Dr. Mantis Toboggan Psychiatry, LLC

[Dr. M Toboggan]

After going back and forth on multiple job offers, I’ve realized that I might as well jump straight into private practice. This wouldn’t have been possible without the information found in this sub-forum, especially @Sushirolls content. I had always planned to build a small side cash practice, and if it proved viable in my market, I would continue growing it into a full-time practice. Even though I’d feel more comfortable having paychecks coming in immediately, my family is in a position where I have a bit of a financial buffer.

On a whim, I looked into the commercial rates from the three insurers that make up over 80% of the market share in my area, and I was pleasantly surprised to see that the largest payer is reimbursing at the same rate—or even more—than what I expected to charge for a cash practice ($400/hr). There will be increased overhead and stress, but I like the idea of (hopefully) filling up much faster. I plan to set up shop in a nearby suburb of a moderate-sized city, so getting patients in the door may be slightly more challenging than if I were in the busiest part of the city.

I’m sure I’ll miss some points in this first post, but here are the things I’m currently looking into. I borrowed @FI-Prexa's format here. ChatGPT cleaned up this post, so sorry if it sounds robotic, but I promise it is better than seeing my grammatical errors:

Business Entity:

• I’ll submit an Articles of Organization form to the state this week to form the LLC. The form is simple, but I’m debating whether to pay an attorney to draft it to ensure we're on the same page throughout this process or just do it myself. I don’t have a physical office yet, so I’m considering setting up a virtual mailbox to avoid using my home address (I’ve seen home addresses use by other psychiatrists in my area...needless to say I do not want my address easily found online).
• After establishing the LLC, I’ll obtain an EIN.
• Business NPI (Type II) – I’ll look into this soon.
• CAQH – I believe I need to register for this?

Office:

• I need to find an office space soon. Ideally, I’d like to sublease a small space (~500 sq. ft.), but I haven’t found many options yet. There is a really nice space, but it’s way too large (2,300 sq. ft.) and more expensive than I’d like to pay upfront ($2,700/month). Since I’d prefer to keep this practice small for now, that space seems like overkill.
• I’ll handle furniture and equipment once I’ve secured a space.

Staff:

• My spouse will be my office assistant, scheduler, and biller. I typically handle more of the accounting and bookkeeping, but my spouse is more than capable of stepping in when needed.
• I plan to pay my spouse a fair salary.
• I may be getting ahead of myself here, but one advantage of keeping the business small (just the two of us) is that we can both have solo 401(k)s. I’d like to get my spouse’s salary to a level where we can max out both solo 401(k)s. We’ll probably also do cash balance plans. As you can probably tell, saving in tax-advantaged accounts is important to us.

Accounting:

• Once the LLC is approved, I’ll open a business checking/savings account and get a business credit card.
• We’ll work with an accountant at some point.
• If it makes sense, we may elect S-Corp taxation in the future.

EMR/Website/Tech:

• I tested PracticeQ/IntakeQ, and while it was okay, I may explore SimplePractice. Luminello seemed to be the favorite among many of you. I’m hoping they integrate Luminello’s best features into their platform. I plan to test out SP over the next few days.
• I spoke with a therapist practice yesterday that uses SP, and they said they love it.
• Since my spouse and I will handle our own billing, I need to revisit @Sushirolls posts to see how they do their billing. I can’t remember if they use clearinghouses or work directly with the insurance company. If I remember correctly, there’s a (somewhat) seamless way to do this through the EMR.
• I’ve seen mixed opinions on this, but can I use Google Workspace for phone/email or is there HIPAA issues here? I plan to have multiple phone options for patient calls:
  • "If this is an emergency, please hang up and dial 911."
  • "If this is an urgent matter, press 1 to be connected with your doctor."
  • "If you need a refill, press 2 to leave a voicemail with the office."
• The website needs to be clean and user-friendly. A friend of mine, who has extensive website-building experience, and I will put together a simple but professional site.

Forms:

• I’d like to be somewhat selective with patients if possible. Having tech-savvy patients who can navigate the website is important to reduce phone calls. I’ve heard of other practices offering a "free consultation" or requiring extensive screening forms to filter out:
  1. Patients who struggle with technology/online scheduling.
  2. Patients unwilling to complete paperwork.
• How much flexibility do I have to say, “I’m not accepting new patients right now” based on screening results? For example, if a patient has significant substance abuse, difficult personality traits, or is seeking benzos, can I decline to take them on?
• I’m using ChatGPT to help create forms, which I’ll refine further. I can input other screening forms from similar practices and tailor them to my needs—pretty cool stuff.

Schedule:

• I want to build this into a full-time practice quickly. Ideally, I’d start early morning (6–7 AM) for patients who need appointments before work and finish by early afternoon so I can keep up with my golf game and work on my large acreage property that’s being transformed. My goal is 30–40 clinical hours per week.
• There’s a possibility of doing a 1099 side gig for TMS consults/mappings at a local therapy group (which also has a psych NP). This would be one day per week. While I may eventually incorporate TMS into my own office, I’d rather let someone else pay $200K for the machine while I collect 40–50% of collections.
• The office will bill TMS sessions under my NPI as the rendering provider. Liability is a factor, but they’re not trying to bill NP services under my license—just the TMS (mapping + tech-administered sessions). The fee schedule looks solid… I’ll keep you updated.

Malpractice:

• I’ll look into this in the coming weeks. I’ll get occurrence-based malpractice to avoid future headaches.

Credentialing:

• The largest payer in my area initially told me I had to complete residency before starting the credentialing process. The more I think about it, the more I believe this is incorrect. Fresh attendings often start jobs in July, so I suspect they just require a letter of good standing and completion date from my residency program. I’m looking into this ASAP.
• My plan is to stick with the top three commercial plans in my area as long as they pay above Medicare rates. I am not going to take Medicare or Medicaid. I am on the fence about Tri-Care but have heard they pay really well for certain services (i.e., TMS). If I was seeing Tri-Care patients for TMS at the other clinic, do I have any obligation to accept Tri-Care at my own clinic? I don't think I do.

Fees:

• I prefer a strict no-show/cancellation policy:
  • Within 48 hours of the appointment or no-show → Full charge.
  • Patients will need to keep a credit card on file.
    • Or maybe I just block scheduling if they have unpaid fees?
• Anything else I should consider for fees?

Advertising:

• Psychology Today.
• Hopefully, I can attract patients simply because there are very few psychiatrists in my metro area.
• I already have a referral relationship with that local therapy practice, and they said they’d send me cases the NP can’t handle.

