Dos and Don'ts of neuropsychology private practice

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Thank you in advance for your input.

I am starting a part-time neuropsychology private practice which will be an addition to my full time job at an AMC. I would like to do clinical and IME work. For reference, I am board certified (ABPP) and live in a major city in the US. For now, I have set up an PLLC, found a quite reasonably priced office space close to where I live, and started applying for insurance credentialing as sole practitioner. For those who are in pp, what are your recommendations and cautionary tales for someone who is just starting out?
 
Agreed RE: finding a mentor, particularly if you haven't done much IME work in the past.

For clinical work, do your best to get your reports done quickly. For referral sources, that's probably more important than anything else.

Edit to add: regarding clinical work again, depending on your area, it's possible to reach out to too many referral sources, get overwhelmed with referrals, develop a huge backlog, and then lose those referral sources. I'd say start slow, especially since this will be parttime.

If you don't have it already, The Paper Office for the Digital Age is a pretty good resource for administrative-type stuff. There's also Barisa's The Business of Neuropsychology, although I don't know if a newer edition is coming anytime soon.
 
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Agreed RE: finding a mentor, particularly if you haven't done much IME work in the past.

For clinical work, do your best to get your reports done quickly. For referral sources, that's probably more important than anything else.
Thank you I will look into possible mentors in the area. I have done minimal IME work, just peer reviews.
 
1) Honest self assessment time. How much education, reading, and know-how do you have about IME work? There is a unique lexicon and set of rules for this stuff. Do you know those laws, terms, and processes? How many books on the subject do you own? Based upon that, should you really get involved in it? There are people like me who are literally professionals at tearing newbies apart. In my early days, I flew too high, a pro destroyed me, and I never received any more of that work.
2) Keep a normal schedule and treat it like a business.
a. You can’t earn money if you’re not available to work. Dropping the kids off, taking a long lunch, leaving a bit early= no billable hours. b. Build admin time into your schedule. You now have to find time to handle phone calls about why the internet is out, go to the CPA/bank, track expenses, etc
3) Bill weekly, at a minimum.
4) Get an EIN for your LLC, then an NPI for your LLC, then an LLC bank account, then Amazon business account (no one wants to lift a case of paper), then watch videos on how to get business credit history. Use that bank account for your insurance credentialing, NOT your personal accounts. Google the term "corporate veil"
5) A good rule of thumb: set 50% of your earnings aside. This will give you plenty of money for taxes, operating capital, retirement, etc. a. ALWAYS keep operating capital on hand. You will have slow months, or extra expenses, or whatever. If you look at the listservs, some fools had nothing in operating capital when the pandemic hit.
b. Put money into a SEP IRA initially. You can convert that at a later date.
6) Create a workflow expectation, including how your full time job and personal life will affect your PP work.
a. Plan for slow productivity days (e.g., if you can usually bang 2-3 reports out in day but sometimes you get zero writing done: work that into your expectations).
b. If you decide to jump into forensic work, decide how you are going to handle time interruptions to your normal job (e.g., Last month, I was court ordered to testify in a rural jurisdiction that was a 5hr flight+45 minute flight+2hr drive away from my home OR I've had 30k+ pages of files to review). Courts don't have a "I'm really busy right now" pause button. How will your normal job handle this?
c. How will your schedule handle feedback sessions + testing+writing?
d. Consider your family+friends.
7) When you're starting out, each test you buy HAS to be considered in terms of how much money it will make you. This won't be so important in 2 years.
8) Figure out how you are going to handle phone calls, emergencies, scheduling, etc. The HI-TEC act says you can't use normal email or text messaging with patients. And the FBI just put out that alert about text messages.
 
