Sushirolls

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I’d love to know what the breakdown of your overhead is just to kind of see how expenses break down. Continue to be very helpful.
Quarterly break down for 2019
Q1Q2Q3Q4TOTAL
Accountant2701,100.0000$1,370.00
Accountant - New accountant0013065$195.00
Advertising & Marketing321.87177186.84719.11$1,404.82
Bank Charges & Fees029.0500$29.05
Board Certification Fees01751750$350.00
Continuing Medical Education2490562.60$811.60
Credit Card Processing Fees32.58129.24239.54206.39$607.75
Hospital Medical Staff Fee7504000$475.00
Insurance02,218.000621$2,839.00
Legal & Professional Services1203500$155.00
Medical Billing Services01,485.009901,797.32$4,272.32
Medical Society Membership Dues002800$280.00
Office Supplies & Software1,761.011,767.15917.181,254.86$5,700.20
Other Business Expenses350.361001140$564.36
Payroll Expenses002,944.355,768.42$8,712.77
Payroll Taxes000883.76$883.76
Rent & Lease7,270.079,797.739,797.739,833.24$36,698.77
Repairs & Maintenance000352.3$352.30
Taxes & Licenses7522900$304.00
Urine Testing Supplies00352.42786.54$1,138.96
Utilities459.97390.81391.8392.47$1,635.05
State taxes341.251.7445.01434.05$872.00
State Medical License00443.50$443.50
Total Expenses$11,326.06$17,684.72$17,969.97$23,114.46$70,095.21
 
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psychapp121

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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.

your wife can just flat out tell you things? Lol
 

Sushirolls

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Some things, but when they make sense in the bigger picture then, absolutely yes. i.e. if unchecked I can barrel towards 'work-a-holic' and time is quite valuable and important for parenting, marriage, family, hobbies, etc.

I don't believe in all the weekends I've ever worked and ever been on call I thought to myself, "Glad I'm working this weekend!"
 
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Sushirolls

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DATA FOR Q4
Total Patients:93
Insurance Payer Mix:41 < Medicare8 Medicare44 > Medicare (47.3%)
Follow Ups:16612.8 (weekly mean)range of 0-23 per week
Consults:483.7 (weekly mean)range of 0-8 per week
Weekly Clinical Hours:*10.1 (quarterly mean)
Blended Payer Mix: **$129.95 per follow up
Overhead Percentage:71.1%

Streamlined an excel spreadsheet to easily compute the blended payer mix, can now produce quickly on Quarterly basis. For 2019 Q4 was $129.95 per follow up. This is a devilish statistic where the details impact what it means and how this number came to be. However, it means something to me despite the imperfections that can be pointed out if really reflected on. For my practice I'll continue with this formula quarterly as just an extra data point.

For all of 2019 I completed 173 consults, 396 follow ups.
 
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TerraceHouse

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@Sushirolls hey doc, quick question as I haven't seen it discussed as much on here but is it pretty rare to find an already successful practice on sale to buy for private practice psychiatry? I've seen some advertised stating revenue 1.5m and cashflow 700k asking price to sell for 500k and was always confused by why they wouldn't sell for more. Is it bc patients are likely to stop going there once the previous owner sells? Super noob question, I know. Thx in advance.
 

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I wouldn't buy another practice for various reasons. Will you get paneled with the same insurance companies? Will they give you the same rates as previous doc? How long will it take for you get paneled (2-8months...). How are they doing the billing? For instance, I only do psychotherapy add on codes for a portion of my patients, some folks do it for 100%. Do you document what you should to justify it if audited or mere check a box as I've seen some clinics do? Are they doing 15 minute follow ups and you would do 30 minutes? Do they give everyone Benzos and you won't give any one benzos? Maybe the practice doc truly is the archetype of knowledge, experience, and bed side manner, but well, you aren't, and how many patients will stick around?
For these reasons above, I wouldn't buy a practice because its too much risk, and you likely walk into to many headaches. No guarantees the patients stick around and you are left paying for what, good will?

There is something to be said for starting your own place and establishing your own clinic policies. You walk into another practice, patients won't want to change, they will be averse to policy changes, and already a new face/person is a source of irritability. But when the patient has to truly change from X to Z they are more accepting of this headache.