I appreciate any and all feedback!
M Toboggan, MD

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[Sushirolls]

Simple Practice is okay. Some things better than Luminello, some things worse. Overall a wash between the two. Negatives include it separating out MSE, plans, and notes as different things. Really weird. Definitely geared a bit more towards therapists in that regard. I just again the MSE section and keep everything in the note section as should be. This will make more sense once you start using it.
*try to lean into the EMR as much as possible
*the SP EMR has an integrated billing house which you want, and means you won't need a 3rd party biller. But your wife will be tasked with troubleshooting the headache claims.
*if you take tri care at another clinic and they are doing the billing, you are not in network with tricare at your practice.
*don't forget to go feed the PCPs and meet them in person.
*Simple Practice, you can have all your in take forms integrated to it, so patients can online complete it all.
*If patient can't online complete or navigate a computer, they are not appropriate for our practice and get pointed towards Big Box Shops.
*I do screening questions, that include are you on benzos, and if yes, get pre-warned will either not be prescribed or tapered off. This is worth a pound of cure and you get the people in who want off or willing to consider coming off, and those who want refills can establish elsewhere.
*Google workspace / GSuite does have a BAA and is therefore hipaa compliant. My assistant and I use it. We real time during clinic message back and forth using the chat feature. We hold our random meetings with the google chat thing. We also heavily utilize a shared drive on the Google Drive, where in are several files. Excell sheet for running patient tasks. EVERY single claim I submit on SP, I make on the excell a follow up task for claim submitted on day XYZ. My assistant has a standard work flow of changing those tasks as they progress until 100% paid off. Granted, SP, you might be able to skip this step and completely use SP, but old habits die hard. The other value of this excell sheet, I keep track of when refills are do - I don't pay attention to pharmacy generated requests and delete those. Another tab on this sheet has miscellaneous things like mailing letters to patients that say are you in or out, otherwise services are closing for you on day XYZ, please reschedule. Another tab for labs when orders need to be mailed for lithium, or UDS, or to be reviewed. Another tab for records reviews. The task/list feature on SP, sucks ... because you and your wife/assistant can't see the same list like you could with luminello. Hence the Google work around. The Google drive also works great as a dumping ground for records needing to be faxed, or other random things. Then if wife needs to fax them, or whatever, make her a task on the Excel document. Conversely, she can make you tasks, too. Use the google chat thing to FYI each other to reload/refresh the document when you have created new things for each other.
*You as the boss need to make sure to create and HR chart for you and the wife. Put this on your google Drive. Just prentend you are like an actual HR big box shop. Have each person's driver license ID, CME hours, med license, whatever. Your state might even require stupid meetings. If so document those on the drive, too. Stupid HR labor things that are supposed to be posted on walls, scan them into PDFs and put them on drive 'so they are accessible to all employees' and then you avoid making your office look like a dump.
*If you are still a resident, part of what happens at Big Box shop employments is two parts. One, they simply don't add those patients to your schedule until several more months into working when they can finally submit proof of residency completion to the insurance company and be paneled later. Truly delayed. The other thing some insurance companies offer for existing contracts with a type II entitity is ability to fast enroll someone... you simply submit the type 1 NPI and name of person, and *bam* they are credentialed. This is where some Big Box entities get things moving fast with residents and moonlighting. In summary, just assume most won't progress until AFTER you have residency certificate in hand...

Good luck!

 

[Bartelby]

I agree SimplePractice has been solid for my small, cash-based practice. The billing, notewriting, sending scales, clinical messaging, mobile app, etc. have all been very easy to use. I also noticed the bizarre separation of mental status exam and treatment plan from progress notes, and I just ignore that (I write progress notes and never create "mental status exam" or "treatment plan" entries).

 

[calvnandhobbs68]

Don't you mean Dr. Mantis Toboggan, MD, LLC? Probably rec for advertising when you're at PCP offices letting a monster condom slip out of your wallet so they remember you have a magnum dong.

- LLC is super easy to get approved in most states. If you're going to be doing things like leasing an office, I would definitely make sure the LLC is set up so you can lease using the LLC. I agree the form is super simple at least in my state, I probably wouldn't bother paying an attorney.

- The address that you needed most states for an LLC is an address for them to serve legal papers at which you can use a registered agent for. So you can use your home address for the business, which isn't available to the public usually and then use a registered agent for document delivery, which is often the address that's public facing when someone goes to look you up in the business directory. At least that's the way it works in my state, I'd double check for whatever state you're in. You often can't use any kind of virtual address or anything because someone needs to be present or available to receive paperwork regularly unless that's what you're referring to. Something like this (I use them but have no affiliation with this, there are a bunch of other ones that do the same thing): https://www.northwestregisteredagent.com/

- About the form thing I've seen other practices do something like have patients fill out an online form, but then say if they don't hear back within a couple weeks, assume they're not taking new patients. I don't really screen much (but I'm child) so I don't know how well that works but seem a viable way to be able to get enough information about people to look up their med history and get some background information before you decide. Other places also make it very clear that the first visit or two they may decide to refer the patient out if they don't feel like they're a "good fit". You technically have a doctor patient relationship with someone after the first time you see them though so you have to formally discharge them once you've had an appointment.

- I would keep a credit card on file but then also have some wording that patients can't carry a balance higher than X amount for longer than X amount of days or you may have to discontinue care as a financial policy. That way it makes it pretty clear when you want to discharge someone for unpaid bills.

- For credentialing stuff you might actually have to complete residency, but that'll probably depend on the insurance company. I remember when I was initially getting credentialed I didn't start for a few months after residency and it took about that long to get on the first couple insurance panels because they wanted the documentation that I graduated. Some of them took them longer like six months.

- Along the same theme I would be prepared for things to be delayed like this with insurance companies in general. Once things have been going steady for 6+ months you're usually pretty good but it can be weeks to months from the first time you see patients to starting to get paid initially depending on how long they take to process claims, then if people have deductibles or the insurance company denies someone because they say they're ineligible or have some COB issue or whatever etc etc. This is kind of why it's hard for lots of people to jump straight into a collections based position or private practice straight out of residency if you don't have some level of financial cushion.

 

[Dr. M Toboggan]

