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Even in NYC area, the demand is there, frankly I think everywhere there is a demand. When I started private practice part time in Manhattan. I took only 4 insurance panels and no medicare, medicaid and screened everyone and I couldnt keep up with the amount of patients, I only planned to do it part time, but must have had 50 to 70 inquiries a week for patients trying to get in, even in one of the most highly congested area of private practice psychiatrists. So I think their practice will be fine and explode with referrals soon.

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Wow. 50-70 inquires per week. I'd estimate with a mix of either online electronic inquiry, phone inquiry answered by reception and actual voicemails left I range from 8-20 per week. Depending on the week 10-20% are C&A inquiries that are diverted else where.

It is possible that there are more that aren't being captured by my receptionist, as she mostly works in AM, and more calls come in afternoon. Sadly there are a lot of Robo calls or people spamming and trying sneaky things to get the doctor of the office on the phone who can agree to purchase or sign up for the product/service.

Despite my spill over from the inpatient insurance paneling I did before this office practice, which was like 8-10 companies. I realistically have 4 big insurance companies; medicare, low payer, low payer, good payer. My two minor volume insurance companies are good payers. The other companies I just haven't seen, I will probably drop in coming months/years if ECT doesn't get up and running.

Of the consults I do, I'd say 70% are leading to follow ups, the other 30% were one time consults.
 
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Smattering of things.
2nd opinion request from start.
2nd opinion after discussing they already had all they needed and simply wanted to know if inpatient unit set them up with good plan.
Pts who clung to belief that cannabis is panacea cure for everything despite their symptoms are worsening and didn't like hearing the recommendation to quit.
Some who had first mental health eval and didn't know where to start, no interest in meds, not a good therapy fit for my skill set, so educated on options and pointed in direction that was good fit.
One was geography mismatch, way too far to consistently see me and with hospital history on table told to establish with psych closer to their home.
One was SUD and other addictive behaviors. No real signs of desire to quit or make real change in life. Needed IP level care foremost. Told to call back after completing IP.
And the classic "I'm only here to appease my family and don't want to anything" ok, come back when you are ready.
Small quantity message before next appointment saying they found another doctor, or didn't like the no cannabis recommendation, or other issue in life popped up and wouldn't be returning.
 
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2nd opinion after discussing they already had all they needed and simply wanted to know if inpatient unit set them up with good plan.
Pts who clung to belief that cannabis is panacea cure for everything despite their symptoms are worsening and didn't like hearing the recommendation to quit.
Small quantity message before next appointment saying they found another doctor, or didn't like the no cannabis recommendation, or other issue in life popped up and wouldn't be returning.
I can't remember if you mentioned your location but I'm currently looking at CO as a potential practice location after I finish residency and I wonder how much the cannabis thing will end up being a frustrating/frequent part of practice out there.
 
I've not mentioned a location.

Just assume any state that is along the cannabis legalization process it will be a headache. And the greater the legislative push for the farce of an agenda that it is 'medicine' the more of a headache it will be. I've had some days where more than half my day was spent advising the negative consequences of continued cannabis use. Good luck.

Even in non-legalized states its still an issue. Conceptually people view it as a harmless inhaled vitamin and its difficult to change that opinion. Until people have crashed and are hospitalized for mood/depression/psychosis or crashed on their other SUDs and are in residential, most cling to it. I inform people they need to lower their expectations of what they can achieve with continued use, and I in return lower my expectations of what I hope the patient to achieve, and do my part with 'motivational interviewing' to elicit change when I can.
 
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I've not mentioned a location.

Just assume any state that is along the cannabis legalization process it will be a headache. And the greater the legislative push for the farce of an agenda that it is 'medicine' the more of a headache it will be. I've had some days where more than half my day was spent advising the negative consequences of continued cannabis use. Good luck.

Even in non-legalized states its still an issue. Conceptually people view it as a harmless inhaled vitamin and its difficult to change that opinion. Until people have crashed and are hospitalized for mood/depression/psychosis or crashed on their other SUDs and are in residential, most cling to it. I inform people they need to lower their expectations of what they can achieve with continued use, and I in return lower my expectations of what I hope the patient to achieve, and do my part with 'motivational interviewing' to elicit change when I can.

Yeah I don’t get this weird idea of cannabis as a cure all for everything. I usually go along the lines of “just because it’s legal doesn’t make it good for you like all these other things that are legal and not great for you” but agree that people cling to this idea that it has no adverse effects.

Although honestly this was the attitude towards cigarettes before about the 1980s-1990s...
 
Spoke to a Cannabis oil rep today, and it seems like there is a growing move towards prescribing in the paediatric population for a number of conditions including depression, anxiety and autism, with one of our leading youth research hubs leading the charge. We've had a situation where those with ADHD have turned 18 and graduated from their paediatrician or child psychiatrist and are having a lot of trouble accessing adult psychiatrists who are willing to prescribe stimulant medication. This has driven a lot of demand to the point where psychiatrists can focus exclusively on ADHD prescribing in a private setting and do very well out of it. Although our GP/PCP group are able to prescribe stimulants, there are very few that will and many are reluctant due to somewhat onerous state regulations.

With that in mind I did wonder if in another 10 or so years a similar situation might arise with cannabis oil prescriptions, and if there ends up being a cohort of patients who legitimately benefit there will likely be a shortage of doctors willing to prescribe it. At the moment I'm not looking into exploring it at all, as having seen too much in the way of substance induced psychotic and mood states, at the moment I'm not particularly convinced that there's much evidence in the way of cannabis oil for psychiatric conditions. It also seems most people enquiring about it are either dealing with cancer or chronic pain (which I'll leave to the relevant specialists), looking for some excuse to get out of a drug driving offence or just as you've experienced wanting some kind of justification to keep on using it. Eg. recently had a family show up who wanted support for a job search exemption to receive a sickness benefit for their son - he smokes 4g+ of weed a day, doesn't want to quit and won't take any other medication. Someone had told them that an autism diagnosis would help his case, but I refused on the basis that it's impossible to tell when someone is permanently stoned.
 
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Spoke to a Cannabis oil rep today, and it seems like there is a growing move towards prescribing in the paediatric population for a number of conditions including depression, anxiety and autism, with one of our leading youth research hubs leading the charge. We've had a situation where those with ADHD have turned 18 and graduated from their paediatrician or child psychiatrist and are having a lot of trouble accessing adult psychiatrists who are willing to prescribe stimulant medication. This has driven a lot of demand to the point where psychiatrists can focus exclusively on ADHD prescribing in a private setting and do very well out of it. Although our GP/PCP group are able to prescribe stimulants, there are very few that will and many are reluctant due to somewhat onerous state regulations.

I have yet to meet any academic CAP that are highly excited about cannabis related compounds for our field. ASD researchers have looked into many unconventional treatments over the years (like oxytocin nasal sprays) and nothing has been terribly exciting. This is a subgroup that is A) very heterogeneous B) experiences more side-effects from medications and not shockingly has been very hard to find positive replicated RCT results not withstanding risperidone/Abilify impact on aggression.
 
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Cannabis oil.
I don't know if the terminology is different in Australia but it's important to know what people mean when they say cannabis oil. In the US it's usually marketed as THC oil, cannabis oil, and CBD oil. CBD oil is the one people are convinced is helpful with pain, anxiety, depression, etc. Something most patients don't know is that the labeled purity rarely coincides with actual purity in these compounds--they're not actual pharmaceuticals and may include significant amounts of THC and other cannabinoids.
 
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I have yet to meet any academic CAP that are highly excited about cannabis related compounds for our field. ASD researchers have looked into many unconventional treatments over the years (like oxytocin nasal sprays) and nothing has been terribly exciting. This is a subgroup that is A) very heterogeneous B) experiences more side-effects from medications and not shockingly has been very hard to find positive replicated RCT results not withstanding risperidone/Abilify impact on aggression.

That is also in keeping with my experiences, but I did ask the rep for the relevant papers as I was also sceptical about many of the claims. What we have locally is a large youth mental health organisation that has been very good at gaining large amounts of government funding due to a very charismatic leader. As they get excited about quite a lot of things, it wouldn't surprise me if they were doing something with CBD oil although I've been out of that particular loop for a while.

I don't know if the terminology is different in Australia but it's important to know what people mean when they say cannabis oil. In the US it's usually marketed as THC oil, cannabis oil, and CBD oil. CBD oil is the one people are convinced is helpful with pain, anxiety, depression, etc. Something most patients don't know is that the labeled purity rarely coincides with actual purity in these compounds--they're not actual pharmaceuticals and may include significant amounts of THC and other cannabinoids.

Yes, my understanding is that there are different types of oil with various ratios of CBD:THC, with the ones with a higher amount of CBD supposedly being more effective. Had one patient telling me they were recommended to take a 1:20 CBD:THC oil by a dubious practitioner for a questionable indication, but after finding out the cost of it was around $400 for a small bottle they baulked at that. Informing them they wouldn't be able to drive and would run into trouble if given a police drug screen probably helped too. My other concern is that there has been a lot of talk about of people importing it from overseas, and even claims of pure CBD oil may contain traces of THC which could be potentially problematic.
 