1) Honest self assessment time. How much education, reading, and know-how do you have about IME work? There is a unique lexicon and set of rules for this stuff. Do you know those laws, terms, and processes? How many books on the subject do you own? Based upon that, should you really get involved in it? There are people like me who are literally professionals at tearing newbies apart. In my early days, I flew too high, a pro destroyed me, and I never received any more of that work.
2) Keep a normal schedule and treat it like a business.
a. You can’t earn money if you’re not available to work. Dropping the kids off, taking a long lunch, leaving a bit early= no billable hours. b. Build admin time into your schedule. You now have to find time to handle phone calls about why the internet is out, go to the CPA/bank, track expenses, etc
3) Bill weekly, at a minimum.
4) Get an EIN for your LLC, then an NPI for your LLC, then an LLC bank account, then Amazon business account (no one wants to lift a case of paper), then watch videos on how to get business credit history. Use that bank account for your insurance credentialing, NOT your personal accounts. Google the term "corporate veil"
5) A good rule of thumb: set 50% of your earnings aside. This will give you plenty of money for taxes, operating capital, retirement, etc. a. ALWAYS keep operating capital on hand. You will have slow months, or extra expenses, or whatever. If you look at the listservs, some fools had nothing in operating capital when the pandemic hit.
b. Put money into a SEP IRA initially. You can convert that at a later date.
6) Create a workflow expectation, including how your full time job and personal life will affect your PP work.
a. Plan for slow productivity days (e.g., if you can usually bang 2-3 reports out in day but sometimes you get zero writing done: work that into your expectations).
b. If you decide to jump into forensic work, decide how you are going to handle time interruptions to your normal job (e.g., Last month, I was court ordered to testify in a rural jurisdiction that was a 5hr flight+45 minute flight+2hr drive away from my home OR I've had 30k+ pages of files to review). Courts don't have a "I'm really busy right now" pause button. How will your normal job handle this?
c. How will your schedule handle feedback sessions + testing+writing?
d. Consider your family+friends.
7) When you're starting out, each test you buy HAS to be considered in terms of how much money it will make you. This won't be so important in 2 years.
8) Figure out how you are going to handle phone calls, emergencies, scheduling, etc. The HI-TEC act says you can't use normal email or text messaging with patients. And the FBI just put out that alert about text messages.
Thank you so much for your input, this is great advice. Makes me rethink the IME work🙂 As for clinical side, I have taken some of the steps (EIN, Type 2 NPI, LLC Bank account) I am looking into testing material costs, keeping an eye on npsych/aacn listserves for used materials.
 
No I don't 😵

This is is something you'll need even if you don't do IME work. You need a local attorney who is familiar with the healthcare laws and psychology statutes in your state. Ask colleagues who they use. You shouldn't be using any legal documents in your private practice (e.g., consent, billing, etc) without a lawyer signing off on them. Do not rely on other colleagues' examples templates. I've run across many local samples that obviously did not consult an attorney and actually violate our state statutes. Don't be that person. The chances of issues is relatively low, but the fallout if something does go wrong is pretty high. Attorney consults are a necessary expense in private practice.
 
Thank you so much for your input, this is great advice. Makes me rethink the IME work🙂 As for clinical side, I have taken some of the steps (EIN, Type 2 NPI, LLC Bank account) I am looking into testing material costs, keeping an eye on npsych/aacn listserves for used materials.
You're going to make plenty of money. Just save plenty for tax time and emergencies, and work your way up. A few other items

a. Read about "NNN" (i.e., "triple net"). I don't know what your office is like, but this can be a hidden expense.
b. When you are self employed, you pay BOTH sides of social security, but only up to like $168k or something. Consider that in your savings (e.g., Let's say you make $50k doing one day per week. $12,500.00 of that goes in your SEP, $11K goes to the IRS, $4650 goes to Social Security, for a net of $21,850.00).
c. In 5 years, you'll start getting curious about tax avoidance strategies. Tax avoidance=legal, tax evasion= illegal. You'll need to have some BIG conversations with your SO or family or whoever you have. If you reduce your taxable income, you can reduce your potential Social Security payouts, and affect your ability to get a mortgage. Maybe that is right for you, maybe it's not.
 
You're going to make plenty of money. Just save plenty for tax time and emergencies, and work your way up. A few other items

a. Read about "NNN" (i.e., "triple net"). I don't know what your office is like, but this can be a hidden expense.
b. When you are self employed, you pay BOTH sides of social security, but only up to like $168k or something. Consider that in your savings (e.g., Let's say you make $50k doing one day per week. $12,500.00 of that goes in your SEP, $11K goes to the IRS, $4650 goes to Social Security, for a net of $21,850.00).
c. In 5 years, you'll start getting curious about tax avoidance strategies. Tax avoidance=legal, tax evasion= illegal. You'll need to have some BIG conversations with your SO or family or whoever you have. If you reduce your taxable income, you can reduce your potential Social Security payouts, and affect your ability to get a mortgage. Maybe that is right for you, maybe it's not.