Simple Practice is okay. Some things better than Luminello, some things worse. Overall a wash between the two. Negatives include it separating out MSE, plans, and notes as different things. Really weird. Definitely geared a bit more towards therapists in that regard. I just again the MSE section and keep everything in the note section as should be. This will make more sense once you start using it.
*try to lean into the EMR as much as possible
*the SP EMR has an integrated billing house which you want, and means you won't need a 3rd party biller. But your wife will be tasked with troubleshooting the headache claims.
*if you take tri care at another clinic and they are doing the billing, you are not in network with tricare at your practice.
*don't forget to go feed the PCPs and meet them in person.
*Simple Practice, you can have all your in take forms integrated to it, so patients can online complete it all.
*If patient can't online complete or navigate a computer, they are not appropriate for our practice and get pointed towards Big Box Shops.
*I do screening questions, that include are you on benzos, and if yes, get pre-warned will either not be prescribed or tapered off. This is worth a pound of cure and you get the people in who want off or willing to consider coming off, and those who want refills can establish elsewhere.
*Google workspace / GSuite does have a BAA and is therefore hipaa compliant. My assistant and I use it. We real time during clinic message back and forth using the chat feature. We hold our random meetings with the google chat thing. We also heavily utilize a shared drive on the Google Drive, where in are several files. Excell sheet for running patient tasks. EVERY single claim I submit on SP, I make on the excell a follow up task for claim submitted on day XYZ. My assistant has a standard work flow of changing those tasks as they progress until 100% paid off. Granted, SP, you might be able to skip this step and completely use SP, but old habits die hard. The other value of this excell sheet, I keep track of when refills are do - I don't pay attention to pharmacy generated requests and delete those. Another tab on this sheet has miscellaneous things like mailing letters to patients that say are you in or out, otherwise services are closing for you on day XYZ, please reschedule. Another tab for labs when orders need to be mailed for lithium, or UDS, or to be reviewed. Another tab for records reviews. The task/list feature on SP, sucks ... because you and your wife/assistant can't see the same list like you could with luminello. Hence the Google work around. The Google drive also works great as a dumping ground for records needing to be faxed, or other random things. Then if wife needs to fax them, or whatever, make her a task on the Excel document. Conversely, she can make you tasks, too. Use the google chat thing to FYI each other to reload/refresh the document when you have created new things for each other.
*You as the boss need to make sure to create and HR chart for you and the wife. Put this on your google Drive. Just prentend you are like an actual HR big box shop. Have each person's driver license ID, CME hours, med license, whatever. Your state might even require stupid meetings. If so document those on the drive, too. Stupid HR labor things that are supposed to be posted on walls, scan them into PDFs and put them on drive 'so they are accessible to all employees' and then you avoid making your office look like a dump.
*If you are still a resident, part of what happens at Big Box shop employments is two parts. One, they simply don't add those patients to your schedule until several more months into working when they can finally submit proof of residency completion to the insurance company and be paneled later. Truly delayed. The other thing some insurance companies offer for existing contracts with a type II entitity is ability to fast enroll someone... you simply submit the type 1 NPI and name of person, and *bam* they are credentialed. This is where some Big Box entities get things moving fast with residents and moonlighting. In summary, just assume most won't progress until AFTER you have residency certificate in hand...

Good luck!

There is a lot to digest here.

It will take us some time to figure out the workflow, but I am confident my wife will make this as efficient of process as possible. She previously was an assistant to multiple surgeons, so I think she is the perfect fit. I like the idea of working in Google Workspace because I presume they would have one of the best systems around. I am hopeful she can still work from home, even though there would be benefit to having a front desk staff member for various reasons.

I agree SimplePractice has been solid for my small, cash-based practice. The billing, notewriting, sending scales, clinical messaging, mobile app, etc. have all been very easy to use. I also noticed the bizarre separation of mental status exam and treatment plan from progress notes, and I just ignore that (I write progress notes and never create "mental status exam" or "treatment plan" entries).

I just started a trial of Charm as well, and it seemed a bit cleaner than SP. I will keep working with both (and others) before I make a decision. Every time I play around with templates in these EMRs, I feel a bit overwhelmed on where to start. I have a general template I have made throughout residency, but have a hard time figuring out where I copy my own templates into the inputs for the EMR template. Do these EMRs allow you to carry forward an old note? Using EPIC in residency, my progress notes typically take 3-5 minutes because so much of the information is carried forward. This is a must.

Has anyone used Heidi or any other dictation/transcription service with their respective EMR? I have played around with Heidi, and it seems awesome! On that note, if I am using the transcription feature, would consent to this go in my intake paperwork or would it be something I need to ask at each visit? Maybe it is state specific..

Don't you mean Dr. Mantis Toboggan, MD, LLC? Probably rec for advertising when you're at PCP offices letting a monster condom slip out of your wallet so they remember you have a magnum dong.

- LLC is super easy to get approved in most states. If you're going to be doing things like leasing an office, I would definitely make sure the LLC is set up so you can lease using the LLC. I agree the form is super simple at least in my state, I probably wouldn't bother paying an attorney.

- The address that you needed most states for an LLC is an address for them to serve legal papers at which you can use a registered agent for. So you can use your home address for the business, which isn't available to the public usually and then use a registered agent for document delivery, which is often the address that's public facing when someone goes to look you up in the business directory. At least that's the way it works in my state, I'd double check for whatever state you're in. You often can't use any kind of virtual address or anything because someone needs to be present or available to receive paperwork regularly unless that's what you're referring to. Something like this (I use them but have no affiliation with this, there are a bunch of other ones that do the same thing): https://www.northwestregisteredagent.com/

- About the form thing I've seen other practices do something like have patients fill out an online form, but then say if they don't hear back within a couple weeks, assume they're not taking new patients. I don't really screen much (but I'm child) so I don't know how well that works but seem a viable way to be able to get enough information about people to look up their med history and get some background information before you decide. Other places also make it very clear that the first visit or two they may decide to refer the patient out if they don't feel like they're a "good fit". You technically have a doctor patient relationship with someone after the first time you see them though so you have to formally discharge them once you've had an appointment.

- I would keep a credit card on file but then also have some wording that patients can't carry a balance higher than X amount for longer than X amount of days or you may have to discontinue care as a financial policy. That way it makes it pretty clear when you want to discharge someone for unpaid bills.

- For credentialing stuff you might actually have to complete residency, but that'll probably depend on the insurance company. I remember when I was initially getting credentialed I didn't start for a few months after residency and it took about that long to get on the first couple insurance panels because they wanted the documentation that I graduated. Some of them took them longer like six months.

- Along the same theme I would be prepared for things to be delayed like this with insurance companies in general. Once things have been going steady for 6+ months you're usually pretty good but it can be weeks to months from the first time you see patients to starting to get paid initially depending on how long they take to process claims, then if people have deductibles or the insurance company denies someone because they say they're ineligible or have some COB issue or whatever etc etc. This is kind of why it's hard for lots of people to jump straight into a collections based position or private practice straight out of residency if you don't have some level of financial cushion.

I wish I could see the faces of people who have never seen It's Always Sunny when they read your first blurb.

My state requires the registered agent part, so I may just go with that service you linked in there instead of going with an attorney.

It sounds like you can basically ghost someone who sends in paperwork that you don't think would be a good fit. I wonder if a good policy on the intake paperwork would be "if a balance is remaining at the end of the month, your credit card will automatically be charged" or something like that.

I just texted my PD and he said usually they will write a letter for us saying we are in good standing. Ill see if that works for at least one insurer. It would be nice to have one contracted insurer from the jump for my bank accounts sake.

 

[clozareal]

Business Entity:

• I’ll submit an Articles of Organization form to the state this week to form the LLC. The form is simple, but I’m debating whether to pay an attorney to draft it to ensure we're on the same page throughout this process or just do it myself. I don’t have a physical office yet, so I’m considering setting up a virtual mailbox to avoid using my home address (I’ve seen home addresses use by other psychiatrists in my area...needless to say I do not want my address easily found online).