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I have yet to meet any academic CAP that are highly excited about cannabis related compounds for our field. ASD researchers have looked into many unconventional treatments over the years (like oxytocin nasal sprays) and nothing has been terribly exciting. This is a subgroup that is A) very heterogeneous B) experiences more side-effects from medications and not shockingly has been very hard to find positive replicated RCT results not withstanding risperidone/Abilify impact on aggression.

People will literally try anything for autism. CBD oil is just another unproven treatment that probably doesn’t do anything besides a placebo effect for the parents for a while. Nothing will “cure” autism (and there’s the question that should we really be trying to cure it anyway but that’s another discussion) since it’s a developmental disorder the same way nothing cures any other developmental disorder. People will continue to prey on desperate parents who have had their lives turned upside down by a very difficult situation.

When there’s a RCT that shows that CBD or THC oil/compounds have any effect on distressing or core autism symptoms I’ll be the first to look into it. Also would have to make sure it’s not just because their stoned all the time if it’s THC.
 
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That is also in keeping with my experiences, but I did ask the rep for the relevant papers as I was also sceptical about many of the claims. What we have locally is a large youth mental health organisation that has been very good at gaining large amounts of government funding due to a very charismatic leader.

This wouldn't be Pat McGorry and Orygen, would it? I would be a little surprised if he was very pro-cannabinoids but I guess I don't know for sure.

My shtick when people ask me about CBD is pretty simple:
a) it seems to be helpful for some seizure disorders, so we know it does something in the brain.
b) we have no idea what that is at present
c) endocannabinoid receptors are basically everywhere, so it could be doing all sorts of things
d) I wouldn't ever take something that could affect my brain in global and mysterious ways and I would beg any relations of mine not to do so as well
e) no I will not write a medical marijuana letter
 
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This wouldn't be Pat McGorry and Orygen, would it? I would be a little surprised if he was very pro-cannabinoids but I guess I don't know for sure.

My shtick when people ask me about CBD is pretty simple:
a) it seems to be helpful for some seizure disorders, so we know it does something in the brain.
b) we have no idea what that is at present
c) endocannabinoid receptors are basically everywhere, so it could be doing all sorts of things
d) I wouldn't ever take something that could affect my brain in global and mysterious ways and I would beg any relations of mine not to do so as well
e) no I will not write a medical marijuana letter

That would be the one. Without wanting to distract too much from this excellent private practice thread, I’ll just say that his approach has upset quite a few people and the model being pushed keeps getting attention and funding without any obvious improvements in access clinical outcomes. Privately, some psychiatrists are of the belief that it is simply an exercise in corporatisation, pushing the brand and business model, duplicating existing child and youth services whilst taking the bulk of funding.
 
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Some weak studies looking at CBD in children, mostly case reports that are loosely formulated. Seems it has a "calming" effect on CNS, was what the studies alluded too..there's too much we don't know about it..
 
Have you been doing any neurostimulation clearances? (per your "Neurostimulation practice dream" plans?) We cant seem to get reimbursed anything for them. BUT on the flip side we've figured out UDS claims
 
Clearance for ECT is the Psychiatrist. No one can be cleared. Its a misnomer. If I refer to Neurosurgery regarding a patient with a shunt, or cardiologist for patient with an arrhythmia, or pacemaker/defib, etc, I pose them consultative questions.
Is this patient optimized for their blood pressure or arrhythmia? Do they feel that condition X optimally treated and capable of enduring the physiology of ECT?

There is no such thing as clearance and the places that feel that there is and force mandatory consults with a PCP for clearance is a sad misunderstanding of the medical system and a waste of time for PCPs. Psychiatrists essentially do the pre-op H&P. I do rely heavily on my anesthesiology colleagues in their clinic for further review of cardiac status or if any arrhythmia's in their opinion warrant a delay for Cardiology. There are some excellent publications for ECT specifically for Psychiatrists and Anesthesiologists for the pre-operative management. Ultimately the risk benefit discussion falls upon the psychiatrist, and their decision to discuss R/B with patient and 'clear' them. Naturally, anesthesiology reserves the right to cancel case, too.

I've not done any neurostimulation consults yet here, as I don't have TMS nor ECT privileges (yet?). I have referred people to these services though.
 
Month Eight (two days early):

Still getting mixed signals from the C&A doc. Not happy with career status and trajectory, wants to make a change but similar to a kid testing the lake water in the summer with toes, you know you want to jump in but that first rush of cold water is still shocking. We’ll see if anything pushes this doc into the lake. So how to pay another doc? Partnership? 1099? Employed? Most 1099 set ups are a legal minefield, because they really aren’t independent contractors and meet the threshold for employment. I’d prefer to avoid this if possible. Employed, well, where to start? One poster on SDN states $180/hr is out there for his practice and a position he is trying to fill. But is that 1099 work? Employed work? Any clauses about no shows? Or benefits? CME? Insurance? Retirement? Etc. So, time to crunch some numbers and see what might actually be feasible. Reflecting on a previous 300K job, my charting and over all weekly hours, and barely using vacation time, my real-world hourly rate was $116-165/hr including the total benefit package (SS, 401k, health insurance, etc). Lot of work for a relatively low amount of pay. But things are always tricky when factoring in the time spent on charting and other documentation time. If I bring in this doc, I will most likely carry the burden of ‘office manager’ myself and have no support in this arena. I have no desire to donate my time in this, so I must take a chunk of income for myself. I’m also blind to the payer mix for the C&A population will it be the same as what I have? Do C&A document the same heavy 99214 or are they more skewed towards 99213? Also will this doc get a flood of existing panel following? How quickly can I add another doc to my insurance contracts? Some I believe are a quick phone call to update additional NPI numbers, others I can foresee the same long process of at most 6 months. So let’s start with the facts, I know the details of this person’s work environment because I used to be there at one point.

-This C&A is likely in $116-165/hr range considering total compensation.
-My current payer mix blended against my personal ratio of 99213 & 99214 only, with actual payment rates yields $130 per follow up visit. I’ve been using very low projections of $90 per follow up before I started this practice. This is a pleasing number, with room to improve for sure, or pending on payer mix changes, decrease, too. This number includes medicare, and payers that even pay less than medicare.
-Knowing what I currently am earning, I know what the max is that I simply cannot exceed in any offers for a hire. Very good factoid to know.

Met with this C&A, open discussion about goals and expectations, and how the person really doesn’t need me and could do well without me and open their own place. But if the person wanted the convenience and buffer of me running things, we can talk the above details. States actually wants to be independent and possibly sublease here. Actually, a relief knowing this. I’m liking the simplicity of the current practice set up. I have offered my experience and a check list guide to this person for opening their own practice free of charge, especially with our past working history. However, I doubt the person will actually resign and open their own. These talks have been going on for more than a year, and still no resignation.

Local hospital I have privileges with, met with the local Psych who is the local dept head. Has no intentions to pull myself or the backup doc I’m connected with into doing any call or work obligations there. That’s a relief.

A local person is changing their practice up, and does geriatric work. I might have just inherited the higher functioning geriatric patients, which could be ~20, and naturally is medicare. Sent a stack of business cards to help facilitate this. The deluge has not yet started. Another bit of networking I did might lead to more referrals on the fringe of my geographic pull; already had one call from one facility in that area.

Mid/late month met with the local hospital overall head psychiatrist and other clinician who run the department. They are supportive of ECT plans, cited previous failure as shuffling of admin and concerns about JCAHO. I pointed out no concerns about JCAHO, same as other procedures; time outs, consents, valid H&Ps, etc. Admin has stabilized and they think it can push thru. They will network on their side. Budget cycle determines when they could purchase a machine, and I’m okay with that that timeline. I offered to buy a used machine and get manufacturer to re-certify as viable, they declined and stated machine and cost not an issue (as it shouldn’t be, ECT price is practically a rounding error in hospital budgets). The ECT dream lives. But in the coming months if they don’t get it on their annual budget cycle, I think I’ll give up. Can’t keep dragging it out.

Things are going quite well with receptionist. She’s excited about getting people in and the nature of this job and practice. She’s even talking about negatives of past job and dropping relief status there she kept. I.e. I interpret that as being happy here, and truly believing in the longevity of this place to give up ‘the devil you know.’ I delegated some workplace safety documents for her to draft up, as required by labor dept. In doing so, she discovered the need for a monthly safety meeting. (MISTAKE: I’ve clung to an almost delusion that I could avoid meetings and other bureaucracy. Apparently, there is no escape from this scourge. We now have a monthly safety meeting. But I protest by making it as efficient as possible, and do a hand written note, scan it, file it, done.) Safety meeting did lead to developing a means to alert each other towards a violent patient or some other context where we need 911. We now each have a desk bell and if we bang away on that (can hear it thru the walls), we lock our doors and call 911. Also, we’ve had people walk in (drug reps) and lost people and prospective patients. My receptionist isn’t here full time, so we will now put lettering on door sign clearly saying enter only if an appointment and no walk ins.

An anesthesiologist is interested in collaborating with ketamine infusions. Saves me from having to do IV’s. Person found an insurance company to get covered for this procedure. I now need to lock down a ketamine supply. I researched this some time back… but I forgot the details (and lost my notes?). So now I’m starting from scratch to figure out how to acquire the controlled substance for my practice to administer. With the practice picking up and other home life constraints my free time to ply to such endeavors is minimal. I need more time.

