Tools for starting a private practice

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Indodo said:
I've been doing PP for almost 3 years now.

Here are some things I have learned, my top 10 list.

1) The start is slow. I would recommend having a side job initially if you have a family or big loans etc. If you can live off a resident type salary, you can probably jump right in.
2) Cash patients are not that easy to find if you live in a busy area. I decided to take insurance and am thankful I did. You can slowly wean off the insurance if you need.
3) Overhead can really vary. If you aren't careful, your overhead can get up to 50% or more of your practice. I have mine around 25-35% now.
4) Do the secretary/billing stuff yourself early on. As you get busier, hire people. Your percentage of overhead will go up but your overall productivity will go up as well and your headaches will go down.
5) Be EMR proficient. Don't just use one, be good at it. Especially if you take insurance, the templates help with the coding but also with writing scripts, labs and having access to notes when you are out of the office. It can be beneficial to have one that local doctors are also using.
6) Get to know PCPs. Everyone says get referrals from therapists or advertising. Nobody will send you referrals like PCPs (except insurance panels). I don't have a website, I never sent flyers to therapists. I just visit one PCP office per month.
7) Have a comfortable work space.
8) Try to work with a group if you can. I know psychiatrists are often loners but sharing overhead is the best decision I made for my bottom line. Also helps with coverage on vacation.
9) If you don't want to go it alone, join a group that will pay for productivity. Make sure the overhead is less than 40% (they give you at least 60 cents on every dollar you earn).
10) Be a good psychiatrist.

I do have a question for others.
What percentage of revenue is going to overhead for other psychiatrists and what do you do with it? For example do you have secretary, biller, your own office or sublease, free EMR or paid (or paper charts), answering service and any other expenses.
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Great list. What about all of you who are doing PP part time (weekends, evenings, etc)? I have a spot that offered me including overhead , part time office, etc, that includes NHome work as well that was able to negotiate to 20%. Are any of you doing Private practice part time only in addition to inpatient work and are you doing everything yourself or using colleagues space?
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Doctor Bagel said:
To follow up on Fonzie's threads and some others in this forum, I'm wondering if it would be useful to put together resources for starting a private practice. With that aim, I was thinking about compiling threads on this topic and having those of us interested in this topic share resources/tools/tips as they come along.
Click to expand...

Please post Recommendations for billing companies and any experience with practicefusion EMR. Has anyone worked out of shared office space viz Regus ?
 
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I was wondering, for people that are doing these concierge type practices where they are trying to have that personal/available practice model? Are there any legal issues that psychiatrist have to keep in mind when seeing patient's, lets say in their home or over the internet? What about meeting in public places like a coffee shop?

I heard that some people use Skype for Telepsych and that it is encrypted so that it is HIPAA compliant. I am not convinced.
 
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carlosc1dbz said:
I was wondering, for people that are doing these concierge type practices where they are trying to have that personal/available practice model? Are there any legal issues that psychiatrist have to keep in mind when seeing patient's, lets say in their home or over the internet? What about meeting in public places like a coffee shop?

I heard that some people use Skype for Telepsych and that it is encrypted so that it is HIPAA compliant. I am not convinced.
Click to expand...
skype is absolutely not hipaa compliant

it's not uncommon in some models to meet people with serious mental illness or disturbed youth who are hard to engage in public settings. However it is asking for trouble doing so in a concierge model - you are more likely to find these patients attractive, the boundaries are more likely to get crossed/violated, their expectations and level of entitlement will be higher, your capacity to manage the transference will be impaired, and they are more litigious.
 
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Any input about networking and how to increase your referrals if you are new in a city? I recently started my private-pay practice (no insurance) in an affluent area where most psychiatrists/therapists are cash pay, but I am not certain whom I should approach to get referrals from beside psychology today and networking with other therapists. I read here that PCPs are a good source. My hesitation with PCP has been that most PCP see insurance patients and they get disappointed to hear that you do not accept insurance. Do you just show up at PCPs offices and request to see the doctor? Or do you try to get connected through phone/email?
 
