F0nzie's Cash Private Practice - The Updates

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Mine is about 5%. As there is a 24 hr cancellation policy, I still collect my fee. Patients get emails and phone reminders, so there are few valid excuses.

I figure you can automate the e-mail reminders through whatever EMR you guys are using, but what about phone calls? How do you guys manage this? Is there some way to do this without having to hire an office manager/secretary?

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I figure you can automate the e-mail reminders through whatever EMR you guys are using, but what about phone calls? How do you guys manage this? Is there some way to do this without having to hire an office manager/secretary?

I'm too busy to not have an office assistant. Actually considering a 2nd.
 
I'm too busy to not have an office assistant. Actually considering a 2nd.

Good problem to have. I was just assuming I'd work for myself in solo PP without hiring any office assistant. That way I could do a solo 401k and put away more for retirement and not have to deal with Backdoor Roth problem if one has a SEP-IRA. Not an option if I have an employee who is not a spouse. How do you handle this? Is your office assistant only part time?
 
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Good problem to have. I was just assuming I'd work for myself in solo PP without hiring any office assistant. That way I could do a solo 401k and put away more for retirement and not have to deal with Backdoor Roth problem if one has a SEP-IRA. Not an option if I have an employee who is not a spouse. How do you handle this? Is your office assistant only part time?
You can still do a solo 401k and have a non-spouse employee as long as said employee doesn't work 20 hours or more per week for you specifically.

I'm in a group of 4 sole proprietors who split one full-time office manager equally. She technically works 10 hours/week for each of us and, therefore, I am still eligible for a solo 401k plan.

As long as you share an employee with at least 2 other providers equally or 1 other provider but less than 50% of the employee's time (based on what you pay the employee), you would remain eligible for a solo 401k. This is something to consider when negotiating office space and administrative/secretarial support.
 
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Good problem to have. I was just assuming I'd work for myself in solo PP without hiring any office assistant. That way I could do a solo 401k and put away more for retirement and not have to deal with Backdoor Roth problem if one has a SEP-IRA. Not an option if I have an employee who is not a spouse. How do you handle this? Is your office assistant only part time?

That's a more complicated question that you may want to research. There are ways to hire the person as a contractor, but that also gives them more freedom, etc.
 
You can still do a solo 401k and have a non-spouse employee as long as said employee doesn't work 20 hours or more per week for you specifically.

I'm in a group of 4 sole proprietors who split one full-time office manager equally. She technically works 10 hours/week for each of us and, therefore, I am still eligible for a solo 401k plan.

As long as you share an employee with at least 2 other providers equally or 1 other provider but less than 50% of the employee's time (based on what you pay the employee), you would remain eligible for a solo 401k. This is something to consider when negotiating office space and administrative/secretarial support.

Makes sense. Part time seems like the way to go for office assistant.
 
What office chair do you guys recommend? If I am going to be sitting for so long, it would be nice if my chair is really comfortable? Imagine instead of sitting, you taking a walk around the garden/building with your patient.
 
What office chair do you guys recommend? If I am going to be sitting for so long, it would be nice if my chair is really comfortable? Imagine instead of sitting, you taking a walk around the garden/building with your patient.

Office max desk chairs baby. Look out for the sales! If you want something nicer for therapy look into club chairs.


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Balance ball for the desk. Do psychotherapy while working on core strength.

Ive done this the past two years, caveat being that I am in CAP. Pts get excited, family members are often confused but I've never had anyone appear to take me less seriously. Where I went to med school, a lot of gen peds attendings used balance balls in their offices and I'm glad I picked this up from them.
 
Ive done this the past two years, caveat being that I am in CAP. Pts get excited, family members are often confused but I've never had anyone appear to take me less seriously. Where I went to med school, a lot of gen peds attendings used balance balls in their offices and I'm glad I picked this up from them.

Balance balls seem like a hazard. Ever had a 250lb autistic child give you a running jump hug? Strong comfy chairs are a must after that.
 