Finished the final week of the month off with 14 follow ups and 7 consults. A solid, good, busy week for me. I will finish this month out like last month, in the positive ~3K. Total practice Net Income is still in the negative, but clawing out of the ~7-8K hole it had been hanging out at. Still on track for putting some money in my pocket at end of the year. I’ve made an excel spread sheet of follow ups and consults per week. Extrapolating that out, I suspect I should be having a minimum of 20 follow ups per week by January. Up, up, and up!
 
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It seems that employing another physician in a small practice like this is always a risk/benefit analysis for both parties. The risk to you is if you guarantee some amount of income or hourly rate (vs. RVU/collections rate) and they don't produce. Risk to them is that something about the practice setup/management makes it hard to get/keep patients or that their work agreement is inherently inconsistent or less than what's guaranteed at a big box shop.

You're not in a place financially where you're able to make this a low-risk proposition for someone else because you can't float a $200k salary, on top of your existing obligations, if that person doesn't produce. Subleasing is attractive because it will get more people in the office generally (more word of mouth about the location, can refer parents of patients to you).

Although I don't think it's realistic, I often wonder about the feasibility of very transparent agreements. i.e. "I take x% of your collections" or "I guarantee x salary but you have to collect more than y amount before you see any additional income and I still take z% of anything collected above y." Obvious downsides being that keeping the back-end/collections obfuscated means you hold a lot of power and the employee is less able to bargain specifics.

Thanks for continuing to share about your journey!
 
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-From January 1st to today, Total revenue is 7.5k. Total expenses are 17.3k. This is for 2019 and just this outpatient practice. Therefore, no income for me so far.
-There is so much variability in payors ranging from potential of +400/hr to a low of 120/hr. One low paying is ~$110 for 99213+90833. Another could be ~$280 for the combo.
-My conservative estimate I use for projections is the $180/hr (so $90 for follow up, $180 for consult)
-I only document the 90833 if the time and therapy modality were truly spent. Some patients truly just came in for a quick med check and are in remission with 3mo follow ups.
-Yes the overhead is fairly fixed. To sublease the contract has a very laborious process that the landlord is intricately involved with for any possible subleases. Had one doc who was interested, but doesn't want to make the private practice leap unless a solid side gig is in place.
-Yes, I grew from 0K income in month 1 to 4K by month 3.5. There is also the billing delay of insurance submission, to getting EOB, to getting patients to pay for their out of pocket expense.
-Its difficult to count steady patients, when some are more severe with SI concerns warranting closer follow up. Others have stabilized and are on 3 month followup. I won't do longer than 3 months out.
-Yes, 20 follow up visits per week would be equal to 10 hours clinical time (30 min slots) for how I do the math.

I'm not worried about marketing. I am more concerned about converting the calls/inquiries I do get into actual consults, this is my target area. A receptionist will assist in this greatly. I know of one who has years of mental health experience, very personable, and I'm really hoping to make it happen.

-I am quite confident as of today to be at 30hrs of clinical time by the end of 2019.
-I suspect with progressing time my real hourly rate when averaged is probably higher than $180/hr, but for my planning/budgeting I use a very conservative number.

Please help me. I just started a solo PP, I only accept cash, Aetna and BCBS, medicaid-which I actually find is the easiest to bill. I simply was put on a panel of insurances through my main job, so I'm not officially credentialed. I have people that want to be patients ask about out of network benefits-I have no idea on this. I basically tell them they can pay cash or use the FSA and ask for reimbursement through their insurer. Is this correct? Since I do billing myself, I don't know how to even submit whatever is considered out of network. Also, how do you handle smaller matters that really can wait for the next follow up appointment. They sign paperwork in the beginning stating something along the lines that I am not on call 24/7, however I will get back to them as quickly as possible, if it's a true medical emergency call 911 or go to the nearest ED. Despite attempting to set limits with certain clients, I continue to get ridiculous questions daily from the same offenders through text message. "I'm afraid to gain weight, do you really think I should take x medication", "I know we talked about x, but I'm very anxious." How would you handle this? What are my responsibilities? I have explained multiple times I am not available to them 24/7..this is an outpatient practice. The two worst offenders are attached to therapists already.
 
Please help me. I just started a solo PP, I only accept cash, Aetna and BCBS, medicaid-which I actually find is the easiest to bill. I simply was put on a panel of insurances through my main job, so I'm not officially credentialed. I have people that want to be patients ask about out of network benefits-I have no idea on this. I basically tell them they can pay cash or use the FSA and ask for reimbursement through their insurer. Is this correct? Since I do billing myself, I don't know how to even submit whatever is considered out of network. Also, how do you handle smaller matters that really can wait for the next follow up appointment. They sign paperwork in the beginning stating something along the lines that I am not on call 24/7, however I will get back to them as quickly as possible, if it's a true medical emergency call 911 or go to the nearest ED. Despite attempting to set limits with certain clients, I continue to get ridiculous questions daily from the same offenders through text message. "I'm afraid to gain weight, do you really think I should take x medication", "I know we talked about x, but I'm very anxious." How would you handle this? What are my responsibilities? I have explained multiple times I am not available to them 24/7..this is an outpatient practice. The two worst offenders are attached to therapists already.
Your insurance paneling through 'your main job' doesn't carry over to your private practice.
You have an NPI number which is like your Social Security number in the medical world, your identifier.
Your NPI gets tacked onto contracts thru your main job with their NPI number. You can have a second NPI number which denotes a business, ranging from the huge nationally recognized hospitals, to some one like me who has a second corporate NPI number.
Those existing contracts are not for you, but for the Tax ID number (which is, well, a business 'social security number' in the eyes of the federal government) that originally signed them. Those contracts your 'main job' have are linked via their business NPI and Tax ID. That means you are only credentialed with them their under the good graces of THEIR NPI & Tax ID. You likely have no contracts, no paneling, and possibly if you are billing those insurance companies, they are getting your money, or if you some how have got your practice address listed as an additional practice location, you have just messed up their end of year taxes by reflecting your income on their 1099 forms as your income... If/when their accountants get wind of this, I suspect a headache and a half...

You need your own contracts with each and every insurance company, there is no circumventing this bureaucratic process. Whether you get more complex to form a second business entity NPI number or keep it simple as just you with a solo practice and just your personal NPI, you'll still need your own contracts.

If you tell patients you don't bill insurance companies (i.e. submit claims to them with intention of getting reimbursed) most doctors will provide a super bill to the patient. This includes things like practice address, Dr full name, degree, NPI, Tax ID number, phone, fax, CPT codes & Diagnosis codes for that visit, Date of Service. If CPT codes are a bit complex, you'll also need to know about the specifiers like 25 and 59... The patient then takes this super bill to submit to their insurance for out of network reimbursement. Or they use it to enter that information into whatever form their insurance company prefers. Some doctors have arrangements, for certain reasons, where its understood that the patient won't submit to their insurance company for out of network reimbursement and are just doing a classic cash fee for service and done.

I use a 3rd party billing company. I provide the super bill as described above to them, in addition to the insurance card details (can literally be just a photo copy of the insurance card) to them too. With Super Bill in hand, and insurance details, they have the information they need to submit the bill to the insurance company. This can be done for both in network and out of network insurance companies. The billing company uses one (of many available) clearing houses. A clearing house, per my understanding, is a large online interface company that submits those super bill details and insurance card details in a more preferred, condensed, and secure manner to the insurance companies. Insurance companies are getting thousands to millions? or claims submitted to them daily and they want a standardized data in, data out process. You can sign up for your own access to a clearing house type entity if you wish, the very same type billing companies use, and bypass them and their services. I've opted not to, long story for another day and instead let a 3rd party billing company do the data entry into the clearing house (billing company pays the clearing house fees themselves, I in turn pay the fees the billing company asks of me, which is a slight mark up from the fees of the clearing house). The days of sending a paper bill to the insurance company may be dead, I know some simply won't process paper any more and simply deny them. But remember this when it comes to Super Bills, for all entities, little solo practice or large health systems, the physician is ultimately responsible for knowing the CPT codes, Diagnosis codes, and making sure they are the appropriate codes entered on the bill. Any place that the physician is removed from this process, or abdicates this coding to a behind the scenes biller is potentially setting themselves up for trouble. Know your codes - its you who gets in trouble if anything is wrong.

How you structure your practice is up to you. Sounds like you gave out a cell phone and are getting text messages. So you need to decide is this communication method a good/neutral/bad communication method, then if this is a good/neutral method, you need to decide how to set boundaries with patients if its problematic communication. If its appropriate communication, well, then deal with it as you are trained.

My practice has electronic written communication through it's secured HIPAA, email like system. Depending on the patient and the questions, I simply respond with full answers. Some patients, I keep it short and say, "that's a good question, let's discuss it at our next appointment more in depth. If you'd like, you have the ability to cancel out your existing appointment, and use the online scheduling feature to book something this week." I then make a not of it to remind myself to bring it up at the next appointment, just in case the patient actually forgot.