I just did mine on LegalZoom.

• After establishing the LLC, I’ll obtain an EIN.
• Business NPI (Type II) – I’ll look into this soon.

Some insurances like a type II NPI number. It's really easy to do online.

• CAQH – I believe I need to register for this?

Yes for insurance purposes.

Office:

• I need to find an office space soon. Ideally, I’d like to sublease a small space (~500 sq. ft.), but I haven’t found many options yet. There is a really nice space, but it’s way too large (2,300 sq. ft.) and more expensive than I’d like to pay upfront ($2,700/month). Since I’d prefer to keep this practice small for now, that space seems like overkill.
• I’ll handle furniture and equipment once I’ve secured a space.

Look up other psychiatrists or therapists in your area with Psychology Today and see where they have an office. Then Google their address to find who the property manager is and give them a call to see if they have any open offices that fit your requirements or if they know of any.

Staff:

• My spouse will be my office assistant, scheduler, and biller. I typically handle more of the accounting and bookkeeping, but my spouse is more than capable of stepping in when needed.
• I plan to pay my spouse a fair salary.
• I may be getting ahead of myself here, but one advantage of keeping the business small (just the two of us) is that we can both have solo 401(k)s. I’d like to get my spouse’s salary to a level where we can max out both solo 401(k)s. We’ll probably also do cash balance plans. As you can probably tell, saving in tax-advantaged accounts is important to us.

This is a good idea. The employee portions and the employer portions of the solo 401ks come out to $140k for both of you this year and with the backdoor Roth IRA it's $154k that you can put into your retirement accounts. It might be worthwhile to look for a plan that will also allow in-plan conversions for a Mega Backdoor Roth in your 401k if you want to diversify your taxes with post-tax contributions as well.

Accounting:

• Once the LLC is approved, I’ll open a business checking/savings account and get a business credit card.
• We’ll work with an accountant at some point.
• If it makes sense, we may elect S-Corp taxation in the future.

Why wouldn't you elect S corp right away? I would think that it's a good idea but I might be missing something.

I use QuickBooks Online for my bookkeeping and it might be worthwhile to learn how to use.

It might also be good to have a payroll processor with the LLC for both of you. I use Gusto and I really like it. Other people use Intuit, ADP, Paychex, or their CPA does it all including bookkeeping.

If you hire your spouse, you need to file all the federal paperwork, including an application, W-4 form for federal tax withholding, I-9, and state specific forms. Gusto can help with all of that. Let me know if you want a referral code.

EMR/Website/Tech:

• I tested PracticeQ/IntakeQ, and while it was okay, I may explore SimplePractice. Luminello seemed to be the favorite among many of you. I’m hoping they integrate Luminello’s best features into their platform. I plan to test out SP over the next few days.
• I spoke with a therapist practice yesterday that uses SP, and they said they love it.
• Since my spouse and I will handle our own billing, I need to revisit @Sushirolls posts to see how they do their billing. I can’t remember if they use clearinghouses or work directly with the insurance company. If I remember correctly, there’s a (somewhat) seamless way to do this through the EMR.

I use Charm. It's really customizable and has mostly everything I need. I miss Luminello though, but this is indeed an upgrade from Luminello. I agree with @Sushirolls in leaning into your EMR for claims processing for insurances. They also have revenue cycle management support as well and integration into QuickBooks. I'm not sure if that can handle what sushirolls does with the Excel spreadsheet in keeping tack of claims.

• I’ve seen mixed opinions on this, but can I use Google Workspace for phone/email or is there HIPAA issues here? I plan to have multiple phone options for patient calls:
  • "If this is an emergency, please hang up and dial 911."
  • "If this is an urgent matter, press 1 to be connected with your doctor."
  • "If you need a refill, press 2 to leave a voicemail with the office."

This is called a phone tree and Google voice does have it. If you sign a BAA with Google Workspace, then phone calls are covered by emails aren't HIPAA complaint outside of emailing with your spouse and other members within the same domain as your workspace.

I use Spruce for phone, fax, and internal communications now after moving from Google Voice and Doximity Fax. It's SO much better. Let me know if you want a referral code.

Forms:

• I’d like to be somewhat selective with patients if possible. Having tech-savvy patients who can navigate the website is important to reduce phone calls. I’ve heard of other practices offering a "free consultation" or requiring extensive screening forms to filter out:
  1. Patients who struggle with technology/online scheduling.
  2. Patients unwilling to complete paperwork.

I do a brief phone screen with every patient. There are things on the form that don't get communicated as well as a phone call does that would help you screen out yellow/red flags. The first screening is the form and I will often decline people who aren't a good fit based on the form. Then if they get through that, they do a phone call with me and I tell many people I'm not a good fit. At the beginning, I was less selective because I just wanted to fill up more but now I only do 1-4 intakes per month to keep full.

The phone screen not only helps screen out patient's who are a bad fit for you, but also gives you a chance to introduce yourself to the patient so that they're more likely to convert from a new patient request to an intake and show up for it. Good treatment comes from a good relationship and how easy the process is from them searching for you to getting to be your patient is the start of that relationship. The phone screen gives you a chance to distinguish your level of service and care beyond what others can provide (although of course without appeasing/catering to unreasonable patients).

• How much flexibility do I have to say, “I’m not accepting new patients right now” based on screening results? For example, if a patient has significant substance abuse, difficult personality traits, or is seeking benzos, can I decline to take them on?

You have tremendous flexibility in declining patients who aren't the right fit for your expertise or clinical practice although if you take insurance, you can't decline them based on certain discrimination factors such as disability (deaf, wheelchair access to your office, etc), language, race, sex, national origin, etc.

I don't take insurance so I'm not sure if there might be specific contractual obligations or policies regarding patient acceptance that you need to follow.

Schedule:

• I want to build this into a full-time practice quickly. Ideally, I’d start early morning (6–7 AM) for patients who need appointments before work and finish by early afternoon so I can keep up with my golf game and work on my large acreage property that’s being transformed. My goal is 30–40 clinical hours per week.

"Quickly" in private practice for a 30-40 clinical hours would probably take 2-3 years.

• There’s a possibility of doing a 1099 side gig for TMS consults/mappings at a local therapy group (which also has a psych NP). This would be one day per week. While I may eventually incorporate TMS into my own office, I’d rather let someone else pay $200K for the machine while I collect 40–50% of collections.

It can be less than that for a machine depending on which one.

• The office will bill TMS sessions under my NPI as the rendering provider. Liability is a factor, but they’re not trying to bill NP services under my license—just the TMS (mapping + tech-administered sessions). The fee schedule looks solid… I’ll keep you updated.

Might be nice to have something on the side while you're building up your practice. It's also a way to network with other psychiatrists as well who refer patients over to the TMS practice but of course don't try to steal their patients.

Malpractice:

• I’ll look into this in the coming weeks. I’ll get occurrence-based malpractice to avoid future headaches.

