Sep 19, 2015
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Hello all,

I am very interested in feedback from Psychiatry med students and Psychiatrists practicing in various settings (Private Practice, Hospitals, etc.) regarding some research for a future Private Practice (Fall 2016).

First off, I am a LPC (Licensed Professional Counselor in the Piedmont area of NC) and have about 14 years of experience working both in the Non-Profit and currently in the For Profit area of Mental Health. I have extensive management experience and am comfortable with many aspects of managed care, client/patient care and of course, psychotherapy. Currently, I work for a Psychiatrist owned practice and I am typically the top billing therapist in the practice. I really enjoy what I do and for some time have considered starting my own practice and bringing on a team of Psychiatrists/PA's/NP's and Therapists. Additionally, I am often surprised by the lack of Psychiatrists in this area that are accepting new patients or can see a new patient relatively quickly (i.e. less than 2 months). For example, for a new patient to see our practice owner (MD), the wait is typically 3 months (to see the PA or NP - possibly 3 weeks). Close by in a larger city, the wait is even longer (if you can even get the Psychiatrist to return the call). I am curious to see what others would think about several areas to find out what is attractive to MD's regarding PP.

1) Would you prefer to work for a practice on a "fee for service" basis or rent office space? Only renting space would include: front desk coverage/check-in/out, appointment setting and referral stream from other practitioners in the office, but MD would do their own billing? Fee for service would include a framework like: ex. practitioner would earn 60% of revenue if billing $15k+ a month, 55% for $14-14999k a month, etc. This would include all of the above, but billing would be included, plus other benefits (401k, bonus potential, practice marketing, website, etc.).

2) Thoughts on working with a team of mental health professionals vs solo practice?

3) In our area, I typically notice that expecting to see a large number of patients that are willing to pay full fee w/o insurance is unrealistic. It seems like that the practices that utilize at least a few insurance panels with self pay, tend to fill quickly. Is this a turn off for MD's (if considering work in a practice)?

4) Suggestions for me to locate MD's? I realize that I could put an ad in the typical places (paper, job search engines), but do you find that your profession searches particular places more often (ex. LinkedIn, APA board, etc.)?

5) This is just a starting point with my questions, but anything else that could be helpful for me to consider from a Psychiatrist's point of view?

Thanks so much in advance! Basically any info and thoughts are helpful.
 

nitemagi

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I'm curious what your practice offers psychiatrists that they can't get elsewhere? There's a high demand, and salary/benefits offered out there looks like it exceeds what you'd be offering.
 

Bartelby

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As someone who will be looking for a job in 1.5 years (current PGY-IV doing fellowship next year) I would wonder the same thing as nitemagi. Comparing this setup to solo private practice the difference appears to be:

1. You take 40-45% of all billing.
2. You provide an office and a receptionist who does scheduling and checkins, along with a website.
3. You help getting referrals, though all of these referrals appear to be insurance-based people in an underserved area (where I'm thinking referrals would not be hard to come by).

The MD still has to do his/her own billing despite paying 40-45% overhead! When you say benefits, are you providing health insurance? Matching contributions to 401k?

So if I saw this offering I would be thinking to myself that I can probably get an office and schedule my patients for less than 45% of my total collections. I would probably be looking elsewhere or starting a solo private practice, though maybe there is something I'm overlooking.
 
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OP
L
Sep 19, 2015
9
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Status
Non-Student
I'm curious what your practice offers psychiatrists that they can't get elsewhere? There's a high demand, and salary/benefits offered out there looks like it exceeds what you'd be offering.
Thank you nitemagi for replying back to me. I am going to reply to Bartelby's question below b/c I may be able to respond to similar questions.
 
OP
L
Sep 19, 2015
9
0
Status
Non-Student
As someone who will be looking for a job in 1.5 years (current PGY-IV doing fellowship next year) I would wonder the same thing as nitemagi. Comparing this setup to solo private practice the difference appears to be:

1. You take 40-45% of all billing.
2. You provide an office and a receptionist who does scheduling and checkins, along with a website.
3. You help getting referrals, though all of these referrals appear to be insurance-based people in an underserved area (where I'm thinking referrals would not be hard to come by).