CAPsychiatry said:
Do you just show up at PCPs offices and request to see the doctor? Or do you try to get connected through phone/email?
Click to expand...
Disclaimer: I'm making this all up but it sounds good to me.

They're busy so likely wouldn't really appreciate you just showing up. I'd call in advance, tell them you're new to town and want to take them to lunch to get to know those in the area better. If they sorry of know you they'd be more likely to recommend you.
 
splik said:
skype is absolutely not hipaa compliant

it's not uncommon in some models to meet people with serious mental illness or disturbed youth who are hard to engage in public settings. However it is asking for trouble doing so in a concierge model - you are more likely to find these patients attractive, the boundaries are more likely to get crossed/violated, their expectations and level of entitlement will be higher, your capacity to manage the transference will be impaired, and they are more litigious.
Click to expand...

FaceTime is, according to the VA however. http://www.va.gov/trm/ToolPage.asp?tid=7953
 
CAPsychiatry said:
Any input about networking and how to increase your referrals if you are new in a city? I recently started my private-pay practice (no insurance) in an affluent area where most psychiatrists/therapists are cash pay, but I am not certain whom I should approach to get referrals from beside psychology today and networking with other therapists. I read here that PCPs are a good source. My hesitation with PCP has been that most PCP see insurance patients and they get disappointed to hear that you do not accept insurance. Do you just show up at PCPs offices and request to see the doctor? Or do you try to get connected through phone/email?
Click to expand...

The part about PCPs and insurance is absolutely true. They don't like it when you don't take insurance. Generally the PCP referral source is really better for those taking insurance.
I do it face to face. You can just show up but it is better to make an appointment, bring lunch etc. (enough for the secretaries/MAs).
 
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Is it true that with inpatient contract you can round with your patients and once you are done you can go to your second job?
If yes, that would be a good way to start a private practice gradually.
 
I have a question about directly billing patients in a private setting. My practice will be rented space at an substance use treatment facility. I do some work for them where I will occasionally see admissions. To further complicate the situation I will also be do some part time outpatient work through a hospital organization in another state. If I'm required to take insurance through the hospital position do I have to take it through my private practice as well? Someone told me that if I did not take insurance one place but I did at another location that would be fraud.
 
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stat777 said:
I have a question about directly billing patients in a private setting. My practice will be rented space at an substance use treatment facility. I do some work for them where I will occasionally see admissions. To further complicate the situation I will also be do some part time outpatient work through a hospital organization in another state. If I'm required to take insurance through the hospital position do I have to take it through my private practice as well? Someone told me that if I did not take insurance one place but I did at another location that would be fraud.
Click to expand...

Insurance contracts are typically location specific, but certainly read yours thoroughly.

A problem may occur if you are renting space at the same location where you accept insurance for the treatment center.

I would get space elsewhere.
 
Indodo said:
The part about PCPs and insurance is absolutely true. They don't like it when you don't take insurance. Generally the PCP referral source is really better for those taking insurance.
I do it face to face. You can just show up but it is better to make an appointment, bring lunch etc. (enough for the secretaries/MAs).
Click to expand...

Really? The pharm rep thing? D:
 
The APA website has some good information for starting a private practice. I suggest you guys check it out. One things that I am curious about is the legal paperwork associated with a private practice. The paperwork patients sign when entering a patient doctor relationship with you. What kind of lawyer should one seek out to get all this done? Anyone even doing this?
 
I was wondering if anyone has any recommendation or can share their experience about finding a good small business bank?
 
Part-time private practice after a day job - do you rent your own office for X and try to rent out rooms, or rent a small room from an established provider for 0.75X? I know it probably varies by geographic location, but what do you guys spend on rent each month?
 
JustAGuy said:
Part-time private practice after a day job - do you rent your own office for X and try to rent out rooms, or rent a small room from an established provider for 0.75X? I know it probably varies by geographic location, but what do you guys spend on rent each month?
Click to expand...

If private practice is planned to be part-time only, I would sublease from another clinician. No need to add extra hassles on top of a part-time job.
 
carlosc1dbz said:
I was wondering if anyone has any recommendation or can share their experience about finding a good small business bank?
Click to expand...