Call and outpatient practices has been discussed before on SDN with a wide variety of responses. Academic Ivory tower doctors who have no problem traveling the country to testify in forensic like capacity will say one thing, where as the community doc down the street will say something else. This is a completely different thread topic issue...
 
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Worthy of its own post:

The local hospital does want to proceed with ECT service line, and I've since got them a quote for a device. I see the storm front of meetings brewing on the horizon. The dream lives and just may come true.
 
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Month Nine:
Open enrollment is approaching and people are doing insurance changes. Losing some who switch to Medicaid. Others are looking to optimize / upgrade their existing insurance to guarantee care here. Discussed what I’m paneled with, but still encouraged they read the fine print and really learn their out of pocket and deductibles. Wish it were as simple as saying just get insurance X, but even insurance X has different flavors with different networks, and carve outs for mental health and different payments.

My busy week from end of month 8, I’m still catching up on those notes. Current work life balance is still better then previous gigs, but sometimes I wish I didn’t over document. I’ve had a few encounters over the years where over documentation has a been a blessing and being able to simply say, “read the notes, they speak for themselves” is a relief. As patients are jumping ship from some of the other psychiatrists in the area, I request their records. It boggles my mind how simply checking a box for 99214 and even 99215 with 90833 is acceptable. The billing metrics for these codes just simply aren’t in these notes. These are psychiatrists who have been in practice for years. It allows thoughts of ‘huh, maybe I too should do illegible hand written notes and simply check a box for billing.’ I’ve even seen it in the ARNP notes, checking 90833 and nothing in there to support it. But life isn’t fair, and standards should be maintained, I’m going to keep on keeping on.

Utilizing SEP-IRA for retirement, and it has equal percentage obligations for employees. If I do 25% contribution, my employee(s) all need 25% contribution. If I make 10K, I can effectively take home 8K, and put away 2K into this pre-tax account which corresponds to about 20% at a real-world glance, but the way the IRS does their math its 25%. My employee if they make 1K, they would get a ‘Free money’ donation to their SEP-IRA account, which also needs to be 25%, and equates to $250. I learned the company I opened an account with can have these loosely affiliated employer/employee accounts, but doing so you can only choose their mutual funds similar to most ‘big box shops’ 401K like programs. My current program is considered brokerage and I can actually invest in specific stocks, which I love. Discussed with employee and she’ll do the same, open her own, to preserve that brokerage feature, and I’ll simply cut a check to her account when it comes time. Others here on SDN have discussed differing ways to optimize retirement accounts, and this may actually not be the best way (MISTAKE: do more research on retirement accounts, and intersection with employees, business structure, and your long term goals, consult with CPA to make sure you are picking right).

Got an email from my Credit Card merchant company that their 3rd party PCI compliance company, if not done you get fee/fine of $40/month. I was aware of this, but was still within my annual window of doing the security certification stuff. This was anxiety provoking that I missed something and was about to be out of compliance and get dinged. Eventually just called them up and it was just a usual spam letter and I’m still in compliance, nothing to worry about. However, to be safe I will extra scrutinize the statements from the Credit Card Merchant company to be sure there are no $40 fees for the next few months. Dealing with the bureaucracy behind the scenes to get set up with credit card processing is a pain – good luck. But in hindsight, the integration with Luminello is so worth it. The convenience is amazing. The operability within Luminello is quite functional.

Met with a bank loan person to get some basic facts on business loans for purchasing land and doing construction for a future office. Basic facts are banks want 2 years of accounting data showing you are stable and making money for conventional loans, and will likely need 20% down for the land purchase, using business equity. May still need a personal guarantee… An alternative is to go through the Small Business Administration (SBA) loan folks, and possibly only need 10-15% but not need 2 years data. However, I suspect the loans rates with the SBA folks will be painful. Also, the banker was saying even for standard loans they are 5 year fixed, 25ARM – ouch. SBA may also require true owner occupancy of 51%, so can’t build it too big to be an investment property. I’m considering taking a page out of the Dentist play book. Look around, they have their own offices on every corner. I loathe watching 3.3K disappear every month for my current lease. Current trajectory of year two (2020) being legitimate income, I could skimp on the personal take home to try and build equity to further this goal by ~Q2/Q3 of year three, just as this three-year lease concludes.

GREAT NEWS: Local hospital psych head called up and they want to proceed with ECT. The dream may just come true. However, first real meeting isn’t until 3 months from now… Glaciers are melting faster then this progress rate.

Someone stole my hand sanitizer tower. I believe it happened over the weekend when land lord let electricians in. And now I learn there are no working cameras in this office complex. Positively only $70 loss. Negatively, adds further fuel to leave this lease for not rectifying their mistake. I then talk to neighbors to discover electricians had put it into their suite that adjoins mine (locked door, neither tennet has a key to, but was opened for their electrical work).

Previous post elsewhere on SDN, I have allotted myself 6 weeks off per year ideally (30 weekdays total). All inclusive of the big holidays, CME, sick days, etc. Other things have cropped up on home front that its looking like I’m taking 8 weeks and 1 day for 2019. Many of these days are ½ days that added up.

This is the first quarter where I actually pay the employee withholdings, and other payroll taxes to the government entities. Little nervous with it being first time. Went well. The tricky one was the IRS. Reached out to accountant to understand that the simple nature of IRS payment for combined Medicare/Social Security/Fed Tax Withholding will all get parsed out at the end of the year by W2. Simply put, I anticipate this process being much quicker on future quarters. In grander summary, I feel doing payroll myself for a single employee is quite doable and I don’t need to turf this out to a 3rd party entity, or accountant. I got this.

For Q3 my average consults per week is about ~3.5. I’ve had a record of 8 consults, and low of 0 for the life of the practice.

CELEBRATION (where’s the dancing banana gif?): Owner investment/equity was placed into the account back in earlier months. I’ve since cruised for several months at a deficit eating into that equity of about 7-9K. At the conclusion of this month 9 (Q3), I am now out of that deficit and truly in the positive. I officially have money that I can extract and pay myself if I wish. So for those who are using this as means to spring board into their own practice it took me three quarters or 9 months to get there. (MISTAKE: there are many things you could do to improve that time line to possibly get profit much sooner, have fun with it and make the right choices for you and your practice goals).
 
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Q1Q2Q3Total
Income$3,551.53$16,825.42$28,936.40$49,313.35
Expenses $11,326.06$17,684.72$17,969.97$46,980.75
NET INCOME-$7,774.53-$859.30$10,966.43$2,332.60
 
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I anticipate doing monthly posts for the remainder of year 1, but things are getting more journal like of my opinions and less ‘meaty’ for those looking to start their own practice. After year 1 concludes, I’m going to switch over to Quarterly updates.
 
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Thanks for your updates and time
Welcome, hope it helps some one out there with their quest to open their own private practice.

Also reviewed my patient panel today and crunched some numbers. Realistically it looks like I have 71 active patients who are actively doing follow ups.

24 are low payers below medicare rates. 7 are medicare. 47 are better payers in excess of medicare.

So my current mix is 66% of the panel is better than medicare.
 
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Not in psychiatry, but interesting to read how things unfold. Thanks for sharing.
I look forward to your future updates.
 
MONTH TEN:
Some posters on SDN have hinted at their practice set up, or even niche focus and broad commentary on their local payers. Someone sent me a direct message that their local payers were Medicaid, then private insurance, and finally medicare the best. I’ve heard rumors of such localities before where private insurance is all less than medicare. Were these my payer rates, I suspect I would have had to pick up a side gig, or perhaps abandon ECT dream very early on and switched to cash only. Its disheartening the forces at work driving these conditions and makes perfect sense why many psychiatrists go cash only.

Medicare advantage plans… what a mess. Some you submit to medicare, and then it automatically gets kicked to the supplemental. Some you submit to the supplemental/advantage plan first. Complete mess figuring this out. One patient says never pays anything out of pocket because secondary/supplemental/advantage plan always cover the OOP. For my services they say medicare already paid the maximum, and they won’t pay anymore. More reason to drop the plans, or even not take medicare – we’ll see what happens with ECT.

Low consults and phone calls and intake activity at start of month. Typically fall is an upswing on hospital admissions, but I can’t recall if that also truly translates to outpatient. Either way, I’m waiting for the next cyclical “Psychsoon” to start. In week 2-2.5, a boon of inquiries. Such ebbs and flows from week to week. I’m thinking I need to stop predicting or thinking about the flows seen during the old era of inpatient work.

Had my first truly planned 1 week vacation. Went well. Receptionist was in office for her usual half days and sent me messages thru Luminello, and most days I logged in for a few minutes at lunch and/or in the evening. Happy with how this management worked out. Could possibly reduce to checking in just once daily on future vacations. She was pleased with my availability; I was pleased with my ability to get away. Win-Win for trial vacation.

Local Psychiatrist is united in his resolve to drop an insurance panel. He called me up to see if I would be united in taking on these patients of his, estimated to be about 15. As I’m paneled with this insurance company, I called him back and left a message of intake process and what the patients would need to do to get in. This company is actually my lowest payor, and if no viable ECT service line, hope I might feel united in my resolve to drop this company in months/year to come as he has. From an earlier post, I never saw the flood of medicare patients from the retiring person.