The MD still has to do his/her own billing despite paying 40-45% overhead! When you say benefits, are you providing health insurance? Matching contributions to 401k?

So if I saw this offering I would be thinking to myself that I can probably get an office and schedule my patients for less than 45% of my total collections. I would probably be looking elsewhere or starting a solo private practice, though maybe there is something I'm overlooking.

Thank you nitemagi and Bartleby for your feedback and I realize that I was not clear on some of my explainations - it's great to be able to clarify now to avoid confusion in the future when I am trying to find providers.

1) Would you prefer to work for a practice on a "fee for service" basis or rent office space? Only renting space would include: front desk coverage/check-in/out, appointment setting and referral stream from other practitioners in the office, but MD would do their own billing? Fee for service would include a framework like: ex. practitioner would earn 60% of revenue if billing $15k+ a month, 55% for $14-14999k a month, etc. This would include all of the above, but billing would be included, plus other benefits (401k, bonus potential, practice marketing, website, etc.).


So this question was attempting to distinguish between 2 possible options that I am considering when addressing collaborating with MD's.
1) One option would be to advertise to local MD's that there is office space available for rent (in a private practice). So let's say the MD would pay $2000 a month (making up a $# here) and with that, they would have the office space w/ utilities, lobby usage that is furnished, front desk coverage, phone/appointment setting/voicemail, referral stream from other practice providers, most likely some sort of marketing with website mentioning the provider's name/services, but they would do their own: billing, taxes, no benefits like 401k, insurance.
2) Next option is the fee for service and would include everything that #1 includes, but also it would cover: their billing, taxes, 401k matching, insurance and likely $ towards CME/CEU's.

Basically the fee for service option (2), allows for someone else to enable that provider to practice, but not worry about having to manage the business side of things. Both of these options are common in our areas/state, so maybe that is why we have so few providers available. I know of some psychiatrists that only accept cash/self pay and may see a small # of clients and they rent an office, do their appt. setting, respond to voicemails, etc. I believe that they see a very small # of patients as compared to those that are in a practice that has more structure/support (also our area does not seem to have a large client base that could afford MD appointments w/o insurance). I currently work for a practice on a fee for service plan and have been there for 3.5 years; it has been really nice to see my clients and know that the business side is covered, but I also believe that I can go beyond this option and manage the business side of things. My good friend and therapist knows that she is not business minded in this sense and appreciates the idea that she gets a paycheck and does not have to also manage a business. It's definitely up to the individual, but
each side has pros/cons. Typically I have found that more practices are allowing providers to rent space and the rent is very high; some have this higher rent and also cover all aspects of the business (including billing/taxes) but do not cover things like 401k, insurance, CME budget.

From your point of view, would it be more attractive to pay a higher rent and include #1's option, but also cover the billing/taxes side as well? (and you would do your own insurance, retirement investing, CME budget).

I'm also curious to find out what others are encountering when they are job hunting? What are the turn offs/concerns?

Again, I really appreciate everyone's help/feedback!
 

michaelrack

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1. This arrangement is certainly common and is certainly workable.

2. This needs to be divided into 2 options (of which you can choose to offer one), as the option you outline doesn't work (in my opinion):
2a: psychiatrist is an employee with a salary and possible bonus based on collections, RVU, etc. CME, 401k, receptionest, etc is provided. Income is W2.
2b: psychiatrist is an independent contractor and income is 1099. He pays a fixed amount for office space, receptionist etc. He pays a % of collections to you for billing services. The basic difference between 2b and 1 is that in 2b you are doing the billing (and presumbably also credentialing). No CME, insurance in 2b
 
M

MrWonderful

What you're suggesting sounds to me like what has happened to anesthesia -- i.e., a non-MD/DO (in some capacity, be it large group or organization) manages and "collects" from docs who are enticed solely by the apparent appeal of "not having to worry" about anything beyond getting a paycheck every week.