Most banks will be able to set up a lockbox account which you can have checks/payments/electronic fund transfers sent to. The cost is $100-$200 per month, depending on how many deposits you get
 
zolof said:
Great list. What about all of you who are doing PP part time (weekends, evenings, etc)? I have a spot that offered me including overhead , part time office, etc, that includes NHome work as well that was able to negotiate to 20%. Are any of you doing Private practice part time only in addition to inpatient work and are you doing everything yourself or using colleagues space?
Click to expand...

What would the average overhead cost be? What should it be with a physical office? Is it any different for telepsych only?
 
Notyetaphysician said:
What would the average overhead cost be? What should it be with a physical office? Is it any different for telepsych only?
Click to expand...
We charge $450/month to rent office space for one day/week. This includes the office space and full secretarial/administrative support (reception, billing, scheduling, phone calls, etc.).
 
medium rare said:
We charge $450/month to rent office space for one day/week. This includes the office space and full secretarial/administrative support (reception, billing, scheduling, phone calls, etc.).
Click to expand...
Thanks! Where are you located? What part of that is the rent vs the overhead?
 
One thing that I did that I thought was really helpful was going to the website of the local psychologist association in my city. There you can see who is renting their office space for anywhere from 1-4 days per week on a month to month basis. It is really affordable that way. You will also likely be surrounded by psychologist and have access to easy referrals.
 
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TexasPhysician said:
What do you need a small business bank for? I use WF for a free business checking account.
Click to expand...

You are right, I did not need that type of bank. I opened up a Chase Business checking account. I used their partner in house partner ADP to set up my own payroll and tax related things. It is going pretty smooth.
 
medium rare said:
We charge $450/month to rent office space for one day/week. This includes the office space and full secretarial/administrative support (reception, billing, scheduling, phone calls, etc.).
Click to expand...

For 1 day/week? That's fairly expensive. You can get full-time access to an office with support through Regus for a similar amount in most cities.
 
You can get a virtual office with x hours per week for a pretty good price. Virtual offices are good so that at least you can have a business address, set up your DEA, get mail, your prescriptions with an address and then transition to a full time office on a lease. I am using Premier Business Centers and they have their own receptionist that is included in the price, they answer phones and can even take calls and make appointments for patients. They have places all over the country.
 
Indodo said:
I've been doing PP for almost 3 years now.

Here are some things I have learned, my top 10 list.

1) The start is slow. I would recommend having a side job initially if you have a family or big loans etc. If you can live off a resident type salary, you can probably jump right in.
2) Cash patients are not that easy to find if you live in a busy area. I decided to take insurance and am thankful I did. You can slowly wean off the insurance if you need.
3) Overhead can really vary. If you aren't careful, your overhead can get up to 50% or more of your practice. I have mine around 25-35% now.
4) Do the secretary/billing stuff yourself early on. As you get busier, hire people. Your percentage of overhead will go up but your overall productivity will go up as well and your headaches will go down.
5) Be EMR proficient. Don't just use one, be good at it. Especially if you take insurance, the templates help with the coding but also with writing scripts, labs and having access to notes when you are out of the office. It can be beneficial to have one that local doctors are also using.
6) Get to know PCPs. Everyone says get referrals from therapists or advertising. Nobody will send you referrals like PCPs (except insurance panels). I don't have a website, I never sent flyers to therapists. I just visit one PCP office per month.
7) Have a comfortable work space.
8) Try to work with a group if you can. I know psychiatrists are often loners but sharing overhead is the best decision I made for my bottom line. Also helps with coverage on vacation.
9) If you don't want to go it alone, join a group that will pay for productivity. Make sure the overhead is less than 40% (they give you at least 60 cents on every dollar you earn).
10) Be a good psychiatrist.

I do have a question for others.
What percentage of revenue is going to overhead for other psychiatrists and what do you do with it? For example do you have secretary, biller, your own office or sublease, free EMR or paid (or paper charts), answering service and any other expenses.
Click to expand...