I have claims-based and have a nest fund set up aside for the tail coverage. Usually it's 2-3x your annual cost for insurance.

Credentialing:

• The largest payer in my area initially told me I had to complete residency before starting the credentialing process. The more I think about it, the more I believe this is incorrect. Fresh attendings often start jobs in July, so I suspect they just require a letter of good standing and completion date from my residency program. I’m looking into this ASAP.

I started my private practice during fellowship but was already board certified as an adult psychiatrist so I'm not sure the answer to this.

Don't forget that credentialing and contracting are different. Contacting is negotiating with insurances on a fee schedule and what services will be provided. Credentialing is when a provider is approved by the insurance company to provide service to their members. Fresh attendings who start at a group/employer have a contract already in place with the insurance and they're just getting credentialed to be added onto the insurance using the same fee schedule, which is a much more streamlined system than what you're trying to do in a fresh private practice.

Fees:

• I prefer a strict no-show/cancellation policy:
  • Within 48 hours of the appointment or no-show → Full charge.
  • Patients will need to keep a credit card on file.
    • Or maybe I just block scheduling if they have unpaid fees?
• Anything else I should consider for fees?

What's your cash rate going to be? Here's what I recommend:
1. Your intake fee is your least important fee because it's just a one time fee and can actually prevent good patients from coming in since it is often a bigger cost than your follow-up. Therefore, I recommend having it lower than your follow-up hourly fee.
2. Your follow-up fees will make up the bulk of what the patient pays you. I recommend having two different hourly rates for one hour rate vs half an hour rate. I don't think your hourly rate should be double your half hour rate. I think your half hour rate should be 30% more.

Advertising:

• Psychology Today.
• Hopefully, I can attract patients simply because there are very few psychiatrists in my metro area.
• I already have a referral relationship with that local therapy practice, and they said they’d send me cases the NP can’t handle.

Every time you get a new patient that already has a therapist, I would make it a point to reach out to that therapist and then try to build a relationship. I ask if they're taking on new referrals, which kind of patients they like, and let them know that I'm taking on new patients as well and let them know how to send a patient over to me. Email therapists and psychiatrists in your area asking to meet and letting them know you're available to take on new patients. Not just a dozen emails. Hundreds. Go give food to PCPs. Have business cards that you send all over. Send letters to different therapy and psychiatry practices.

Try to shrink down your niche and create a unique selling proposition. That way people can know that you're the doc that therapists, other psychiatrists, primary care doctors can know to think of you when they come across a patient needing a referral. How do you come up with one?
1. What is unique about you clinically? It can be specializations, certifications, training background, clinical experience during residency, job experience even before residency/medical school.
2. What is unique about you nonclinically? Personal lived experience
3. What unique modalities do you offer in your practice? Different psychotherapies, TMS, ECT, ketamine, integrative treatments, etc.
4. Who do you treat (niche) and what outcome do you provide them?

A niche is more than just a diagnosis, it's a group of people. You have to identify what group of patients you most enjoy working with as you grow your practice. Then you want to focus all your marketing efforts and clinical skills on reaching and serving your niche.

Good luck and continue to post here with questions and updates!

 

[clozareal]

My state requires the registered agent part, so I may just go with that service you linked in there instead of going with an attorney.

Just be your own registered agent instead of paying someone an annual fee to do so.

 

[Dr. M Toboggan]

@clozareal Thank you for your detailed reply. I will have a few more questions that I will type out later tonight or tomorrow. Awesome stuff!

 

[calvnandhobbs68]

Just be your own registered agent instead of paying someone an annual fee to do so.

You shouldn't unless you actually already have an office or you want to list your home address as your business address. At least in my state, the "registered agent" address is the actual public facing address for your business entity when someone looks you up in the state business directory. So if you put your home address as your registered agent address, everyone knows your home address.

You also have to put an address where you can be served legal papers during regular business hours so things like a PO box or virtual address and stuff doesn't work.

 

[Jules A]

-Definitely see if you can rent an office a couple of days per week in therapy practice especially in the beginning. You will get referrals and it may be geographically specific but in my area approx 70%-80% of patients want virtual. I do 8-10h per week cash practice and only go in about once a month generally to see 2-3 evals and maybe 1-2 in person follow ups. Check out Doxy.me for virtual sessions. The free version has worked well for me.
-Although you can dictate your hours don’t get your heart set on early mornings only if you want to fill quickly. My busiest times are afternoon to early evening for both kids and people who work.
-Consider seeing everyone who submits the paperwork if you have openings especially initially. I can’t tell you the times I thought someone would be problematic but they were really great to work with and were willing to have their sloppy regimen cleaned up. If not a good fit or they don’t appreciate your recommendations they aren’t obligated to see you and will likely move along. I find private practice is very different from clinics in that regard.
-If you can moonlight at a nearby hospital you will get to know unit and ED social workers which should generate referrals particularly if you are able to get patients in quickly. ED docs have been a good source of referrals also.
-Rethink your phone prompt with option for urgent matters to be connected to doctor.
Best wishes.

 

[aquatic ape]

Appreciate the post, will be following.

Only thing I can add is this link from WCI regarding hiring your spouse. I am no expert on this but I trust him when it comes to most financial topics that aren’t REITs or other sponsored products

Can I Hire My Spouse as an Employee? | White Coat Investor

There are actually a few good reasons to hire your spouse in your business. But you probably won't come out ahead financially by doing so.

www.whitecoatinvestor.com

 

[splik]

Don't you mean Dr. Mantis Toboggan, MD, LLC?

unless you have 2 doctorates it’s either Dr OR MD - never both. Often fake doctors will put both, but a real MD should never use both

 

[Dr. M Toboggan]

@splik Thankfully, I won’t have to worry about it as I’ll use “[Regional name] Psychiatry.”

 

[calvnandhobbs68]

unless you have 2 doctorates it’s either Dr OR MD - never both. Often fake doctors will put both, but a real MD should never use both

It's a joke from it's always sunny lol

 

[splik]

It's a joke from it's always sunny lol

I have seen some people do this tho! So it’s worth mentioning unless people think it’s for real!

 

[clozareal]

You shouldn't unless you actually already have an office or you want to list your home address as your business address. At least in my state, the "registered agent" address is the actual public facing address for your business entity when someone looks you up in the state business directory. So if you put your home address as your registered agent address, everyone knows your home address.

You also have to put an address where you can be served legal papers during regular business hours so things like a PO box or virtual address and stuff doesn't work.

Right. I have a work address. Some people don't care having their home address as their registered agent though. If a patient wanted to find your home address, it wouldn't be too difficult.

 

[Dr. M Toboggan]

Look up other psychiatrists or therapists in your area with Psychology Today and see where they have an office. Then Google their address to find who the property manager is and give them a call to see if they have any open offices that fit your requirements or if they know of any.

Really good advice. I just did this and actually found a few potential great spaces. Three options are 150 sqft, 280, and 850. I may go tour those this week. This could be a nearly 30k savings. If I decide I want to grow with other docs or TMS, I can always reevaluate.

