owned with chiro-billing-compliance-specialist.

When to invoke: designing a membership / cash / wellness-plan model, or setting cash-visit pricing.

Output: a priced, compliant cash/membership model with the covered/cash boundary and discount guardrails. Regulatory specifics are [verify-at-use] and flagged for counsel.

Procedure

1. Segment the model by care type first. Active, medically-necessary care follows the insurance/covered path; supportive/maintenance and wellness care is the cash/membership model. The membership is for the maintenance patient — not a discount on covered care.
2. Cost the delivered visit. Provider time, room, supplies, front-desk, and overhead per visit — the membership floor is above this, not below.
3. Price to the clinical cadence. A wellness-cadence patient (e.g. 1-2x/month) sets the visit count the membership covers; price the monthly fee to that cadence and to value, with a margin. A plan that assumes fewer visits than patients use loses money; one priced above what they'll use churns.
4. Draw the covered/cash boundary explicitly. Document that membership visits are supportive/maintenance (non-covered) care and that active covered care is billed separately — so nothing bills as both.
5. Apply the compliance guardrails. Cash discounts and memberships can implicate discount, dual-fee-schedule, and inducement rules that are state- and payer-specific — keep the cash fee defensible, avoid routinely waiving insured patients' cost-share, and flag the ABN for the transition. This is where you route to a certified compliance professional / counsel — [verify-at-use].
6. Model the P&L. Members × fee − delivery cost = contribution; sensitivity on utilization and churn. Show the practice lead the break-even utilization.

Worked example

Wellness membership for maintenance patients.

• Cost/visit ≈ $28 delivered. Cadence ≈ 2 visits/month.
• Fee → $79/month (covers 2 supportive visits + a member rate on extras), floor cleared, priced to value.
• Boundary → membership = supportive/maintenance only; any flare that becomes active care is re-examined and billed on the covered path with fresh necessity.
• Compliance → cash fee defensible, no insured cost-share waivers; state discount/inducement rules flagged for counsel.

Guardrails

• A membership is not a discount on covered care — that blurs the necessity line and invites audit.
• Never routinely waive an insured patient's cost-share to fill a plan.
• Discount / dual-fee / inducement rules are state-specific — flag them for counsel; don't improvise compliance.