Buy something more than 'good will' like an office and the land it sits on, that's a different story. I could see paying 500k for a physical office, that happened to also include an attempt at transferring over the patients/practice.
 
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TexasPhysician

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@Sushirolls hey doc, quick question as I haven't seen it discussed as much on here but is it pretty rare to find an already successful practice on sale to buy for private practice psychiatry? I've seen some advertised stating revenue 1.5m and cashflow 700k asking price to sell for 500k and was always confused by why they wouldn't sell for more. Is it bc patients are likely to stop going there once the previous owner sells? Super noob question, I know. Thx in advance.

Depends on the practice. A generic 1 psych insurance practice has no value regardless of revenue. It is too easy to replicate. No sense in paying for what I can replicate in 4-6 months.

It’s different if in my preferred city I can purchase an all cash practice with 3 psychiatrists and 4 counselors in which I’m collecting passive revenue from them. It could easily be worth a multiple of passive revenue.
 
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psyguru

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Setting up aprivate practice seems far more complicated than setting up an expert witness practice. After about 2 years I have been able to cut back to being part time clinician.
 
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Sushirolls

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Setting up aprivate practice seems far more complicated than setting up an expert witness practice. After about 2 years I have been able to cut back to being part time clinician.
Well, done! Sadly, I don't have much interest or drive in being an expert witness. You should start a thread similar to this, try to do some retro/back dated type posts and do a play by play moving forward. Could be quite educational for folks.
 
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Setting up aprivate practice seems far more complicated than setting up an expert witness practice. After about 2 years I have been able to cut back to being part time clinician.

Would love to hear how you got this business up and running and/or advice.
 
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Sushirolls

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YEAR TWO, Q1​
SUBJECTIVE:
Put up on website and extra words to a sign outside my office door, no walk-ins and you need an appointment. Have had same lab rep enter twice, and prospective patients. Traditional office/clinics this isn’t an issue, but as I have a receptionist who is part time and not in the office for all open hours, walk-ins aren’t permitted. Baffles me how people read it, vocalize how they have read it ‘but I just need 5 minutes of your time’ believing they are an exception. Locums have now discovered my office number, took them a year!

Since college I have been diligent in keeping an updated CV. College, early med school, late med school, early residency, late residency, early attending, etc. Every stage, and tweaking as things need tweaking. In order to be prepared for the next step. Or ready for the next job change. Now, I’m scratching my head and wondering if there will ever be a next, another thing I will actually need to provide an updated CV for? Kind of a weird sensation to think, I don’t even need to add this practice, I don’t even need a CV anymore… I’m CV Free.

Growing tired with some of the current practice building stage with new consults, and recognizing this is likely to be a two-to-three year long process. End of 2019 data reflected having 173 total consults and ~93 active patients, that’s ~ 50% conversion from consult to follow up patient. This 2-3 year timeline is mostly impacted by future goals of dropping lower paying insurance panels which extends out this process. Lots of time and effort spent in these encounters. I’ve historically done this twice. Once for general psychiatry over 2 years, and again for an OUD clinic (1 year) which was >90% Medicaid. This is my third and hopefully final time of doing the practice building phase of an outpatient practice. Looking forward to the day when either closed or only doing 1-2 consults per week.

Got one EOB back from an insurance company, saying $0.00 payment. I just grumbled and passed to receptionist to process. She was perplexed by the rejection comment. Took initiative to call insurance to understand why denied. Learned it was listed as several dates of service and not just one! Well, done by her to take the initiative on this error from our billing company. Billing company resubmitted correctly and we actually got paid. Another billing positive, submitted a 99354 with one insurance company and they actually paid.

The new year effect, with insurance updates, seems to have been favorable with 4-6 transitions to better-than-Medicare. Some patients are getting caught unawares with the new year and deductibles re-setting. So, this has slowed collections way, way down. Really need to emphasize the impact of Q1 “deductible season” which really dampens Q1 collections (see objective data below), but I’m optimistic its mostly a delay that resolves by Q2. Hoping to keep my 99.2% collection rate. However, receptionist has observed also that much of bad debt now is stemming from consults, the patients that are a one-time consult, or simply don’t follow up. These observations might be valuable for others, away from more consultative heavy practices – unless some sort of prepay arrangement is made – which some insurance contracts don’t permit…

Local group of ARNPs dropped a lower-than-Medicare insurance, which may increase inquiries here for that insurance.