A couple of additional general suggestions related to this (with the caveat that I am not a neuropsychologist):

1. If you are only part-time, narrow your practice to 1 or 2 popular diagnoses (just XYZ evaluation) and start with those materials and anything needed for rule outs.
2. Get all your paperwork in order before scaling the practice and getting too busy to focus on that.
3. Buy a reliable car and a house (if you are considering it) before leaving your w-2. The first few years in full-time PP will make loans more difficult (they usually want two years income records, etc.).
 
A couple of additional general suggestions related to this (with the caveat that I am not a neuropsychologist):

1. If you are only part-time, narrow your practice to 1 or 2 popular diagnoses (just XYZ evaluation) and start with those materials and anything needed for rule outs.
2. Get all your paperwork in order before scaling the practice and getting too busy to focus on that.
3. Buy a reliable car and a house (if you are considering it) before leaving your w-2. The first few years in full-time PP will make loans more difficult (they usually want two years income records, etc.).
Indeed. There may be ways around this, and you could look into buying a vehicle via your company (big/heavy Land Rover, anyone?), but the mortgage part is something people may not think about ahead of time.
 
A couple of additional general suggestions related to this (with the caveat that I am not a neuropsychologist):

1. If you are only part-time, narrow your practice to 1 or 2 popular diagnoses (just XYZ evaluation) and start with those materials and anything needed for rule outs.
2. Get all your paperwork in order before scaling the practice and getting too busy to focus on that.
3. Buy a reliable car and a house (if you are considering it) before leaving your w-2. The first few years in full-time PP will make loans more difficult (they usually want two years income records, etc.).
I don't think I am going to let go of the W2 anytime soon. I have decent benefits/health insurance. I am hoping that I get to choose the referrals I see for the pp, focusing on older/geriatric dementia differential cases but I don't know if this is possible or feasible.
 
I don't think I am going to let go of the W2 anytime soon. I have decent benefits/health insurance. I am hoping that I get to choose the referrals I see for the pp, focusing on older/geriatric dementia differential cases but I don't know if this is possible or feasible.

Are you taking Medicare? I am a geropsychologist and I can't think of anywhere that is near me and not filled up with long waiting-lists if taking those cases that accepts insurance. If you are going to stick to part-time and want that work, you may want to skip getting paneled on any private insurance and just accept straight Medicare or out of pocket. It is easier and you won't see enough cases to ever be an audit risk (even a full-time solo prac would have a hard time).

I would familiarize yourself with MIPS, MACRA, and Medicare billing. You are automatically opt-in as a medicare provider, but you still need to enroll to receive payment.
 
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Are you taking Medicare? I am a geropsychologist and I can't think of anywhere that is near me and not filled up with long waiting-lists if taking those cases that accepts insurance. If you are going to stick to part-time and want that work, you may want to skip getting paneled on any private insurance and just accept straight Medicare or out of pocket. It is easier and you won't see enough cases to ever be an audit risk (even a full-time solo prac would have a hard time). I

I would familiarize yourself with MIPS, MACRA, and Medicare billing. You are automatically opt-in as a medicare provider, but you still need to enroll to receive payment.
I am planning on taking Medicare, currently working on my Medicare application. I have not heard about Mips or Macra, so thanks for the tip!
 
I am planning on taking Medicare, currently working on my Medicare application. I have not heard about Mips or Macra, so thanks for the tip!

No problem, the key for you right now is to be aware of the low volume provider exemptions (what is the max you can see without having to report quality measures and do extra paperwork).
 
No problem, the key for you right now is to be aware of the low volume provider exemptions (what is the max you can see without having to report quality measures and do extra paperwork).

It's like <90k, <200 patients with medicare. Not a concern for me at the moment
 
Sounds about right. I think the audit threshold is 1599 annual claims. It's been a minute though.