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Balance balls seem like a hazard. Ever had a 250lb autistic child give you a running jump hug? Strong comfy chairs are a must after that.
You have to train your core so that when a child of any size gives you a running jump hug, you can stay on your balance ball. :)
 
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For all the private practice docs,
Do you use an EMR at your practice, or paper charts? If EMR-which one? Also, do you check vitals at every visit? Do you have parents sign a consent for their child to be evaluated, or have the patient sign to be evaluated, or is this implied by their presence/attendance at appointment?

How are you liking it vs employed practice?

I am looking into starting something in the next couple of years, and just starting to look into practice models, etc. Kind of overwhelmed by it all...
 
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For all the private practice docs,
Do you use an EMR at your practice, or paper charts? If EMR-which one? Also, do you check vitals at every visit? Do you have parents sign a consent for their child to be evaluated, or have the patient sign to be evaluated, or is this implied by their presence/attendance at appointment?

How are you liking it vs employed practice..

I prefer paper, but utilize EMR for scheduling, lab results, eRx, etc. Always have consents signed. Vitals when I deem them to be potentially relevant. I am not an 8-5 person, so I much prefer private practice.
 
Another question - if I am working at a clinic that accepts insurance but I would like to open a part time practice that does not accept insurance, do I need a new NPI?
 
No. Your NPI is like a SSN.

This is incorrect. You should get another NPI for your part time practice as a "facility NPI" (i.e. your private practice is a technically a facility). Only bill using your facility NPI for private patients. Ideally, your personal NPI should also be separate for each facility, but if you already credentialed with the facility you worked at using your personal NPI, it's a bit too late...

Remember, insurance contracts goes with facility, not provider. Except Medicare. That one goes with provider. You are either in or out regardless of where you are. (Except you are not: you are par in, non-par in, or out).

That said, in your facility contract, especially you are full time, there might be a clause limiting your ability to practice outside of the facility. This is usually called "non-compete", though common parlance "non-compete clauses" refer to non-compete applications after termination. Nevertheless, in practice I've noticed that it's often very common for people to practice outside a facility ("moonlighting") even though their contracts said they shouldn't or all their clinical revenue should be routed to the facility. This is technically a breach of contract, and if the facility decides to sue you later to recover what they believe they are entitled to, it would be difficult to argue against in arbitration. However, as far as I know, this kind of lawsuit does not happen very frequently. Facilities don't typically care about the whatever tiny amount you generate through moonlighting and such arbitration could easily cost more than whatever is recovered, unless something very unusual happens (e.g. you started a competing facility on the side that "steals" patients).

Based on my experience, there are also LOTS of situations where the locum provider isn't technically credentialed (i.e. the individual NPI is not credentialed in-network with an insurance company and/or is opted out of Medicare). However, the facility (i.e. typically a hospital or community clinic) uses a different number to bill for reimbursement (i.e. their "medical director"). This is a legal gray area. Is the medical director personally involved in supervising? What kind of threshold is required for billing using a different provider number? Typically they are spelled out in group insurance contracts, but in practice insurance companies (even Medicare) RARELY file lawsuits or even audits for improprieties, unless such improprieties are egregious. Even when they do, audits often don't reveal much, as the provider may have long left the facility and responsibility for such improper billing rests in the facilities credentialing department. The facility might pay back whatever the audit reveals to be fined, but nobody is really personally held responsible. More likely scenario is the claims get rejected by the insurance company for "unable to locate provider in network", in which case the failed claim loops back to billing and gets reprocessed in some standard way. After repeated non-reimbursement the hospital eats the cost. Nobody cares. Locum's personal salary is typically not pegged to reimbursement, but rather, at worst, to billing. At best it's salaried or per hour. Audits of this type has been uncommon in mental health (compared to say gray zone billing for procedures), because the revenue is tiny and typically facilities lose money over them regardless of audits, and the response from the facility is typically--you want to fine me and shut me down, go right ahead. However, lately because of opioids and the rise of illicit rehabs and etc., some facilities are starting to become rather profitable, so perhaps one ought to prepare for more frequent audits of this type in the future.