Started the practice a bit more than a year ago and thought area to be low in Psychiatrist and ARNP saturation. With slow growth rate, acknowledging my own hand in that, started to still wonder if area was saturated with ARNP. Local area does have an ARNP school minting new grads. Made a list of all the psychiatric folks in the area ranging from C/L to CMH agencies to IP to private groups, etc. Probably still missing a few, but was surprised how many people there actually are in total. Did some quick google and noted a range of Psychiatrists per 100,000 people. Going with some couple year-old WHO data, looks like US is about 10.5/100,000. My half hazard calculations reflect my area to be 6.5/100,000 but if counting a nearby area, possibly 7.2/100,000. Not sure what to think of this, but it’s a number?

Looked online at a possible office within bicycle distance of home. ~16K per year for that lease. Currently have 2 more years to go on this lease, but playing the ‘what if game’ is always painful, probably should stop doing that. MISTAKE: apparently, the local fire marshal wants to do an inspection. My presumption was wrong, and discussion with another tenant reflects I am responsible for the cost, $150. I would like to think this is covered by the land lord, but nope, I pay for my suite to be inspected. Should have got this in the contract to not have to foot the bill. So glad the pain is just a 3-year lease. I’m trying to focus on the positive of this as a 3-year learning experience.

Forgot to note this in prior posts, for all of 2019 the overhead percentage was 87.45%. Rough calculations for future projections, I should be able to get that down to 20-25% once full at 30hrs/week clinical time. Earlier monthly posts I was reflective on the weekly ebbs and flows of patients, now it’s less of a stress. Knowing that I’m clearly meeting my practice overhead and covering payroll there’s breathing room. Conceptually I’m able to switch over to looking at things from a quarterly perspective. This feels good.

Luminello finally got around to converting my Rx service from DoseSpot to DrFirst. Slightly better interface, bit complex at first impression, but with use, its quicker than DoseSpot. Also, now prescription refills automatically integrate with pharmacy requests and present in Luminello for 90% of refill requests, the remaining 10% are still thru faxes. However, the conversion to it is slowing things down lately as I need to input allergies and pharmacies in for each patient all over again and that’s a pain.

Now that I’m refining my quarterly data for what I keep track of, I’m a bit antsy. Low level excitement feeling like a kid on birthday “what’s it going to be?” So, throughout the quarter I have to remind myself, just wait, it’s not time to crunch the numbers. I know at some time in the future it’ll be like ‘meh’ and won’t even bother….

COVID-19 now enters the scene: I add to this post throughout the quarter, and everything prior was first ~9 weeks, and early March everything has changed with Covid. Now I have drastically reduced my expectations of growth, and simply hope to keep the lights on, and meet payroll with no real reductions. For Q2 and Q3, I have no expectations to even pay myself. *sigh* As result of Coronavirus I urgently added doxy.me to facilitate telepsych service line. I wanted to delay this for a few years, but need to dive in now. The UDS requirement for Stimulants and Suboxone have been suspended until further notice. Positively my electronic emphasis from the start with intakes, has contributed to an easy conversion for majority of my patient panel. Sending more 90 day prescriptions in for patients to limit pharmacy trips, and encouraging at risk cohorts to switch to drive thru pharmacies. The handful of hypnosis patients, I have suspended that part of their treatment due to lagging audio/video at times. I have given the receptionist the ability to work from home, which means no active answering of the phone, only voicemail returns, and could hurt our ability to get people in. Getting some waves of payments from patients on their deductible sized bills, in March, so ‘Deductible season’ might just be Jan/Feb phenomenon. March and a bit of late Feb was a low consultation period and definitely reduced my calculated weekly clinical hours compared to 2019 Q4. However, there is quite the ebb/flow to consults, and even if this is all Covid related, there may be a counter Covid upswing in the coming weeks? Optimism? Receptionist and I have talked about if a down swing persists possible cost cutting with need to close 1 day of the week. She’s motivated to keep this place afloat, as she too has no desire to go back to a Big Box Shop level employment. Luminello supposedly will roll out some sort of integration with Doxy.me, which is nice as that was the tele service I elected anyways! A good friend keenly noted that had Covid-19 started this time in 2019, this practice would have sank hard – this is a positive, and in celebrating the positives where they come, I’m glad Covid wasn’t a year ago. However, I do believe if someone were to plan to open a practice on the downswing, improvement side of Covid, it could be excellent timing. I mean, many employed physician jobs are slashing pay right now or even cutting hours for their docs, so if you were to already get hit, may as well be productive with a practice start up.