This is a good idea. The employee portions and the employer portions of the solo 401ks come out to $140k for both of you this year and with the backdoor Roth IRA it's $154k that you can put into your retirement accounts. It might be worthwhile to look for a plan that will also allow in-plan conversions for a Mega Backdoor Roth in your 401k if you want to diversify your taxes with post-tax contributions as well.

I typically look to the WhiteCoatInvestor for this info. I think the LLC vs S-Corp affects this in some ways, so if I elect for the LLC to be taxed as an S-corp (most likely option), I will be making sure to pay ourselves a fair salary that also makes sense to max out our solo-401ks.

Why wouldn't you elect S corp right away? I would think that it's a good idea but I might be missing something.

I use QuickBooks Online for my bookkeeping and it might be worthwhile to learn how to use.

It might also be good to have a payroll processor with the LLC for both of you. I use Gusto and I really like it. Other people use Intuit, ADP, Paychex, or their CPA does it all including bookkeeping.

If you hire your spouse, you need to file all the federal paperwork, including an application, W-4 form for federal tax withholding, I-9, and state specific forms. Gusto can help with all of that. Let me know if you want a referral code.

Correct, LLC electing to be taxed as an S-corp. I think there is a March date for deadline to elect this. For now, there is a chance I elect to be taxed as a sole-proprieter if things are going to take awhile. Maybe I will just plan to elect to be taxed as an S-corp for 2026.

This is called a phone tree and Google voice does have it. If you sign a BAA with Google Workspace, then phone calls are covered by emails aren't HIPAA complaint outside of emailing with your spouse and other members within the same domain as your workspace.

I use Spruce for phone, fax, and internal communications now after moving from Google Voice and Doximity Fax. It's SO much better. Let me know if you want a referral code.

Why did you decide to change from Google/Doximity to Spruce? It sounds like it was the right choice.

I do a brief phone screen with every patient. There are things on the form that don't get communicated as well as a phone call does that would help you screen out yellow/red flags. The first screening is the form and I will often decline people who aren't a good fit based on the form. Then if they get through that, they do a phone call with me and I tell many people I'm not a good fit. At the beginning, I was less selective because I just wanted to fill up more but now I only do 1-4 intakes per month to keep full.

The phone screen not only helps screen out patient's who are a bad fit for you, but also gives you a chance to introduce yourself to the patient so that they're more likely to convert from a new patient request to an intake and show up for it. Good treatment comes from a good relationship and how easy the process is from them searching for you to getting to be your patient is the start of that relationship. The phone screen gives you a chance to distinguish your level of service and care beyond what others can provide (although of course without appeasing/catering to unreasonable patients).

Do you mind me what types of things you are asking them about that you would not ask about on a screener?

"Quickly" in private practice for a 30-40 clinical hours would probably take 2-3 years.

I am hoping I can fill faster than that with insurance but I understand that may be the reality.

It can be less than that for a machine depending on which one.

I would love to buy a machine, but maybe I can get some experience under my belt without the risk of buying a chair that no one uses before I buy my own. One thing at a time..

Don't forget that credentialing and contracting are different. Contacting is negotiating with insurances on a fee schedule and what services will be provided. Credentialing is when a provider is approved by the insurance company to provide service to their members. Fresh attendings who start at a group/employer have a contract already in place with the insurance and they're just getting credentialed to be added onto the insurance using the same fee schedule, which is a much more streamlined system than what you're trying to do in a fresh private practice.

Really good info, thank you! @Sushirolls or anyone else with experience negotiating contracts with insurance - I received the reimbursement rates from BCBS...I don't feel I have any negotiating power as a one-man show. Should I ask them to give me a higher rate? They seemed like the rates they gave me were 'the' rates. Again, I was pleasantly surprised by the rates.

What's your cash rate going to be? Here's what I recommend:
1. Your intake fee is your least important fee because it's just a one time fee and can actually prevent good patients from coming in since it is often a bigger cost than your follow-up. Therefore, I recommend having it lower than your follow-up hourly fee.
2. Your follow-up fees will make up the bulk of what the patient pays you. I recommend having two different hourly rates for one hour rate vs half an hour rate. I don't think your hourly rate should be double your half hour rate. I think your half hour rate should be 30% more.

Just so I understand you, you are saying that if I charge $200 for an intake, I should charge $260 for a 30-min follow-up? If so, I get it based on getting people in the door. This seems slightly more geared towards cash, which may be my only choice for 3-6 months depending on credentialing.

Every time you get a new patient that already has a therapist, I would make it a point to reach out to that therapist and then try to build a relationship. I ask if they're taking on new referrals, which kind of patients they like, and let them know that I'm taking on new patients as well and let them know how to send a patient over to me. Email therapists and psychiatrists in your area asking to meet and letting them know you're available to take on new patients. Not just a dozen emails. Hundreds. Go give food to PCPs. Have business cards that you send all over. Send letters to different therapy and psychiatry practices.

I like all of these ideas!

 

[Dr. M Toboggan]

To opt out of Medicare or not...

It would make things easier if I opted out, but there is another side-gig I am looking at in the short term with an FQHC that would likely make it difficult/impossible to do. We have discussed using a collaborative/indirect care model where I do not see the patients directly, but instead act as a consult to the PCPs. Can I opt in for 3-6 months before opting out of Medicare?

 

[calvnandhobbs68]

Right. I have a work address. Some people don't care having their home address as their registered agent though. If a patient wanted to find your home address, it wouldn't be too difficult.

You can make it pretty hard and no reason to make it completely obvious by listing your home address as your searchable address for your business on the state database.

I know you can make it pretty hard cause I search myself every now and then on incognito mode (so my cookies don’t influence results) to see what pops up lol.

 

[Geraltofrivia]

Where did you find how much insurers reimburse? How do I find that?

 

[Dr. M Toboggan]

Where did you find how much insurers reimburse? How do I find that?

I called/emailed a few contacts I found online and one sent me an email back. The liaison did ask what my cash rates were so at the time I said $250/$400.

I think some companies want you to have a contract in place before they will share. I am just going to keep digging around to find the rates. I may call a few of the docs around town to see if they will share that info.

 

[clozareal]

I called/emailed a few contacts I found online and one sent me an email back. The liaison did ask what my cash rates were so at the time I said $250/$400.

I think some companies want you to have a contract in place before they will share. I am just going to keep digging around to find the rates. I may call a few of the docs around town to see if they will share that info.

I think the idea of signing an unknown fee schedule to be so abhorrent. Some also will say they don’t negotiate the fee schedule until you sign the contract, which makes absolutely no sense to me because you’re literally signing that you’re okay with the current fee schedule.

 

[Sushirolls]

@randomdoc1 is the negotiation expert from what I recall.
I tried a few times with a few and didn't get much traction. These days before I cut one out, I give them ultimatum increase, or get cut.