Great advice. Where can I find out what forms I legally need to give to my patients if I start a private practice? Do you need to display the medical board's phone number?
 
Was hoping to get this thread going on - specifically if you are using EMR, and how you are scheduling for part time practice if you don't have staff yet. Any phone services (internet based) that you recommend, or is it better to get a land line? I am looking to sublet from another physician for a few months before transitioning so its murky. Thanks in advance!
 
aa1984 said:
Was hoping to get this thread going on - specifically if you are using EMR, and how you are scheduling for part time practice if you don't have staff yet. Any phone services (internet based) that you recommend, or is it better to get a land line? I am looking to sublet from another physician for a few months before transitioning so its murky. Thanks in advance!
Click to expand...

I graduated from residency in July and I went right into full-time private practice. It's a solo psychotherapy-focused practice with very low overhead (~1k/mo). I take two local insurances which pay fairly and I do all of my own billing. I'm able to be efficient because I rely heavily on tech. Granted, this limits my patient population to those who are technologically literate.

I use 8x8 virtual office (virtual fax, phone w/ auto-attendant--rings to iPhone), OfficeAlly EMR Suite (PracticeMate [Scheduling, Accounting, Claim Submission], EMR 24/7 [Charting, E-Rx, E-Labs], PatientAlly [Patient Portal]), Google Business Apps (Docs, Sheets, Drive, Sites; all HIPAA compliant), and Doxy.Me (tele-psych platform; HIPAA compliant).

PM me for any questions!
 
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carlosc1dbz said:
You can get a virtual office with x hours per week for a pretty good price. Virtual offices are good so that at least you can have a business address, set up your DEA, get mail, your prescriptions with an address and then transition to a full time office on a lease. I am using Premier Business Centers and they have their own receptionist that is included in the price, they answer phones and can even take calls and make appointments for patients. They have places all over the country.
Click to expand...

Hey had a question. They are able to make appointments ? What about taking patients insurance information and entering them into your emr?
 
WisNeuro said:
For 1 day/week? That's fairly expensive. You can get full-time access to an office with support through Regus for a similar amount in most cities.
Click to expand...

Where I am at this is a steal, is 450 for just office space here, no support from reception, scheduling or billing. But then again these are the nicer looking offices,
 
zolof said:
Where I am at this is a steal, is 450 for just office space here, no support from reception, scheduling or billing. But then again these are the nicer looking offices,[/QUOTE

I'm sure they vary depending on the location, but the Regus offices in my area are very nice, especially for the price.
Click to expand...
 
Hi Guys - I've been out of residency for 2 1/2 years. Was actually a tough transition (I was surprised - you always dream of being an attending). Residency had a lot of comradery; job not so much. Most relationships are at a strictly professional level and at arms-length. Anyway, I've been daydreaming of starting a private practice; though nervous because I have a family who is dependent on me. A few questions for the veteran private practice people:

#1 - Am I crazy to consider taking Medicare? Reimbursement rates seem alright if done correctly. Here's my calculation.

see 10-12 patients a day - 2 new patients 10 follow-ups: (Pulled data off CMS website)

2 x new intakes (90792) $148.97 = $297.94
5 x 99213 followups /day $74.65 = $373.25
5 x 99214 followups /day $109.75 = $329.25
50% of visits I will do supportive or other psychotherapy (90833 add on code) $67.07 = $335.25

If I work 221 days/year = 1335.69 x 221 assuming 90% fill rate = $265,668

Please prescribe me an antipsychotic if I'm not thinking about this right. I've never billed Medicare - does it take forever to get reimbursed? Do they reject your claims a lot?

#2 - Thinking about doing TMS treatments - there has been other forms about this, but they are old. Insurance and Medicare now covers this, so times have changed. Can anyone with experience with this PM me? I would greatly appreciate it.

#3 - Does billing and getting reimbursed take a lot of time? I was thinking of billing myself and if it gets rejected, then hand it over to the billing and collector people who take a cut. Anyone do this?

Thanks for reading.
 