Last day of the quarter a random employee from a neighboring medical office, enters into the office, and I’m kicking myself for not remembering to lock the door. In comes a box being dragged, and she asks, if I use these toner cartridges, and imagine the odds, I do! She was instructed to throw away 7 perfectly good cartridges but instead opted to try and find them a home first. I just got for free $525 worth of office supplies! About a month ago I had just bought two replacements at $75 each. I think I’m good for a few years now. Made my day.

Positively pay for this quarter was more than the total of all of 2019, that’s progress!

OBJECTIVE: (compare to post #155 for 2019 Q4)
Total Active Patients:95
Insurance Payor Mix:37 < Medicare7 Medicare51 > Medicare (54.8%)
Follow Ups:17013.1 (weekly mean)range of 6-22 per week
Consults:362.8 (weekly mean)range of 0-7 per week
Weekly Clinical Hours:*9.3 (quarterly mean)
Blended Payer Mix: **$135.45 per follow up
Overhead Percentage:63.58%
Days Off:2.5
*simply dividing the follow ups by two, and adding to consults (goal is 30 per week)
**Using the custom made Sushirolls’ formula
Jan 2020Feb 2020Mar 2020Total
Total Income$9,353.57 $8,760.90 $14,149.06 $32,263.53
Expenses
Accountant
0.00​
0.00​
515.00​
515.00​
Advertising & Marketing
107.57​
137.72​
131.32​
376.61​
Board Certification Fees
350.00​
0.00​
0.00​
350.00​
Credit Card Processing Fees
75.93​
103.64​
115.69​
295.26​
Medical Billing Services
605.74​
495.00​
495.00​
1,595.74​
Office Supplies & Software
82.29​
50.64​
193.41​
326.34​
Other Business Expenses
0.00​
0.00​
126.00​
126.00​
Payroll Expenses
1,351.62​
1,346.81​
1,515.16​
4,213.59​
Payroll Taxes
0.00​
0.00​
845.72​
845.72​
Rent & Lease
3,301.42​
3,301.42​
3,482.75​
10,085.59​
Repairs & Maintenance
27.10​
0.00​
0.00​
27.10​
Taxes & Licenses
0.00​
150.00​
731.00​
881.00​
Utilities
130.84​
129.83​
129.83​
390.50​
State Tax
0.00​
0.00​
483.95​
483.95​
Total Expenses$6,032.51 $5,715.06 $8,764.83 $20,512.40
Net Income$3,321.06 $3,045.84 $5,384.23
$11,751.13

ASSESSMENT:
1) Professional Dissatisfaction
2) Slow practice growth rate
3) Optimization Deficiency
4) Infrastructure Deficits
5) Retirement Exposure