Accountant was keen to inquiry if I submitted a form to the IRS. Go figure, there has to be a form. So I paid the IRS on time electronically. However, there must also be a form submitted. Accountant helped me with first draft and I got a final off before the deadline. Form 941.

One insurance company apparently wasn’t happy with my W-9 on file and wanted a fresh one. I suspect it’s a tactic to stall/delay or use to deny payment on a claim. Got them their fresh (unchanged) W-9 form. We’ll see how this pans out.

I’ve had a few insurance companies discover that a younger patient was still listed under parents’ insurance in addition to their own private insurance from their work. Patient notes no issues with any other medical services billing out to their work insurance (better payor), but go figure, now the insurance company is pushing back and parental insurance wins the tug of war to be primary (lower payor).

Another patient had insurance that was still showing on panel with employer from 3+ years ago(!), despite the employer no longer actually paying premiums. The current insurance pushed back on paying saying was dual enrolled. This one was a pain for receptionist to get details to even be allowed to talk with the old company to get patient off their records. Newer bills are now going thru with current insurance, but still waiting to see what happens with old bills…

Having some cash in the business checking account is good. To cover random expenses, a buffer for a bad month, or unforeseen expenses. I have some of the initial deposits/equity I invested early on. The question is, how much should a simple business like this have on reserve in cash? I have no idea. I was thinking 20K should do the trick, or even one month’s worth of actual collections has a nice ring to it, but I have no clue. Anyone want to comment on this one?

Reviewed the records from an older doc in area with hybrid typed/written notes. Progress notes were checking the box of 99215 and 90838, and checking a minimally worded ‘greater than 50% spent in counseling.’ No time documented. No description of what constitutes counseling and coordination of care, never mind you can’t bill a 99213/4/5 based on time, AND drop a therapy add on code simultaneously. Just mind boggling what other clinicians are doing locally.

Here are some numbers; when reviewing just the past 12 weeks, I have an average 3.25 consults per week, this linear trend appears to be flat, not going up, not going down, but intra week variability is wide from 1-7 consults. Follow ups for past 12 weeks is showing a slight upward trend line, with an average of 11.25 per week. I did a lazy number estimation on if the CLIA lab and UDS is generating a positive income, not worth my time/effort to fully crunch these numbers considering clinically I will keep this service anyways, but for the life of this practice thus far it could be a positive of $100-600 depending on how the rough estimates are done, but possibly could be higher if a true number were crunched.

MISTAKE: Receptionist, is pushing the intake process of scheduling appointments without the Luminello online pre-paperwork filled out. Could this potentially capture more patients - yes - and the growth she would like to see happen here. But I’m not making this change at this time, because it also means people who won’t want to use the luminello electronic interface for further communications. Patients who do the process from the start are capable of all future office communications electronically, appointment reminders, care questions they have for me, re-scheduling, billing notices, or even service exit/closure notices, etc. We make very few phone calls, and use very few stamps. Very efficient. But it does impact who follows thru with getting in the door. But I do believe this has a positive impact on my on-call duties. I have very limited messages needing response over the weekends/evenings that doesn’t even feel like a burden, and have only been called twice for my afterhours phone. If I extrapolate my current panel size to what I’d like to see when full, I anticipate having a low intensity ‘on call’ obligation. This is important to me to reduce long term burn out. Onward ho (with this slower growth rate)!

On recent Monday I trudged into work, thinking the usual Monday thoughts. But I also realized, of all the past Mondays I’ve had these are still the best Mondays. Being my own boss, and coming here, is still such a positive experience that I’ll still take these Mondays over end of Friday from any previous gig. Life is so much better.

Post #85, I put up an excel spreadsheet with some extrapolated numbers for income. I had been exceeding them for the previous few months, but not Month Ten. I fell short. Projected was $11,677.58, and I came in at $8,797.95. Profit for the month after overhead, $2,197.86. When reflecting on the revenue cycle, which prior to this practice was bit more of just a word, and superficial understanding. I feel I’m getting to know more of what Revenue Cycle is as I live it. Similar to when you finish medical school, you understand what Bipolar Disorder is, but at the end of residency it conjures up so much more in your mind. This dip might be related to a dip in the cycle from payers, but it may actually be from older bills having been caught up, and variable lower volume weeks in the past that finally rippled into the present. Even if one high dollar stack of bills from one patient/insurance company were to be finally paid on, it won’t be enough to get to that 11.6K projection.
 
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Thanks as always Sushi.
Giving great examples of why people don’t want to deal with BS insurance companies. So much stupid work just to get money you’re owed in the first place.
 
Really appreciate your ongoing updates. A couple of thoughts: Your receptionist, who sounds excellent BTW should probably be given the title of office manager with tiny bonus if possible, based on her skill and commitment. Perhaps others will chime in but having someone like this can be nearly impossible to find and is invaluable. Consider allowing her to take new patients who are adverse to the whole Luminello online experience. I wouldn't anticipate much difference in work load for you, minimally for her possibly, but in the initial stages of a business that would not be one of my exclusions. You may find people more receptive when they have established a relationship with your practice and continue to learn of the benefits from being plugged in to your EMR.

Again what is the future plan regarding your lease? I cringe whenever I think of that amount for a solo practice. In my experience keeping the overhead manageable is a key component to success. Good luck, I hope the ECT comes to fruition soon and again thanks for sharing your experience.
 
Something to think about. You are greatly slowing your expansion by requiring online paperwork/scheduling only. Even though I would be more than happy to follow-up electronically, I hate initial scheduling online. Companies like ZocDoc and others post availability to schedule. Once I schedule online, I’ll get a call 1-3 days later saying my appointment time never really existed due to an error in the system or some other excuse. They’ll ask me to reschedule. By then, I’ve already requested time off or blocked a clinic which is quite frustrating. Often these systems require me to input all of my information before scheduling which is time consuming to later get rescheduled, feel frustrated, tell them to forget my info, and call some other doctor/service provider instead. It’s to the point where I refuse to do business with anyone that requires online initial booking. It signals that my time is not as valuable as yours which is insulting to others. You may never reschedule online, but it happens enough that it turns many off instantly.

It is true that by changing your structure, you will get more people that prefer phone calls though.
 
I attempted to have all new patients schedule themselves online when I started my practice. Some made it through and others got lost. Now that my schedule is fairly full and there are only a few spots per week to fill, I schedule new consults by email. If you see on my website, there is a request appointment link that takes you to a google form with the Luminello screening questions (I stole them XP). I actually do ask if people would like to be called or emailed (with the caveat that I'll be quicker by email). When I see a patient who fits, I email them directly with times. Once confirmed, I reply with instructions on how to access my patient portal and fill out the related intake forms. At the consultation, when we agree to treatment, I describe that I communicate primarily through a portal. BTW, I use office ally patient ally.

For perspective, I don't have admin support and my weekly average includes 12 (30-min, med-focused appts) and 33 (45/60-min, therapy focused appts) per week for ~ 40h.
 
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I attempted to have all new patients schedule themselves online when I started my practice. Some made it through and others got lost. Now that my schedule is fairly full and there are only a few spots per week to fill, I schedule new consults by email. If you see on my website, there is a request appointment link that takes you to a google form with the Luminello screening questions (I stole them XP). I actually do ask if people would like to be called or emailed (with the caveat that I'll be quicker by email). When I see a patient who fits, I email them directly with times. Once confirmed, I reply with instructions on how to access my patient portal and fill out the related intake forms. At the consultation, when we agree to treatment, I describe that I communicate primarily through a portal. BTW, I use office ally patient ally.

For perspective, I don't have admin support and my weekly average includes 12 (30-min, med-focused appts) and 33 (45/60-min, therapy focused appts) per week for ~ 40h.
Not to derail the thread, but I got a chuckle out of your address. :rofl:
 
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Really appreciate your ongoing updates. A couple of thoughts: Your receptionist, who sounds excellent BTW should probably be given the title of office manager with tiny bonus if possible, based on her skill and commitment. Perhaps others will chime in but having someone like this can be nearly impossible to find and is invaluable. Consider allowing her to take new patients who are adverse to the whole Luminello online experience. I wouldn't anticipate much difference in work load for you, minimally for her possibly, but in the initial stages of a business that would not be one of my exclusions. You may find people more receptive when they have established a relationship with your practice and continue to learn of the benefits from being plugged in to your EMR.

Again what is the future plan regarding your lease? I cringe whenever I think of that amount for a solo practice. In my experience keeping the overhead manageable is a key component to success. Good luck, I hope the ECT comes to fruition soon and again thanks for sharing your experience.
She is fantastic. Still states her preference of being told and instructed what to do, and feels uneasy with open ended instructions. Luminello is fantastic with the Task feature. We're both constantly creating Tasks for each other. It makes it great to be able to leave work at work knowing all the tiny minutiae is Tasked up. Right now with the current size there really is no need need for labels of office manager vs receptionist etc. It's more of a team with understanding her goal is to take on as much as possible that isn't clinically seeing patients. (there's still some admin stuff I'm clinging to for various reasons, but will eventually unload all that I can as the practice gets busier because of no alternative) I asked what she wanted to be called, and receptionist was good for her. Then with Luminello labeling her as Assistant, she has decided to go with that for patient interactions. She got a raise when starting with me compared to her previous job. And I anticipate when looking at the end of year SEP-IRA deposit, she'll be very pleased. Right now she and I both are at a point with family care that we need flexibility and that can be more valuable then money - this practice affords me flexibility with getting the life stuff done. Oil changes, in demand grocery runs, childcare appointments, airport pick ups, etc, etc. With her being part time it really is damage control, so if one day she needs an hour delay or other accommodations say for school teacher in-service stuff, I'm like 'Sure, I get it.' I have very low concern of abuse of this flexibility by her.