Obviously everybody will have their own aversion to perceived risk, but I'd sooner start my own thing than work for anybody who needs me to diversify their practice anyway
 
OP
L
Sep 19, 2015
9
0
Status
Non-Student
1. This arrangement is certainly common and is certainly workable.

2. This needs to be divided into 2 options (of which you can choose to offer one), as the option you outline doesn't work (in my opinion):
2a: psychiatrist is an employee with a salary and possible bonus based on collections, RVU, etc. CME, 401k, receptionest, etc is provided. Income is W2.
2b: psychiatrist is an independent contractor and income is 1099. He pays a fixed amount for office space, receptionist etc. He pays a % of collections to you for billing services. The basic difference between 2b and 1 is that in 2b you are doing the billing (and presumbably also credentialing). No CME, insurance in 2b

Thank you Dr. Rack for your thoughts - I believe for my practice to work in the earlier stages, I would have to offer option 1 or 2b. My guess is that to offer such a large (and well deserved!) salary to a MD, I would probably need to have a very large practice to cover that sort of overhead. It's definitely something (option 2a) that I would want to offer in the future.

A large part of my thinking towards the fee for service option was that as the owner, I would be able find the best person for our group in terms of personality, goals and philosophy of treatment. As most of you can likely relate, I have encountered some interesting characters in this line of work: from providers that are telling their patients that they themselves are bipolar and typically making the session about them vs the patient, to people having meltdowns/slamming doors and cussing out other staff all in front of the patients, to providers that are so socially anxious that they cannot make eye contact with the patient and so patients end up going elsewhere due to their own discomfort. These are just a few examples and of course these kinds of situations involve providers of various professions in the mental health field. I think that even if I look at options 1 or 2b, I believe that it is still viable to interview the provider wanting to rent space.
 
OP
L
Sep 19, 2015
9
0
Status
Non-Student
What you're suggesting sounds to me like what has happened to anesthesia -- i.e., a non-MD/DO (in some capacity, be it large group or organization) manages and "collects" from docs who are enticed solely by the apparent appeal of "not having to worry" about anything beyond getting a paycheck every week.

Obviously everybody will have their own aversion to perceived risk, but I'd sooner start my own thing than work for anybody who needs me to diversify their practice anyway
Right - I agree with you MrWonderful and that is a large part of the reason why I want to venture out on my own.
 

TexasPhysician

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In regards to 2nd option (employ the MD with benefits) - that is illegal in my state. If you consider this route, thoroughly evaluate your state's laws, and you will likely need an attorney to be sure everything is kosher.
 
M

MrWonderful

Any psychiatrist with the least bit of business Savy will probably opt for a collaborative approach, i.e., you each split rent and utilities and Bill separately OR share the cost of using a billing company and keep your respective collections for the individual patients you see
 
OP
L
Sep 19, 2015
9
0
Status
Non-Student
In regards to 2nd option (employ the MD with benefits) - that is illegal in my state. If you consider this route, thoroughly evaluate your state's laws, and you will likely need an attorney to be sure everything is kosher.
Thanks TexasPhysician - agreed. I will definitely consult with an attorney regarding each option that I am considering. Although, the more I am thinking through everyone's feedback, I think it would likely be easier to rent space to a Psychiatrist that includes front desk coverage, appointment setting, check-in's and the MD would take care of their billing, taxes, benefits, etc. Additionally, if I have enough interest from MD's, I would like to find a provider to rent space that would be receptive to collaboration (hopefully) with our staff (therapists) for better continuity of care for possible shared clients/patients. My concern though is that there will not be enough interest due to the lack of available psychiatrists in our area. Wake Forest University (very close by) has a Psychiatry program, but I rarely hear of those graduates opening up local practices, so it appears that they move out of the area; most of the current providers have been around for some time and have established practices. It seems though that our area would be a prime spot to begin a new practice - I know of a wonderful Psychiatrist in Greensboro, NC (from several clients I have referred) that when they called in July, she did not have an opening for a new patient until Feb. 2016. It is even more surprising to hear about this long wait, b/c she works M-F from 8am-7pm and every other Saturday from 8am-2pm; not sure how she does it.
 