PLAN:
1) In Remission, continue this private practice and never return to Big Box shop employed practice. Continue to cruise over other forums on SDN where dissatisfaction reigns more intensely, and use that as a reminder – never again.
2) Growth rate had continued to steadily increase at pace of comfort, limited stress, until Covid-19 struck. It is acknowledged that the SDN diaspora is quite displeased by this rate of growth, but no drastic change in marketing nor intake process at this time to accelerate it. Did drop Google ads due to limited yield and considering doing a local online newspaper.
3) Not yet time to drop Medicare, nor lower payer insurance until about 20 clinical hours per week achieved. Currently paying $60/month for website maintenance and back up and upgrades, might consider dropping this safety net of ensured web presence. Would be nice to get locums to stop contacting me as I’m highly unlikely to need them. Starting to reply/end their inquiries on email by clicking ‘unsubscribe’ now. Debating what to do with texts/calls. Another poster on SDN noted haggling down the fee rates for credit card processing with Luminello 3rd party processor, might need to do this. An issue that as time passes, will become more pressing when do I switch from 3rd party biller and shift to in house? Currently thinking of using Luminello built in feature with ApexEDIs. Humans make mistakes, more humans in the process the more mistakes, so when billing company makes a mistake that adds 30-45 minutes of extra work for my assistant to square it away. Shifting the billing to internal may be an optimization. I’ve crunched some numbers for when the inflection point will happen, but don’t want to even consider it until after Medicare is dropped due to its complexities. This really is one of those chin stroking conundrums. How you do the math, and how much faith can you put in the projections. I have a relatively good rate company at about 5%, and as billings increase their percentage drops. Will put a pause on this for now.
4) Still debating on buying a blood pressure cuff, defer until after Covid. Delaying securing loans for owner occupied construction loan to facilitate transitioning away from this lease until after Q2. But with Covid juggernaut thrusting the economy into the Tele sphere, there may be a long term down trend in office real estate that pursuing building ownership might be a poor choice?
5) Although exposed to retirees and showing high risk behaviors of reading on retirement account management, very low risk of conversion to retirement at this time. Will continue to treat with high dose of bills for suppression, and monitor with these quarterly assessments. And of course, Covid market crash is further ensuring against this conversion. Pay for this quarter will be ~$11.7K, and 20% of that will be put aside for SEP-IRA contribution, and then 25% of that 0.8 put aside for taxes, leaving ~$7.0K to pay personal bills.
 
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Love your assessment and plan. Looking forward to follow up in 1 month. Fingers crossed for your success
 
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finalpsychyear

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I think perspective is important here. Not everyone will have booming practices right away and it can be a few years to get to that point. Some who have worked and gotten to know what goes on with the big box shops want the autonomy over everything else.

Pay will lag significantly lower in the beginning and sometimes its just how it is. It takes a lot to keep this going knowing what you have netted after expeneses in 16 months would be likely close to your big box 1 month paycheck. That hurts me just typing that but the autonomy especially after not having it in the past makes it worth it in the end. Good luck and onwards.
 
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Jules A

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Thanks as always for sharing your experiences. If you got the $16,000 a year office that would make a significant difference in your bottom line. Love the free office supplies!
Two questions and my recent experience. 1. Why isn't your office mgr having the phone calls forwarded to her so patients don't have to leave a message? They don't need to know the office is essentially closed. 2. Why isn't she also doing the chart set up including putting in pharmacy, allergies etc? She sounds excellent btw and I'm sure wouldn't mind doing that task which will free you up to see patients.

My recent experience with my part-time private practice which is just under a year 1 year old that was coming along nicely and screeched to a halt 3 weeks ago has now picked back up full speed. I think some of it is that I'm advertising telepsych which many in my area aren't doing and also many people who have had underlying depression and anxiety but never sought treatment due to the current situation are interested in getting in quickly. I bet you will be pleasantly surprised to see an uptick soon.
 
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Sushirolls

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Call forwarding hasn't happened because I haven't looked into it. I suspect it is possible with my service/carrier, but she also only works part time.

I've kept the input of allergies and pharmacy for myself because it's just logistically quicker. I also have a lot of patients due to Covid changing their pharmacies, or they have two with local & mail order. She isn't an MA/LPN, etc. I'm able to ensure the quality control on this nuance. Post covid and we are back in the office, I'll have an excellent grasp of the new prescription interface (DrFirst) and will be able to sit down and train her how to do refill prep. Positively, there is no way she can accidentally send off a prescription so that fail safe exists. We were doing it that way before Covid when it was DoseSpot.

Jules, would love to see a similar post thread as this one with your private practice ramp up. Feel up to it?
 

Jules A

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Jules, would love to see a similar post thread as this one with your private practice ramp up. Feel up to it?