We've trialed before taking on patients not using Luminello, once when it was just me, and again when she joined at her request. We were never able to get a hold of these patients, they'd miss an appointment, no show, or not respond to bills, and then at the office, say, 'oh, I'll log in later and pay online.' The time it took for her to sit down and get the pre-paperwork done and the poor following interactions with the patients, and my spending more time during consults documenting the factoids was a big turn off.

Conversely the majority of patients I do get are ecstatic with their interaction and love it, and praise the interface, its ease, and even access to me.

As for the lease, yeah, I cringe too. I've made a few minor overhead adjustments recently. Found a better accountant, saving ~$750-500. Dropping APA membership and its corresponding state membership ~$800. Long term lease will resolve with one of the following:
1) no change, stay put, be lazy, its the devil I know.
2) bring on some as employee/partner/sublease to overall reduce the cost
3) move to cheaper office
4) get a business loan to buy own property and build own building
5) The Boss might buy land, build a larger office then option 4, and I'll be the anchor tenet who continues to pay the same high rate while trying to capture other quality tenants for her property LLC.

Option 4 or 5 are getting the most attention lately.
 
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Something to think about. You are greatly slowing your expansion by requiring online paperwork/scheduling only. Even though I would be more than happy to follow-up electronically, I hate initial scheduling online. Companies like ZocDoc and others post availability to schedule. Once I schedule online, I’ll get a call 1-3 days later saying my appointment time never really existed due to an error in the system or some other excuse. They’ll ask me to reschedule. By then, I’ve already requested time off or blocked a clinic which is quite frustrating. Often these systems require me to input all of my information before scheduling which is time consuming to later get rescheduled, feel frustrated, tell them to forget my info, and call some other doctor/service provider instead. It’s to the point where I refuse to do business with anyone that requires online initial booking. It signals that my time is not as valuable as yours which is insulting to others. You may never reschedule online, but it happens enough that it turns many off instantly.

It is true that by changing your structure, you will get more people that prefer phone calls though.
I'm sorry your online experiences have been poor. This is not an issue for this clinic. I've only re-scheduled 3 patients on a single day due to being sick. Hadn't been sick like that in years. I've had a surgery before and gone to work on post-op days most people are recovering for weeks at home. Naturally no CNS altering meds on board when working then.

The Luminello system allows patients to view my schedule and the open consult slots - for the next 90 days - and pick the best option for them. I keep it unless they change it. I'm getting people in 1-3 business days, or on some busier stretches we change to 3-5 days. Receptionist and I keep a board where we change the date interval as needed for what we report to possible inquiries.

I do agree that changing the structure would get more in by a classic phone call, schedule, and do paperwork later model. Currently as you say, I am greatly slowing my expansion - agreed.

Positively I can say, I have only had like 2, maybe 3 consult no shows with my current intake process. I haven't looked to see how many consults I've done thus far, but 3 out of 100 at minimum, is 3%. When I worked for a Big Box shop health system my outpatient component had a much higher no show rate for general psychiatry. *Granted it could be possible that by doing as you suggest the total growth rate would still be faster even with an ensuing higher no show rate.
 
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I attempted to have all new patients schedule themselves online when I started my practice. Some made it through and others got lost. Now that my schedule is fairly full and there are only a few spots per week to fill, I schedule new consults by email. If you see on my website, there is a request appointment link that takes you to a google form with the Luminello screening questions (I stole them XP). I actually do ask if people would like to be called or emailed (with the caveat that I'll be quicker by email). When I see a patient who fits, I email them directly with times. Once confirmed, I reply with instructions on how to access my patient portal and fill out the related intake forms. At the consultation, when we agree to treatment, I describe that I communicate primarily through a portal. BTW, I use office ally patient ally.

For perspective, I don't have admin support and my weekly average includes 12 (30-min, med-focused appts) and 33 (45/60-min, therapy focused appts) per week for ~ 40h.
Thank you for being willing to show your website to folks. Always great to see a peer's web presence. Love the yellow bridge photo. I've actually been in the city before and drove over it. I remember thinking to myself, 'huh, a mustard yellow bridge.'

My question for you though, by having your patients scheduled, before filling in the intake forms and signing policies, what's your estimated rate of incompletes? Toss my some numbers if you can. People who only fill out a few forms, or those who show up to the appointment with none, or those who show up late with none that you turn away for another day? etc. Or do you see everyone but just expediently make the best of the time you have? How do you manage the permutations of presentations that are less then as instructed?

I applaud your ability to manage without office staff. I do believe your accepting only 2 insurance companies, and having such a therapy heavy practice (i.e. longer visits, less patients) makes it much more manageable. I'm currently on the other end of the spectrum with a greater med management emphasis and have 10-14 med management 30 min appointments with 0-1 therapy focused for a 45/60min session per week. I'm currently doing about 6-8 follow up hours per week and varied consult hours, with ~70 patients - I anticipate a goal of ~240-350 patients. I'm currently on panel with 6 (including medicare) insurances I routinely see, and possibly 2-4 more I don't really see. Of those, there are weird networks where I'm with insurance company U, and I'm not with P. But because P carved out the mental health and addiction to be serviced by U, I'm apparently considered to be in network with P. My receptionist spends more than half her time on billing and other insurance related items. One company notoriously has the employer sponsored entities that contract with them to use their network/infrastructure, but when issues with billing arise they say talk with the business subsidiary and the business says talk with the national company... On one hand, a biller is paid less then what she is, but the elements she does that are trending toward office manager sort of counter balance that.

I see that you listed forensics as a fellowship training. Are you doing any of it? Or did general psychiatry just take over for you? Love to hear a bit more about you journey if willing to share it.
 
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My question for you though, by having your patients scheduled, before filling in the intake forms and signing policies, what's your estimated rate of incompletes? Toss my some numbers if you can.

I take about 1-3 new consults per week; I'd say 1/5 fails to complete the intake forms. I see a lot of college kids; that may make a difference. The new patients who are older seem to be the ones with trouble.

Also, my patients may be more motivated, considering that many patients who consult with me either have therapists or want therapy. I've found that patients who are medication-focused from the start, seem to be the "I want a quick fix, impulsive-type" which would not do homework. Another thing that may increase my rate of people who do intake paperwork: I schedule them fairly soon after they request an appointment. I hope to take advantage of their motivation. When scheduling out 3-months, people have an easier time procrastinating.

People who only fill out a few forms, or those who show up to the appointment with none, or those who show up late with none that you turn away for another day? etc. Or do you see everyone but just expediently make the best of the time you have? How do you manage the permutations of presentations that are less then as instructed?

I see all new consults for 1-hour with the first ~5-10 minutes letting the person talk in an open-ended fashion about what brought them there. If it seems things are simple/straightforward, I expect to start the eval and save about 10 minutes, in the end, to incorporate the tx contract/HIPAA into my discussion about the frame of treatment. In those cases, I usually don't make them fill out the intake form again, because I've already elicited that information on the interview. Now, if the case immediately sounds complicated, I caution that no treatment plan will likely be agreed upon in the hour and that they need another consultation appointment, either that week or next (In the meantime, they can fill out the paperwork).

I see that you listed forensics as a fellowship training. Are you doing any of it? Or did general psychiatry just take over for you? Love to hear a bit more about you journey if willing to share it.

I didn't complete a forensic fellowship. However, I pursued many additional training experiences during (competency eval training at local jail, violence risk assess consult team, mock trial participation, AAPL poster presentations, AAPL forensic board review course, careful review of all the good texts [Resnick, Gutheil, Melton, Rosner, Reid ) and after (AAPL annual special topics courses [filicide, PTSD, insanity, etc], part-time criminal-matter evaluator for local courts w/ supervision/opinion critique from a senior forensic psychiatrist) residency I'd say 90% of my practice is general psychiatry and 10% being forensic work.
 
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Month Eleven:
Starting to get the patients who will soon be out of network from the other psychiatrist. One patient described this is the second time it has happened in ~2 years. One patient calling in relayed to receptionist that other doc attempted to renegotiate the contract rates, and insurance company wasn’t interested. Good to know, so I won’t waste my time in the future if that’s something I elect to do.

One random insurance, who denied me a year ago, because their panel was supposedly full, started requesting documents now, a year later to finish credentialing. I’m not bothering because I just don’t see that company locally (i.e. zero patients in past year have called saying they have that insurance) and I believe it’s one of the larger companies people have issues with nationally. So, going to skip that.