Considering clinical is only about 40% of my time, and that includes other payor sources, I don't come close to most of these thresholds. Even if I was 100% clinical, it'd be tough to hit some of these unless I were exclusively seeing Medicare and nothing else.
 
Considering clinical is only about 40% of my time, and that includes other payor sources, I don't come close to most of these thresholds. Even if I was 100% clinical, it'd be tough to hit some of these unless I were exclusively seeing Medicare and nothing else.
For part-time, it should not be a problem, but good to be aware of these limitations. I was looking at it in terms of full-time solo practice and payor mix in the future if there is growth. In my case, to fill daytime therapy slots in the future.
 
For part-time, it should not be a problem, but good to be aware of these limitations. I was looking at it in terms of full-time solo practice and payor mix in the future if there is growth. In my case, to fill daytime therapy slots in the future.

Most definitely, for therapy providers, easier to hit those benchmarks. It'd be a slog for us assessment folks.
 
I am planning on taking Medicare, currently working on my Medicare application. I have not heard about Mips or Macra, so thanks for the tip!
1. Medicare is great because:
a. They pay on time, in an expectable way. It may be less than a private insurance, but there are rarely any delays in getting paid.
b. Guess which patient population is free to go to the psychologist in the middle of the day? Medicare patients.
c. Neuropsychological disorders disproportionately affect the elderly. They have Medicare.

2. Medicare patients can be difficult because:
a. You're trying to schedule someone who has a cognitive impairment. Guess how often they forget their appointments, or get lost, or cancel because they don't want to drive in the rain?
b. You can get some referrals for some social problems that you cannot solve, in the SSDI community.
 
1. Medicare is great because:
a. They pay on time, in an expectable way. It may be less than a private insurance, but there are rarely any delays in getting paid.
b. Guess which patient population is free to go to the psychologist in the middle of the day? Medicare patients.
c. Neuropsychological disorders disproportionately affect the elderly. They have Medicare.

2. Medicare patients can be difficult because:
a. You're trying to schedule someone who has a cognitive impairment. Guess how often they forget their appointments, or get lost, or cancel because they don't want to drive in the rain?
b. You can get some referrals for some social problems that you cannot solve, in the SSDI community.

I will say, with a very quick reminder call only to those I feel are high risk, my no-show/late cancel rate is very low. Low single digits a year, and even those are weird cases (patient died, patient hospitalized night before, etc).
 
I will say, with a very quick reminder call only to those I feel are high risk, my no-show/late cancel rate is very low. Low single digits a year, and even those are weird cases (patient died, patient hospitalized night before, etc).

Lol, these are regular occurrences in my VA practice. I look forward to it being rare when I am the person responsible for the money side of things.
 
I don't think I am going to let go of the W2 anytime soon. I have decent benefits/health insurance. I am hoping that I get to choose the referrals I see for the pp, focusing on older/geriatric dementia differential cases but I don't know if this is possible or feasible.
Accepting Medicare, you likely will have no problem filling a part-time practice with only older adult dementia/cognitive impairment referrals. Doubly so if you can keep your wait list under 1-2 months.
 
It's like <90k, <200 patients with medicare. Not a concern for me at the moment
This is really
1. Medicare is great because:
a. They pay on time, in an expectable way. It may be less than a private insurance, but there are rarely any delays in getting paid.
b. Guess which patient population is free to go to the psychologist in the middle of the day? Medicare patients.
c. Neuropsychological disorders disproportionately affect the elderly. They have Medicare.

2. Medicare patients can be difficult because:
a. You're trying to schedule someone who has a cognitive impairment. Guess how often they forget their appointments, or get lost, or cancel because they don't want to drive in the rain?
b. You can get some referrals for some social problems that you cannot solve, in the SSDI community.
I have always seen/am seeing Medicare patients through both AMCs I have worked at, although I am not familiar with the payment aspect when it comes to MCR patients. Thank you!
 
Accepting Medicare, you likely will have no problem filling a part-time practice with only older adult dementia/cognitive impairment referrals. Doubly so if you can keep your wait list under 1-2 months.
That is what I am hoping, thank you!!
 