I hope you don't mind a hijack. I thought I would add mine here because it is small potatoes and not nearly as interesting as the operation you are building. I'm renting nice office space one day a week for $175 per month at a colleague's therapy practice that is about 5 minutes from my home. I don't accept insurance and am doing everything myself which hasn't been bad considering my small patient load. My initial start up was minimal for a decent blood pressure machine, cheap scale, cell phone, EMR, additional insurance, business cards, printer etc. I don't have a website, just advertising on Psychology today and local free papers. Most of my referrals come from psychologists and social workers who I know from my other jobs. I'm a reluctant convert to telepsych due to the pandemic but actually like the flexibility particularly with scheduling. My hope is to eventually net around $75,000 a year working ~6h week. My fourth quarter will likely be another modest increase from Q3. Time will tell, so far it has been pleasant. Thank you again for sharing your experience and much continued success.

Q1Q2Q3Total
Gross$2,550$7,950$8,850$19,090
Expenses$2,671$1,776$1,829$6,276
Net($121)$6,174$6,721$12,744
 
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Sushirolls

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Jules, that's awesome. Thank you for posting. Interesting to see with your cash only set up, and smaller overhead the Q1 also ran negative. Success wishes for you, too. Welcome to continue to hijack the thread.
 
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Jules A

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Jules, that's awesome. Thank you for posting. Interesting to see with your cash only set up, and smaller overhead the Q1 also ran negative. Success wishes for you, too. Welcome to continue to hijack the thread.

Thank you for being so gracious. I took my start-up costs out of Q1 but the figures do not reflect taxes. It was agonizingly slow going initially but thankfully my low overhead and lack of attachment allowed me the luxury to wait and see. I keep in mind that I am losing a day of income elsewhere though and on several occasions have picked up shifts when I didn't have anyone scheduled. My preference is inpatient but the climate in hospitals recently has me frustrated so I thought it would be worth mixing it up and so far I am happy I did. I have worked with an amazing office manager who is interested in moonlighting action which I may consider in the future if scheduling, tracking down labs, PAs etc becomes too cumbersome. Yours sounds like a keeper and as I'm sure you know finding a strong admin who is invested in the business succeeding is possibly the best asset you can have.

Have you been following the available loans some which are forgivable if spent on payroll and rent during the pandemic? A colleague secured one for their practice which will allow them to continue to serve their patients and keep staff employed.
 

Sushirolls

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I did apply for the EIDL, and PPP. See what happens, but not expecting anything. Currently I'm getting more motivated to make the change away from my third party biller to the Luminello integration, could save potentially, at least on a spread sheet, ~$4800/year minimum. But its the unseen work flow and unexpected things that might eat into that savings. That could be a decent boost if this transition will work.

Got an email this morning from HHS, about the CARES act. They used one of the commercial insurance companies to disperse the money directly to medical folks. I suspect this 'free' money to be about ~9-10% of previous years medicare billing. Not sure if others got this or not, but that was a surprise to see as an actual deposit today, too. For me it was a very tiny amount of no real impact. But I'm sure some clinic out there somewhere it made a larger impact.

My assistant is less of an admin, and more assistant/biller/receptionist.

Your cash pay patients are likely capable, so let them do their own scheduling? I let my patients currently online schedule themselves, or I do it at the end of the appointment for them. 95% of my labs appropriately get faxed to me, less than 5% need a phone call chaser. I have done 1 saphris PA, for a patient who was already on it. I did brain imaging PA once. Depending on your prescribing it might not be an issue. I've had other PA pop up but when you look at the cash price of the medicine or even the GoodRx.com price, I let folks know I won't do the PA, and just to use GoodRx.com and pay the cheap out of pocket. I'm optimistic at most you would only need an assistant, and I'm sure there are some good MA/LPN/CNA, unit secretaries you've interacted with on the units...
 
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I did apply for the EIDL, and PPP. See what happens, but not expecting anything. Currently I'm getting more motivated to make the change away from my third party biller to the Luminello integration, could save potentially, at least on a spread sheet, ~$4800/year minimum. But its the unseen work flow and unexpected things that might eat into that savings. That could be a decent boost if this transition will work.