Lights stopped working in one section of office. I learned how to open the outer case, and how to pull out florescent bulbs. Rotated in and out a bunch of bulbs, new and from other banks to ascertain issue is the light bank. Messaged land lord, they were like nope, your contract says you fix it, but we’ll call someone on your behalf for a 20% admin fee. No thanks. I’ll take care of it. Guess it might be something with the ballast? Just another reminder of the unfavorable lease terms here, and relative low occupancy in the building and their attrition of two tenets, but gaining one, points to need to find new lease in coming years. Got fixed for ~$350.

Other interesting thread was started on credit card processing companies. Reviewing my numbers, it looks like 4.8% is about what I’ve paid so far. However, considering my cash pay is a smaller fraction of my collections compared to insurance, and how much I value the simplicity and integration with Luminello, I don’t foresee any plans to change this any time soon. We can also send billing statements to patients, and they login on their own and pay whenever, and its immediately reflected on our running account for the patient – convenient. If I were to optimize this to an ideal of 2%, is this slightly more difficult process worth ~$300 in current numbers?

It appears the window of opportunity has closed with the anesthesiologist for possible IV ketamine infusions. The person is transitioning to different job opportunities elsewhere.

ECT saga continues, learned local hospital Admin again has change up in leadership. This has caused the meeting to be cancelled with a tentative we’ll schedule again in the future.

Receptionist is being quite proactive with calling potential patients at different stages of intake process to encourage their progression or remove from list if disinterested, too. Got several larger outstanding bills that the insurance companies are inserting bureaucracy into. Frustrating. Also had one past patient many months back basic stiff the entire consult bill (high deductible). MISTAKE: Need to spot this before the consult and collect this out of pocket cost up front at time of service.

Holiday decorations... go PC and stick with Happy Holidays and generic? Don't decorate? Risk offending those who want decorations, risk offending those who are tired of political correctness, go with certain Holiday decorations and risk offending those who don't share same beliefs? Discussed with Receptionist, discussed with The Boss, discussed with own internal monologue, and ultimately said, decorations for X are going up. Not going big but very simple, token of "we did something." I have beliefs Y, but putting up decorations for X, some people believe either my looks and/or name I have beliefs Z. Either way, limited decorations for X are going up.

Finished with total income $10298, overhead $7025, and income of $3273 for the month.
 
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Holiday decorations... go PC and stick with Happy Holidays and generic? Don't decorate? Risk offending those who want decorations, risk offending those who are tired of political correctness, go with certain Holiday decorations and risk offending those who don't share same beliefs? Discussed with Receptionist, discussed with The Boss, discussed with own internal monologue, and ultimately said, decorations for X are going up. Not going big but very simple, token of "we did something." I have beliefs Y, but putting up decorations for X, some people believe either my looks and/or name I have beliefs Z. Either way, limited decorations for X are going up.

This is a great addition to your already great series. My partner recently had a scathing critique about the large and significant number of religious pictures/paintings/items that her health care organization had in their outpt clinic. This one comment actually got many of these taken down by people of that religious ideology with rational minds thinking that one should probably make this decoration theme milder/lighter, one of the wiser decisions I think they've made. Ultimately I think if you do something that fits the market you are going for or fits you, or ideally both and do it gently you've come to the right spot.
 
I just wanted to play mad libs. (Is this not PC?)
Let's keep this going.

I have beliefs Y am Zoroastrian, but putting up decorations for X Yule, some people believe either my looks and/or name I'm Asatru because I wear a helmet and am named Snorri and I have beliefs Z am celebrating Thorrablot. Either way, limited decorations for X plants and s**t are going up.
 
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Month Twelve:

Busy week one, new record I believe for follow ups and consults.

The entropy of time… I’m settling in to the role of a heavy med check clinic. I’m loving the beauty and simplicity of this practice. Only one brief 10 minute monthly meeting. I have a great receptionist/assistant. There’s no work place drama. No ridiculous “quality” metrics being pushed, no billing people looking over my shoulder. No scheduling or vacation barriers to deal with or pages of rules for CME reimbursement. No counting wRVUs. The heavy, wet concrete blanket of bureaucratic oppression is … gone. Whether I was on a burn out spectrum in the past or simply being a psychiatrist who spotted scat in his own life and took steps to improve them, this practice set up is amazing! However, being on staff at the local hospital where ECT might develop has now exposed me to the flood of emails rampant in large health systems once again. I was adept in the past at cruising and deleting non-essential emails pouring in from admins, but having been free of them for some time, to again get them is painful.

Another flu/cold moved thru the house. And it hit me hard, too. Reality is I’m the flex person who gets the kids to and from places, more prone to do sick care for kids. Without a quality practice partner to share in logistics of an ECT service start up, I can’t be 100% devoted to work for 1-2 years of getting this service up and running. I’m officially going to kill the ECT dream. Some sadness, similar to the closing of doors as med student to resident, and resident to attending, etc. But I’m now more accepting of not being the Psychiatrist who does ‘More’ or has extra ‘Bells and Whistles.’ Simply doing med check focus is good enough. I can still do more by precepting third year students. I used to have a sweet rotation with IP, OP, CL, ECT, Suboxone clinic, etc all packed nicely into a month-long rotation, but what I lack with these other exposures I’ll try to supplement with more designated 1:1 didactic teaching. The communications were officially sent – dead. THE BOSS is sad with this decision but understanding. I do still believe the future of Psychiatry may trend towards most offices having TMS, and offering ketamine in some fashion, but I am willing to accept not being ahead of this curve and trying to react and catch up in the future if needed. To paraphrase a non-medical good friend, "I'll choose lifestyle every time."

Updated website to show I’m no longer taking schizophrenia or schizoaffective, nor offering LAI. I simply didn’t see the vivitrol numbers I originally thought, and haven’t been able to test out the relationship I attempted to start with a local pharmacy. Secondly, my few young first break psychosis patients are not med compliant, and my hopes of having thoroughly educated on diagnosis, treatment plan early with family would yield positive outcomes, but both patients have already had some non-compliance. This office isn’t set up with case management for these purposes. So this will be a new practice limitation. Also, updated website to reflect ESA letters not written out of this office. Did other website updates like adding Assistant, sort of end of year housekeeping.

Have some forms/documents I need to create within Luminello but struggling to get the time. Whenever I think I have a window, it gets used up for catching up on charting delays from previous setbacks that got me behind. May truly just need to block a whole darn day in the future to devote to these admin/process/flow improvements.

Goals for 2020:
  • Pay myself Quarterly, and however small/big that number, remember I am free and not working for some Big Box Shop entity.
  • Achieve 20 clinical hours per week by end of Q2
  • Start taking on some med students again
  • After Achieve 2, look at patient panel and consider dropping Medicare, low payor, or low payor.
  • By end of Q2 know if THE BOSS is going to open/build an office I rent from or if I will pursue it myself using my own business identity.
  • Achieve 30 clinical hours per week by end of Q4
Review of patient panel shows 93 total active patients: 44 have better rates than Medicare (two are cash pay), 8 are Medicare, 41 have lower rates than Medicare. 47.3% of the panel is better than Medicare in summary. Census increased from Q3 to Q4 by 22 patients. Earlier posts had reflected my optimism to be at 20-30 clinical hours by the end of 2019. That didn’t happen. Disappointing, but the growth rate currently is manageable with how I document and I’m not feeling overly stressed. Estimate I’m 10-12 clinical hours currently per week overall. Just by the number, if I am growing 22 patients per quarter, and if 93 patients correspond to 10-12 clinical hours, I should be at 181 patients and 20-24 hours by end of 2020. So, we shall see, end of 2020 will it be 20 or 30 clinical hours and will I achieve the above 1-6 goals?

Bad debt for the year. Total of $3271.20, which also includes some intentional charity care. My understanding is that because I’m a professional and not a non-profit organization, none of this can be ‘written off’ or used as a tax deduction. Just pure monetary loss. $2771 was from the first 6 months, and some were hard learned lessons noted in earlier posts of being HMO insurance, one was a HMO/Medicaid insurance. Positively, I try to learn, and the last 6 months of 2019, only $499 was bad debt, which was mostly co-pays or co-insurance of patients that didn’t follow up. To further put in perspective the first 6 months I had ~20K in collections, and the last 6 months I had ~64K in collections, and I had a collections rate of 88.03% for the first 6 months, and 99.22% for the last 6 months.

Month 12 finished with total income $16095, minus overhead of $9489, yielding income of $6606 for the month.

JAN - MAR, 2019
APR - JUN, 2019
JUL - SEP, 2019
OCT - DEC, 2019
TOTAL
Income
$3,551.53
$16,825.42
$28,936.40
$35,192.57
$84,505.92
Expenses
$11,326.06
$17,684.72
$17,969.97
$23,114.46
$70,095.21
NET INCOME
($7,774.53)
($859.30)
$10,966.43
$12,078.11
$14,410.71

Not yet reviewed and finalized by an accountant, but my rough draft income I’ll actually pay myself, for the entirety of 2019, is ~$12K (this is a pre-tax number). Approximately 20% of that number is going into a SEP-IRA. Had to also subtract out employee SEP-IRA, too.