OP
L
Sep 19, 2015
9
0
Status
Non-Student
Any psychiatrist with the least bit of business Savy will probably opt for a collaborative approach, i.e., you each split rent and utilities and Bill separately OR share the cost of using a billing company and keep your respective collections for the individual patients you see
Good ideas - I appreciate your suggestions. Do you have suggestions as to where to advertise office space? Original thoughts: local University Psychiatry job boards, American Psychiatric Assoc., LinkedIn.
 

TexasPhysician

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Although, the more I am thinking through everyone's feedback, I think it would likely be easier to rent space to a Psychiatrist that includes front desk coverage, appointment setting, check-in's and the MD would take care of their billing, taxes, benefits, etc.
How big of a practice are you opening? 1 psychiatrist that takes insurance likely needs 1-2 dedicated front office staff. Checking in patients typically includes evaluating insurance deductibles, co-pays, coordinating with billers, and accepting payment. MD won't have time for that. In-house or outside billers are in addition to the above office staff.

Insurance companies sometimes negotiate higher reimbursements to groups of psychiatrists. Having just 1 can leave you at a disadvantage in getting good rates.

Can your practice refer enough cash only patients? That may help in recruiting.
 
OP
L
Sep 19, 2015
9
0
Status
Non-Student
How big of a practice are you opening? 1 psychiatrist that takes insurance likely needs 1-2 dedicated front office staff. Checking in patients typically includes evaluating insurance deductibles, co-pays, coordinating with billers, and accepting payment. MD won't have time for that. In-house or outside billers are in addition to the above office staff.

Insurance companies sometimes negotiate higher reimbursements to groups of psychiatrists. Having just 1 can leave you at a disadvantage in getting good rates.

Can your practice refer enough cash only patients? That may help in recruiting.
Tentatively, I am thinking of having 2 FT therapists (I would be one of those providers) and 2-3 PT therapists (which would utilize the FT therapist's offices when we are not working) for evening and/or Saturday mornings (if possible). Eventually, I would like to expand upon those staff/hours. If I am fortunate enough to even find 1 interested Psychiatrist to rent space, I would love to have 1 more; although I have wondered if it may be easier to find 2 PT Psychiatrists that could be working on the side from a FT Hospital position, etc.

Currently, I work in a small private practice and have years of experience doing quite a bit of those office tasks and you are right, it does take time to complete all of those services. In our (current place of work) practice, FT is 30 hours a week and covers 4 days, however, in my future practice, I would likely spread my 30 therapy hours over 5 days and work PT as well with front office support, etc. To start, I would definitely need a minimum of 1 FT and 1 PT dedicated office staff for front office as well as a separate billing person. If the practice becomes quickly successful, I would have to have at least 2 FT front office staff, in addition to some of the PT work (and the billing person) that I would do focused on the business. Currently, my office has 1 Psychiatrist/Owner, 2 PA's, 1NP and 4 therapists. We have 3 FT office staff and 2 are generally on Facebook/playing games on their computer for large chunks of time; there is also an outside billing person that also contracts with several other practices. We stay full, so there are quite a few check-ins/outs, phone calls, reminder calls, insurance checks, etc. and our office staff still have free time.

Locally, there is a large private practice that has some higher tech options via their EHR, which includes the option for clients to schedule returning appointments via an online calendar, as well as prepaying for their appointments with the set session cost (provided at their first appointment). This EHR also sends the appt. reminders (phone, text, email), which saves the work from going to the already busy front desk/office staff.

Unfortunately, it does not appear that our general location has large #'s of people who utilize Psychiatry/Psychotherapy services and only pay cash. Most of the area large and small practices accept insurance; recently though, my current practice stopped accepting UHC due to their low reimbursement rates and various other difficulties.

Thanks for your feedback TexasPhysician!