Mastac741 said:
Hi Guys - I've been out of residency for 2 1/2 years. Was actually a tough transition (I was surprised - you always dream of being an attending). Residency had a lot of comradery; job not so much. Most relationships are at a strictly professional level and at arms-length. Anyway, I've been daydreaming of starting a private practice; though nervous because I have a family who is dependent on me. A few questions for the veteran private practice people:

#1 - Am I crazy to consider taking Medicare? Reimbursement rates seem alright if done correctly. Here's my calculation.

see 10-12 patients a day - 2 new patients 10 follow-ups: (Pulled data off CMS website)

2 x new intakes (90792) $148.97 = $297.94
5 x 99213 followups /day $74.65 = $373.25
5 x 99214 followups /day $109.75 = $329.25
50% of visits I will do supportive or other psychotherapy (90833 add on code) $67.07 = $335.25

If I work 221 days/year = 1335.69 x 221 assuming 90% fill rate = $265,668

Please prescribe me an antipsychotic if I'm not thinking about this right. I've never billed Medicare - does it take forever to get reimbursed? Do they reject your claims a lot?

#2 - Thinking about doing TMS treatments - there has been other forms about this, but they are old. Insurance and Medicare now covers this, so times have changed. Can anyone with experience with this PM me? I would greatly appreciate it.

#3 - Does billing and getting reimbursed take a lot of time? I was thinking of billing myself and if it gets rejected, then hand it over to the billing and collector people who take a cut. Anyone do this?

Thanks for reading.
Click to expand...
I think this is going to be regional as to medicare. If you can get by without it, I'd say do so. At minimum talk with a billing company and get their estimates on how much to expect in receivables and the turnaround time.

TMS is a massive upfront investment. Neurostar was $1M previously (I'm sure it's come down). But in a field where overhead can be quite minimal, I wouldn't go for that unless you're in a totally saturated environment.
1. Get a PT gig so your bills are paid. 1-2 days a week. Always good if they have additional per diem work if you need it.
2. Start the practice, get all your logistics set up, including billing, office, phone, fax, and make a list of referral sources.
3. Start getting the word out and accepting patients.
 
Billing, coding, How much lately if anyone is utilizing a company or individual doing this ? I cannot find less than 7 to 8 percent, in my search. Anyone else?
 
Mastac741 said:
Hi Guys - I've been out of residency for 2 1/2 years. Was actually a tough transition (I was surprised - you always dream of being an attending). Residency had a lot of comradery; job not so much. Most relationships are at a strictly professional level and at arms-length. Anyway, I've been daydreaming of starting a private practice; though nervous because I have a family who is dependent on me. A few questions for the veteran private practice people:

#1 - Am I crazy to consider taking Medicare? Reimbursement rates seem alright if done correctly. Here's my calculation.

see 10-12 patients a day - 2 new patients 10 follow-ups: (Pulled data off CMS website)

2 x new intakes (90792) $148.97 = $297.94
5 x 99213 followups /day $74.65 = $373.25
5 x 99214 followups /day $109.75 = $329.25
50% of visits I will do supportive or other psychotherapy (90833 add on code) $67.07 = $335.25

If I work 221 days/year = 1335.69 x 221 assuming 90% fill rate = $265,668

Please prescribe me an antipsychotic if I'm not thinking about this right. I've never billed Medicare - does it take forever to get reimbursed? Do they reject your claims a lot?


#3 - Does billing and getting reimbursed take a lot of time? I was thinking of billing myself and if it gets rejected, then hand it over to the billing and collector people who take a cut. Anyone do this?

Thanks for reading.
Click to expand...

Medicare is a pain to sign up for/add a practice location, but once you do the $ comes in fairly regularly. I believe that the reimbursements above are for medicare allowables, meaning you will have to collect the 20% copay (and deductibles) yourself and/or bill their secondary insurance. you aren't going to get all of it, so that will bring the $265,000 down to $230k at best, and then you will have expenses including your billing company, malpractice, etc. You will likely end up netting in the 175-200k range
 
Is it legal/possible to do a mix of cash/insurance patients? Example having 4 appointment slots insurance and 6 slots reserved for cash only on a given day at the same location?
 
gebor said:
Is it legal/possible to do a mix of cash/insurance patients? Example having 4 appointment slots insurance and 6 slots reserved for cash only on a given day at the same location?
Click to expand...
not sure what your question is but it is of course common for people to take a few insurances and then see other people as cash (because they don't have insurance you are contracted with). what you cannot do is charge cash to patients who have insurance you are in network with. if you are a medicare provider you cannot charge cash to see medicare patients.
 