These quirks of the American healthcare system also NP-related issues, as often group practices use credentialed physician NPIs to bill for NP visits for higher reimbursement. Technically, you are allowed to do it if the physician is the responsible person (like a resident supervised by an attending). In practice, the difference maybe the physician signs a note without knowing a lot except during team rounds.
 
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This is incorrect. You should get another NPI for your part time practice as a "facility NPI" (i.e. your private practice is a technically a facility). Only bill using your facility NPI for private patients. Ideally, your personal NPI should also be separate for each facility, but if you already credentialed with the facility you worked at using your personal NPI, it's a bit too late....

That is incorrect.
 
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you should use your personal NPI number for your solo private practice, no matter how many locations you do your private practice at.

for medicare (and for most other insurance companies) you will need to add each location as a practice location.

If you are part of a medical group, you can certainly get an NPI # for the group and then assign your benefits (medicare payments) to the group, but the billing in that case is still done under your personal NPI
 
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That said, in your facility contract, especially you are full time, there might be a clause limiting your ability to practice outside of the facility. This is usually called "non-compete", though common parlance "non-compete clauses" refer to non-compete applications after termination. Nevertheless, in practice I've noticed that it's often very common for people to practice outside a facility ("moonlighting") even though their contracts said they shouldn't or all their clinical revenue should be routed to the facility. .

Non-competes and prohibitions against outside employment are 2 separate issues. And Non-compete clauses definitely do apply during active employment.
 
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you should use your personal NPI number for your solo private practice, no matter how many locations you do your private practice at.

for medicare (and for most other insurance companies) you will need to add each location as a practice location.

If you are part of a medical group, you can certainly get an NPI # for the group and then assign your benefits (medicare payments) to the group, but the billing in that case is still done under your personal NPI

I just checked this and I made one mistake but I'm not entirely wrong:
https://www.cms.gov/Medicare/Provid...SupEnroll/downloads/EnrollmentSheet_WWWWH.pdf

"Health care providers who are individuals, including physicians, dentists, and all sole proprietors. An individual is eligible for only one NPI." (In fact, if you are a sole proprietor, you must use your SSN and not EIN in applying for your NPI).

"If you are an individual who is a health care provider and who is incorporated, you may need to obtain an NPI for yourself (Type 1) and an NPI for your corporation or LLC (Type 2)."
This describes a typical private practice set up (LLC or S-Corp). In my opinion, it's best to incorporate and get a facility NPI for billing.
 
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A few thoughts:

1) Anthem BlueCross and Aetna identify you by your group tax ID, while United HealthCare, MediCare, Cigna and Magellan identify you by your individual NPI number. But even in the latter group, there are some exceptions. I have found out the above facts when I have had moonlighters working for me (see point #4 below).

2) I really feel ethically if you are part of the insurance panel under one tax ID, then you should honor the rates across all settings and all tax ID's. I have known practices who have two tax ID's to get around that issue. I don't agree with it but people can do whatever they want. It is none of my business.

3) I have an NP who works for me. I negotiated rates for the NP and for the patients seen by the NP, the claims are billed under the NP. I would consider billing under me to be unethical as well. Plus, I spent all the time to get the NP's contract set up properly so she can work "independently" of me. I am not supposed to look over her shoulder at every single turn.

4) Under 1500 claim form, the servicing provider is always done correctly (i.e. the moonlighter, or me or the NP) while the billing provider is our corporation and our tax ID. I have never, ever cheated on that claim form. Then whatever reimbursement comes in, we just process it as it is.

Taking insurance is not bad.
 
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Does anyone here have a set-up in which they are credentialed with multiple panels including medicare in their main job, and only accept cash in their private practice? Just wondering how this works!
 
Does anyone here have a set-up in which they are credentialed with multiple panels including medicare in their main job, and only accept cash in their private practice? Just wondering how this works!

My understanding for Medicare, is that if you opt out, you're opted out for both your main job as well as your cash practice. Not sure about Medicaid. Maybe someone else with more experience will chime in
 
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