 

[Dr. M Toboggan]

So there aren’t many office space options in the area that I am wanting to open up. In a later post I’ll touch on why I’m opening in this specific area, but suffice it to say this is the only option for right now. It’s technically a “rural” area even though it’s 5 minutes or less from a midsize city.

I found one larger building that would be great, but it’s too much space for a solo-doc right now (2300 sqft, $2700).

I found some office space in a building that houses approx 30 offices/business suites. It’s upscale, but surprisingly affordable. It’s in a country club so there is a restaurant and bar on the first floor. 2 options here:

Option A is a suite with a “waiting room” and 3 offices. Pros: 850 sqft, waiting room, space to expand if needed. Cons: higher cost ($1500), a few windows I may need to block out with curtains for privacy.

Option B is a single office with 150 sqft. No waiting room but there is a public conference room that would actually be a decent place to wait a few doors down as long as privacy isn’t a concern. Pros: cheap ($280/mo). Cons: no true waiting area, no area to expand. With that said, if the clinic takes off over the next few years, I’d probably be looking at a space in the larger city’s city limits in about 4 years anyway. I like the idea of keeping overhead as low as possible this first year or so.

 

[Bartelby]

Do you plan to remain solo?

If so, the extra two offices will pretty much go wasted with option A. More important, though, you want to look professional and you don't want your practice to look cheap.

I rent a solo office in a building with other professionals, but there is a really nice waiting room and everything looks very polished. I bought nice furniture and art for the office and even though I only have a small office, the additional common room works out great. If I had to direct patients to wait in a conference room (unless it was used), or wait in their cars until the appointment time, that would be a problem because it strays into looking cheap. While keeping overhead low is important your presentation should instill trust in patients, especially if you are looking for a cash pay patient pool.

Also think about how much you anticipate bringing in per month. If you anticipate pretty typical gross income (such as $300k-400k range) then spending $18k per year on office space is not bad at all. I would lean toward that based only on what you've written.

As an aside, ask your spouse or even trusted friends if the space looks professional! When you are building a practice you can get caught up in all the excitement and a fresh pair of eyes can bring some options back down to earth. Having my wife see spaces I was thinking about renting was very helpful, she was able to quickly "thumbs down" some places I was seriously considering and in retrospect it was the right call because those places did not "feel" like a professional medical setting.

 

[Bartelby]

I would also mention that if you really feel better in one space than another, it can be worth the extra expense. My main barrier to increasing income is scheduling/accepting less work, and the more I enjoy my work day the more open I am to taking new work.

 

[Merovinge]

Option B is a single office with 150 sqft. No waiting room but there is a public conference room that would actually be a decent place to wait a few doors down as long as privacy isn’t a concern. Pros: cheap ($280/mo). Cons: no true waiting area, no area to expand. With that said, if the clinic takes off over the next few years, I’d probably be looking at a space in the larger city’s city limits in about 4 years anyway. I like the idea of keeping overhead as low as possible this first year or so.

One of my friends/colleagues has an office around that size but as part of a suite that also has a significant waiting area, private bathroom. It feels small to me but seems to be going alright for her. If I only had a single office, 150 sq ft would be quite a bit smaller than what I would be looking for, I am not sure I would hire a lawyer/doctor/accountant who had a footprint of 150 sq ft.

 

[Stagg737]

Agree with others I wouldn't do option B. Honestly just seems cheap to make patients wait in a conference room down the hall and seems off putting. Could even be a HIPPA violation, but idk there.

Option A seems like a good option if the first place (2,300 sq ft) isn't what you want. Enough room to be professional, but not too large that you're going to seem empty/isolated. That rent seems reasonable and you've got the space to add a therapist or another psychiatrist to the practice if you want. If you're looking to do that right away, you may want to just start with the bigger space and eat the cost if you plan on growing and staying in that location for a while.

Best of luck!

 

[Jules A]

Its a shame OP can't find an office to rent in an already established therapy practice to get started. I'd be interested in hearing @Sushirolls take on office requirements, cost recommendations and also percentage of in person vs virtual that he is doing now.

 

[Sushirolls]

I started years ago with a bigger office space that had like 3-4 offices, and was ~$3000/month and rising in cost per year. Plans to have TMS, and even bring on another Psych, etc. That lease killed me. Now I'm in middle of nowhere with shortage of viable spaces. Currently in a single room suite. Not perfect, but heck of a lot cheaper and gets it done. Assistant helps to let people know - be on time - since there is no waiting room. Works overall.

I'd estimate after the initial consult [I require 1st visit in office], 70% of my follow visits are telemedicine, and the other 30% are diehard in office people. If I or family or sick, I can always pivot and telecommute, but that's rare and I try to respect peoples preferences for in/out of office visits.

 

[Bartelby]

Oddly I work for a large health system part-time doing outpatient work and would estimate 80% or more follow-ups choose telehealth. Most of my cash private practice patients, though, end up coming in person (likely >75% in person total cumulatively). That may just be a quirk of my practice, or may be because I emphasize therapy in private practice versus 30-minute visits in the employed role.

 

[clausewitz2]

Agree with others I wouldn't do option B. Honestly just seems cheap to make patients wait in a conference room down the hall and seems off putting. Could even be a HIPPA violation, but idk there.

I agree with you that it seems cheap and off-putting and is probably not the way to go, but I'm not sure where the HIPAA violation is. Unless we are to argue that others simply knowing you are visiting a physician because they can see you walk into the physician's office is a HIPAA issue. Not sure how we would solve that without an Elvis-style secret trapdoor from a private parking garage.

 

[Stagg737]

I agree with you that it seems cheap and off-putting and is probably not the way to go, but I'm not sure where the HIPAA violation is. Unless we are to argue that others simply knowing you are visiting a physician because they can see you walk into the physician's office is a HIPAA issue. Not sure how we would solve that without an Elvis-style secret trapdoor from a private parking garage.

Sure, I doubt it would be a HIPAA violation, but would not be surprised if a patient pulled this at some point. Keep in mind that option is in a country club and the waiting room would be a conference room down the hall, so definitely a possibility of running into privacy issues and some patients could file HIPAA complaints if people they know see them walking into the psychiatrists office while at the country club. Same issue with the other option, but at least they’re not having to walk through public areas to get from the waiting room to the actual office.

Again, at the very least it just seems cheap and off putting.

 

[Sushirolls]

I don't even have a waiting room. I tell patients be precisely on time. I believe after people experience no waiting at all, but simply being on time leads to a punctual appointment, they are pleased.

 

[Merovinge]

I don't even have a waiting room. I tell patients be precisely on time. I believe after people experience no waiting at all, but simply being on time leads to a punctual appointment, they are pleased.

What do you do when a patient shows up actively suicidial or psychotic and requires IP hospitalization?

 

[Sushirolls]

So far that hasn't happened. But if needed to, I'd message ensuing patients need to reschedule. Or if when my assistant is working, have her reschedule the next 1-2 follow ups. Then proceed to call for ambulance for acute intervention.