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splik said:
not sure what your question is but it is of course common for people to take a few insurances and then see other people as cash (because they don't have insurance you are contracted with). what you cannot do is charge cash to patients who have insurance you are in network with. if you are a medicare provider you cannot charge cash to see medicare patients.
Click to expand...
I think the real question being asked is if you can section off your schedule. That is, you contract with some insurances but only make certain intake and follow up slots available for those with those insurances, and then make your other intakes and follow ups for those without the insurances you take.
 
zolof said:
Billing, coding, How much lately if anyone is utilizing a company or individual doing this ? I cannot find less than 7 to 8 percent, in my search. Anyone else?[/QUOTBilling companies in Salt Lake City charge anywhere from 7.45 to 9.1% of any monies that go through them, including co-pays that you collect. My PCP friend in NJ got a billing company to work for them at some 2-3%. He is established with a busy 3 PCP practice
Click to expand...
 
RomanticScience said:
I graduated from residency in July and I went right into full-time private practice. It's a solo psychotherapy-focused practice with very low overhead (~1k/mo). I take two local insurances which pay fairly and I do all of my own billing. I'm able to be efficient because I rely heavily on tech. Granted, this limits my patient population to those who are technologically literate.

I use 8x8 virtual office (virtual fax, phone w/ auto-attendant--rings to iPhone), OfficeAlly EMR Suite (PracticeMate [Scheduling, Accounting, Claim Submission], EMR 24/7 [Charting, E-Rx, E-Labs], PatientAlly [Patient Portal]), Google Business Apps (Docs, Sheets, Drive, Sites; all HIPAA compliant), and Doxy.Me (tele-psych platform; HIPAA compliant).

PM me for any questions!
Click to expand...
Thank you. How is your experience using OfficeAlly EMR so far? is it time consuming or expensive? How much time does it take to enter an initial assessment? Have you looked into other EMrs before joining them....AdvancedMD, Kaero, NueMD, Tharepy Notes?
 
Nitya2 said:
Thank you. How is your experience using OfficeAlly EMR so far? is it time consuming or expensive? How much time does it take to enter an initial assessment? Have you looked into other EMrs before joining them....AdvancedMD, Kaero, NueMD, Tharepy Notes?
Click to expand...

I have used a couple different therapy notes and office ally. I didn't really like either but thats my preference I use my own modified template when I can. It doesn't take too long to do an assessment, just about 5 to 10 min for me. I think kareo and some of the others were too pricey. therapy notes and office ally were less exp. How did your friend in NJ find a company that takes 2to 3 percent billing? If you know any names please PM me.
 
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Hi, still mulling over starting my practice. I think I'm getting close to making the dive. Just another insurance question: Is it true that once you take one Medicare patient that you have to take all of them (if you're accepting new patients)?

Is this true for Blue Cross/Blue Shield or UnitedHealthCare? If you are contracted with them in-network, can you refuse to see nightmare patients who have their insurance?

I would like the ability to fire patients if it's not working out.

Thanks.
 
Mastac741 said:
Hi, still mulling over starting my practice. I think I'm getting close to making the dive. Just another insurance question: Is it true that once you take one Medicare patient that you have to take all of them (if you're accepting new patients)?

Is this true for Blue Cross/Blue Shield or UnitedHealthCare? If you are contracted with them in-network, can you refuse to see nightmare patients who have their insurance?

I would like the ability to fire patients if it's not working out.

Thanks.
Click to expand...

Curious about this too. My understanding is that yes, you can most definitely fire your patients, whether they’re paying cash or on United/some other insurance if they’re not following your prescribed treatment plan.
 
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