You're going to make plenty of money. Just save plenty for tax time and emergencies, and work your way up. A few other items

a. Read about "NNN" (i.e., "triple net"). I don't know what your office is like, but this can be a hidden expense.
b. When you are self employed, you pay BOTH sides of social security, but only up to like $168k or something. Consider that in your savings (e.g., Let's say you make $50k doing one day per week. $12,500.00 of that goes in your SEP, $11K goes to the IRS, $4650 goes to Social Security, for a net of $21,850.00).
c. In 5 years, you'll start getting curious about tax avoidance strategies. Tax avoidance=legal, tax evasion= illegal. You'll need to have some BIG conversations with your SO or family or whoever you have. If you reduce your taxable income, you can reduce your potential Social Security payouts, and affect your ability to get a mortgage. Maybe that is right for you, maybe it's not

There are so many things to think about, these replies have been so helpful 👏
 
There are so many things to think about, these replies have been so helpful 👏
another thought

1) Wait two years, then buy "OWN OCCUPATION" disability insurance. It is insanely cheap. Disability insurance comes in two varieties
a. "Any Occupation"- this policy pays if you cannot do any job at all (i.e., you have to be so disabled that you can't even be a grocery store stocker).
b. "Own Occupation"- this policy pays if you cannot do your occupation as a psychologist (e.g., you have a CVA and become aphasic).

When you buy it, they will ask for 2 years of tax returns, and then you can insure yourself for any monetary amount, up to your income. It is a good idea to identify a number that will pay your mortgage, student loans, and health insurance. You can also pick a "term" (i.e., how long you are disabled before they have to start paying). Maybe you want to be covered if you're disabled for 3 months, or maybe you're fine covering your bills for 6 months before the policy kicks in. You can play with the term and payout, to identify a cost that is acceptable to you. It's a good idea to also play with those numbers, relative to savings (e.g., if you have enough savings to pay off the mortgage, you can lower the pay out when you renew). Discuss that number with your family. I like using the Trust, but there are other carriers.
 
another thought

1) Wait two years, then buy "OWN OCCUPATION" disability insurance. It is insanely cheap. Disability insurance comes in two varieties
a. "Any Occupation"- this policy pays if you cannot do any job at all (i.e., you have to be so disabled that you can't even be a grocery store stocker).
b. "Own Occupation"- this policy pays if you cannot do your occupation as a psychologist (e.g., you have a CVA and become aphasic).

When you buy it, they will ask for 2 years of tax returns, and then you can insure yourself for any monetary amount, up to your income. It is a good idea to identify a number that will pay your mortgage, student loans, and health insurance. You can also pick a "term" (i.e., how long you are disabled before they have to start paying). Maybe you want to be covered if you're disabled for 3 months, or maybe you're fine covering your bills for 6 months before the policy kicks in. You can play with the term and payout, to identify a cost that is acceptable to you. It's a good idea to also play with those numbers, relative to savings (e.g., if you have enough savings to pay off the mortgage, you can lower the pay out when you renew). Discuss that number with your family. I like using the Trust, but there are other carriers.

Did you have to have recently had or take a physical / labs for them? Or do they just pull whatever is already available for medical records?
 
Another option woud be to join an already established practice. Most well established Neuropsych practices already have all of the tests, EMR system, referrals, admin support, supplies, billing, etc. Many already have everything in place.
 
OP - Does your AMC contract not prevent you from seeing CMS patients in PP? Most neuropsychologists I've known in AMCs who have started side PPs have done only forensic work, as that is not directly competing with the clinical services they provide in their 9-to-5.

I'm honestly not sure how some of the FTC changes to non-competes might have affected this, so maybe my information is out of date.
 
OP - Does your AMC contract not prevent you from seeing CMS patients in PP? Most neuropsychologists I've known in AMCs who have started side PPs have done only forensic work, as that is not directly competing with the clinical services they provide in their 9-to-5.

I'm honestly not sure how some of the FTC changes to non-competes might have affected this, so maybe my information is out of date.
I am currently trying to figure that out myself. I never signed a contract with a non-compete clause. I know one of the providers at my department, a neurologist, has a private practice. I think the FTC changes were challenged in court.
 
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