 

[Dr. M Toboggan]

Do you plan to remain solo?

If so, the extra two offices will pretty much go wasted with option A. More important, though, you want to look professional and you don't want your practice to look cheap.

I rent a solo office in a building with other professionals, but there is a really nice waiting room and everything looks very polished. I bought nice furniture and art for the office and even though I only have a small office, the additional common room works out great. If I had to direct patients to wait in a conference room (unless it was used), or wait in their cars until the appointment time, that would be a problem because it strays into looking cheap. While keeping overhead low is important your presentation should instill trust in patients, especially if you are looking for a cash pay patient pool.

Also think about how much you anticipate bringing in per month. If you anticipate pretty typical gross income (such as $300k-400k range) then spending $18k per year on office space is not bad at all. I would lean toward that based only on what you've written.

As an aside, ask your spouse or even trusted friends if the space looks professional! When you are building a practice you can get caught up in all the excitement and a fresh pair of eyes can bring some options back down to earth. Having my wife see spaces I was thinking about renting was very helpful, she was able to quickly "thumbs down" some places I was seriously considering and in retrospect it was the right call because those places did not "feel" like a professional medical setting.

I would also mention that if you really feel better in one space than another, it can be worth the extra expense. My main barrier to increasing income is scheduling/accepting less work, and the more I enjoy my work day the more open I am to taking new work.

One of my friends/colleagues has an office around that size but as part of a suite that also has a significant waiting area, private bathroom. It feels small to me but seems to be going alright for her. If I only had a single office, 150 sq ft would be quite a bit smaller than what I would be looking for, I am not sure I would hire a lawyer/doctor/accountant who had a footprint of 150 sq ft.

Agree with others I wouldn't do option B. Honestly just seems cheap to make patients wait in a conference room down the hall and seems off putting. Could even be a HIPPA violation, but idk there.

Option A seems like a good option if the first place (2,300 sq ft) isn't what you want. Enough room to be professional, but not too large that you're going to seem empty/isolated. That rent seems reasonable and you've got the space to add a therapist or another psychiatrist to the practice if you want. If you're looking to do that right away, you may want to just start with the bigger space and eat the cost if you plan on growing and staying in that location for a while.

Best of luck!

I am not sure on the HIPAA issue, but I am usual punctual with my 30-min appointments for the most part, and that includes 5+min of supervision and me getting my notes done before I see my next patient. There are always going to be situations that may make one appointment run long (i.e., suicidal pt), but for the most part I think I will keep things moving at a good pace.

If I went with the 150 sqft option w/ conference room down the hall, I would let the follow-ups know they may use the conference room to wait, or they can just show up right at the appt time and I will be ready 95% of the time. If I go with this space, the leasing office will let me throw my name on waitlists for any of the other 30 spaces if they become available. There are three therapist clinics in the building and I believe they all have a single office and have a few chairs outside of their room. I don't like the chairs outside of room idea, so the conference room could make sense.

The 850 sqft unit does make sense if I add a doc/midlevel down the road, but I think it is more likely in the future I would move into a more private building of my own if the clinic takes off.

I keep going back and forth because like Sushi mentioned, the rent will be the largest overhead expense, so keeping it cheap could be really helpful for a year or two as the clinic is growing. I would rather not be paying $1500+ per month if I am not getting credentialed until late 2025.

I started years ago with a bigger office space that had like 3-4 offices, and was ~$3000/month and rising in cost per year. Plans to have TMS, and even bring on another Psych, etc. That lease killed me. Now I'm in middle of nowhere with shortage of viable spaces. Currently in a single room suite. Not perfect, but heck of a lot cheaper and gets it done. Assistant helps to let people know - be on time - since there is no waiting room. Works overall.

I'd estimate after the initial consult [I require 1st visit in office], 70% of my follow visits are telemedicine, and the other 30% are diehard in office people. If I or family or sick, I can always pivot and telecommute, but that's rare and I try to respect peoples preferences for in/out of office visits.

I am sure if I have a decent side gig to start, I could survive the lease, but it does worry me without any 1099 contracts signed yet. Again, this is technically considered "rural" so I do wonder about perspectives from small town America versus NYC/Chicago residents. Overall, with the country club vibe, I think patients may like it. Both spaces are classy imo.

I agree with you that it seems cheap and off-putting and is probably not the way to go, but I'm not sure where the HIPAA violation is. Unless we are to argue that others simply knowing you are visiting a physician because they can see you walk into the physician's office is a HIPAA issue. Not sure how we would solve that without an Elvis-style secret trapdoor from a private parking garage.

Sure, I doubt it would be a HIPAA violation, but would not be surprised if a patient pulled this at some point. Keep in mind that option is in a country club and the waiting room would be a conference room down the hall, so definitely a possibility of running into privacy issues and some patients could file HIPAA complaints if people they know see them walking into the psychiatrists office while at the country club. Same issue with the other option, but at least they’re not having to walk through public areas to get from the waiting room to the actual office.

Again, at the very least it just seems cheap and off putting.

I don't know if this would be any different than any other business office spaces?

 

[brosa]

For office furniture, just get an interior designer. I think it's crazy that people don't get them more often, consider that with the global market you can get someone from another country paying very cheap. I plan to do that myself, if you need help setting that up just DM me. I wanna do that 2-3y from now, so might as well just find someone good now already.

 

[Dr. M Toboggan]

For office furniture, just get an interior designer. I think it's crazy that people don't get them more often, consider that with the global market you can get someone from another country paying very cheap. I plan to do that myself, if you need help setting that up just DM me. I wanna do that 2-3y from now, so might as well just find someone good now already.

Good thought.

Any recommendations from your research?

 

[smalltownpsych]

For office furniture, just get an interior designer. I think it's crazy that people don't get them more often, consider that with the global market you can get someone from another country paying very cheap. I plan to do that myself, if you need help setting that up just DM me. I wanna do that 2-3y from now, so might as well just find someone good now already.

Just to chime in on design. My experience has been that if you do it well, you will get frequent positive feedback. If it is not then you will get no feedback. My wife and I are a pretty good team with design and in two different office settings including my current private practice have received lots of good feedback. Last company I worked at who did their own design because the owner thought she was good at it, in three years didn’t get a single positive comment. We aimed for broad appeal and appropriate feel that is comfortable yet professional. Clean lines and subtle color with a few pops of interest or color here and there. Having a professional designer is helpful if you don’t have a lot of real talent and interest, just have to make sure that they understand the business approach, clientele, and philosophy of your practice and what fits your personality and style as a person so it is congruent.

 

[clozareal]

Good thought.

Any recommendations from your research?

I used Havenly and it was a satisfactory experience for the price. I have no interior design sense.

 

[Dr. M Toboggan]

Does anyone here do any TMS work where they are contracted with a practice that owns the machine? If so, could I pick your brain about how you set up the contract?