The way some expenses have fallen I have just left them where the dates materialized, I’ll sit down with accountant in coming days to see how things truly need to be. For instance, Payroll taxes to government show up not during the quarter they are for, but several days into the following quarter. Is that where they belong? Good thing I have an accountant to square this away.

My future posts will now be on a Quarterly basis.
 
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Month Twelve:

Busy week one, new record I believe for follow ups and consults.

The entropy of time… I’m settling in to the role of a heavy med check clinic. I’m loving the beauty and simplicity of this practice. Only one brief 10 minute monthly meeting. I have a great receptionist/assistant. There’s no work place drama. No ridiculous “quality” metrics being pushed, no billing people looking over my shoulder. No scheduling or vacation barriers to deal with or pages of rules for CME reimbursement. No counting wRVUs. The heavy, wet concrete blanket of bureaucratic oppression is … gone. Whether I was on a burn out spectrum in the past or simply being a psychiatrist who spotted scat in his own life and took steps to improve them, this practice set up is amazing! However, being on staff at the local hospital where ECT might develop has now exposed me to the flood of emails rampant in large health systems once again. I was adept in the past at cruising and deleting non-essential emails pouring in from admins, but having been free of them for some time, to again get them is painful.

Another flu/cold moved thru the house. And it hit me hard, too. Reality is I’m the flex person who gets the kids to and from places, more prone to do sick care for kids. Without a quality practice partner to share in logistics of an ECT service start up, I can’t be 100% devoted to work for 1-2 years of getting this service up and running. I’m officially going to kill the ECT dream. Some sadness, similar to the closing of doors as med student to resident, and resident to attending, etc. But I’m now more accepting of not being the Psychiatrist who does ‘More’ or has extra ‘Bells and Whistles.’ Simply doing med check focus is good enough. I can still do more by precepting third year students. I used to have a sweet rotation with IP, OP, CL, ECT, Suboxone clinic, etc all packed nicely into a month-long rotation, but what I lack with these other exposures I’ll try to supplement with more designated 1:1 didactic teaching. The communications were officially sent – dead. THE BOSS is sad with this decision but understanding. I do still believe the future of Psychiatry may trend towards most offices having TMS, and offering ketamine in some fashion, but I am willing to accept not being ahead of this curve and trying to react and catch up in the future if needed. To paraphrase a non-medical good friend, "I'll choose lifestyle every time."

Updated website to show I’m no longer taking schizophrenia or schizoaffective, nor offering LAI. I simply didn’t see the vivitrol numbers I originally thought, and haven’t been able to test out the relationship I attempted to start with a local pharmacy. Secondly, my few young first break psychosis patients are not med compliant, and my hopes of having thoroughly educated on diagnosis, treatment plan early with family would yield positive outcomes, but both patients have already had some non-compliance. This office isn’t set up with case management for these purposes. So this will be a new practice limitation. Also, updated website to reflect ESA letters not written out of this office. Did other website updates like adding Assistant, sort of end of year housekeeping.

Have some forms/documents I need to create within Luminello but struggling to get the time. Whenever I think I have a window, it gets used up for catching up on charting delays from previous setbacks that got me behind. May truly just need to block a whole darn day in the future to devote to these admin/process/flow improvements.

Goals for 2020:
  • Pay myself Quarterly, and however small/big that number, remember I am free and not working for some Big Box Shop entity.
  • Achieve 20 clinical hours per week by end of Q2
  • Start taking on some med students again
  • After Achieve 2, look at patient panel and consider dropping Medicare, low payor, or low payor.
  • By end of Q2 know if THE BOSS is going to open/build an office I rent from or if I will pursue it myself using my own business identity.
  • Achieve 30 clinical hours per week by end of Q4
Review of patient panel shows 93 total active patients: 44 have better rates than Medicare (two are cash pay), 8 are Medicare, 41 have lower rates than Medicare. 47.3% of the panel is better than Medicare in summary. Census increased from Q3 to Q4 by 22 patients. Earlier posts had reflected my optimism to be at 20-30 clinical hours by the end of 2019. That didn’t happen. Disappointing, but the growth rate currently is manageable with how I document and I’m not feeling overly stressed. Estimate I’m 10-12 clinical hours currently per week overall. Just by the number, if I am growing 22 patients per quarter, and if 93 patients correspond to 10-12 clinical hours, I should be at 181 patients and 20-24 hours by end of 2020. So, we shall see, end of 2020 will it be 20 or 30 clinical hours and will I achieve the above 1-6 goals?

Bad debt for the year. Total of $3271.20, which also includes some intentional charity care. My understanding is that because I’m a professional and not a non-profit organization, none of this can be ‘written off’ or used as a tax deduction. Just pure monetary loss. $2771 was from the first 6 months, and some were hard learned lessons noted in earlier posts of being HMO insurance, one was a HMO/Medicaid insurance. Positively, I try to learn, and the last 6 months of 2019, only $499 was bad debt, which was mostly co-pays or co-insurance of patients that didn’t follow up. To further put in perspective the first 6 months I had ~20K in collections, and the last 6 months I had ~64K in collections, and I had a collections rate of 88.03% for the first 6 months, and 99.22% for the last 6 months.

Month 12 finished with total income $16095, minus overhead of $9489, yielding income of $6606 for the month.

JAN - MAR, 2019
APR - JUN, 2019
JUL - SEP, 2019
OCT - DEC, 2019
TOTAL
Income
$3,551.53
$16,825.42
$28,936.40
$35,192.57
$84,505.92
Expenses
$11,326.06
$17,684.72
$17,969.97
$23,114.46
$70,095.21
NET INCOME
($7,774.53)
($859.30)
$10,966.43
$12,078.11
$14,410.71

Not yet reviewed and finalized by an accountant, but my rough draft income I’ll actually pay myself, for the entirety of 2019, is ~$12K (this is a pre-tax number). Approximately 20% of that number is going into a SEP-IRA. Had to also subtract out employee SEP-IRA, too.

The way some expenses have fallen I have just left them where the dates materialized, I’ll sit down with accountant in coming days to see how things truly need to be. For instance, Payroll taxes to government show up not during the quarter they are for, but several days into the following quarter. Is that where they belong? Good thing I have an accountant to square this away.

My future posts will now be on a Quarterly basis.

Your def on your way to 150k minimum collections in year 2 but I think you will break 200k easily imho. I don't get why your area is on the slower side as 22 patients in a quarter seems surprising to me. Are you picky on which panels or do you exclude a lot of patients? Of course if you were taking medicaid your numbers would be doubled/tripled in terms of volume but that comes with its own issues in terms of severity and low $ and high no shows.

Ultimately, it won't matter as I think your going to get to where you want to be by end of year 2 regardless. Would doing some moonlighting at the local hospital help? I know every shift I did I got referrals just from being in the hospital and showing a face to a name and many consults and even on inpt follows ups many wanted to follow up as outpatient post discharge.
 
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Bummer about the ECT especially for the patients although for physicians it doesn't seem to be especially profitable.

Interesting that you decided on the schizophrenic/schizoaffective exclusion. I don't find patients with schizophrenia as challenging to manage on an outpatient basis as Bipolar 1 for example who can be stable until they aren't...

What is the term of your current lease? Without doing anything different other than securing a reasonable rent your business will immediately be more solvent. Thanks for the update and best wishes for 2020!
 
Your def on your way to 150k minimum collections in year 2 but I think you will break 200k easily imho. I don't get why your area is on the slower side as 22 patients in a quarter seems surprising to me. Are you picky on which panels or do you exclude a lot of patients? Of course if you were taking medicaid your numbers would be doubled/tripled in terms of volume but that comes with its own issues in terms of severity and low $ and high no shows.

Ultimately, it won't matter as I think your going to get to where you want to be by end of year 2 regardless. Would doing some moonlighting at the local hospital help? I know every shift I did I got referrals just from being in the hospital and showing a face to a name and many consults and even on inpt follows ups many wanted to follow up as outpatient post discharge.
Moonlighting with Inpatient facilities could help some. However, THE BOSS, has flat out told me I am not working weekends. The local psych hospital doesn't really refer to me anymore because I don't just schedule an appointment for patients. They have to do the online pre-paperwork first. Since the SW on unit don't want to spend the time with patients to allow them computer access, I just don't get these referrals from inpatient sources.

I am broad paneled and pretty much the only person taking the two private insurances that pay less then Medicare.

Requiring patients to pre-complete their paperwork electronically does limit intakes for sure. But downstream it makes future communications, and billing, and refills, etc so much more streamlined with patients.
 
Bummer about the ECT especially for the patients although for physicians it doesn't seem to be especially profitable.

Interesting that you decided on the schizophrenic/schizoaffective exclusion. I don't find patients with schizophrenia as challenging to manage on an outpatient basis as Bipolar 1 for example who can be stable until they aren't...

What is the term of your current lease? Without doing anything different other than securing a reasonable rent your business will immediately be more solvent. Thanks for the update and best wishes for 2020!
Absolutely, right on the lease. Its a 3 year, so I got 2 more years. Actively looking into the process to buy land and build an office for owner occupied. THE BOSS was looking into doing this and I lease, but now the banking/loan process looks like it'll be easier if I do it with my practice/corporation.

Essentially, I am going to do my best to capture that lease money and not keep throwing it in a fire.
 
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