Got an email this morning from HHS, about the CARES act. They used one of the commercial insurance companies to disperse the money directly to medical folks. I suspect this 'free' money to be about ~9-10% of previous years medicare billing. Not sure if others got this or not, but that was a surprise to see as an actual deposit today, too. For me it was a very tiny amount of no real impact. But I'm sure some clinic out there somewhere it made a larger impact.

My assistant is less of an admin, and more assistant/biller/receptionist.

Your cash pay patients are likely capable, so let them do their own scheduling? I let my patients currently online schedule themselves, or I do it at the end of the appointment for them. 95% of my labs appropriately get faxed to me, less than 5% need a phone call chaser. I have done 1 saphris PA, for a patient who was already on it. I did brain imaging PA once. Depending on your prescribing it might not be an issue. I've had other PA pop up but when you look at the cash price of the medicine or even the GoodRx.com price, I let folks know I won't do the PA, and just to use GoodRx.com and pay the cheap out of pocket. I'm optimistic at most you would only need an assistant, and I'm sure there are some good MA/LPN/CNA, unit secretaries you've interacted with on the units...

I thought this was a scam. Then saw the ACH check. It was not a minor one. Its a percentage of previous years medicare?
 

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I thought it was a scam too at first glance, and was going to read more today about it. But then when I saw the ACH deposit, it got real. That's my best guess without having actually read up on it yet, and how they determined the number. Have you read or got another theory?
 
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This link is the HHS description of this payment that doesn't need to be repaid. Looks like the formula is 2019 medicare payments you (or an institution) received for medicare monies multiplied by 0.06198. The rules behind the disbursement are listed and soon to follow an actual form to sign/attest.
 

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Bag it. They now want tax records for 2019 as part of this HHS money. My tax structure has both the personal and business on same forms. I have no desire to upload my personal tax records for this. Considering now they have the public database who and how much people got from HHS.

I'm sending the tiny money back.
 

Marasmus1

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These things are too complex for my simple mind. 2 questions

1- How likely could I pull 250k annually pre-tax in urban metro areas in private practice without working more than 40h a week?
2- How long would it take to start pulling that number starting from scratch ?
 
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These things are too complex for my simple mind. 2 questions

1- How likely could I pull 250k annually pre-tax in urban metro areas in private practice without working more than 40h a week?
2- How long would it take to start pulling that number starting from scratch ?

I say this in a completely non condescending way. If you're unable to think about some of the issues discussed in this thread because your mind isn't geared towards this type of financial thinking (many people aren't), developing a profitable business as a single owner is likely going to be magnitudes more difficult for you .
 
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ArdorAyurveda

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What's the purpose of having Medicare patients in your payor mix? Is it required by law?

Just trying to figure out why you don't minimize your percentage of Medicare patients in order to maximize profit.
 
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What's the purpose of having Medicare patients in your payor mix? Is it required by law?

Just trying to figure out why you don't minimize your percentage of Medicare patients in order to maximize profit.
I'm not OP but in some areas Medicare reimburses more than some of the private and/or medicaid insurers.
 
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vistaril

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I'm not OP but in some areas Medicare reimburses more than some of the private and/or medicaid insurers.

this.....

That said, as someone who has never been a solo practice owner for any extent, this thread has been depressing(but interesting). To see all this work put into it for so little money.

I'm pretty convinced that the only way to really make money in outpt psych in most places(especially places like here where the code reimbursements are so low) is to just hire psych nps and keep the delta as your profit. I know I could make money by paying psych nps 110k and making sure they are mostly booked with medicare patients. Get 3-4 of them use your collabs on them, and then keep the delta as your profit.....

It's not anyone's idea of a rewarding practice, but it's the best shot you have to make actual money I think.
 

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What's the purpose of having Medicare patients in your payor mix? Is it required by law?

Just trying to figure out why you don't minimize your percentage of Medicare patients in order to maximize profit.
No its not required by law. If you read in earlier posts you'll see why I was taking medicare. I do plan at some point to opt of of Medicare.
 

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this.....

That said, as someone who has never been a solo practice owner for any extent, this thread has been depressing(but interesting). To see all this work put into it for so little money.

I'm pretty convinced that the only way to really make money in outpt psych in most places(especially places like here where the code reimbursements are so low) is to just hire psych nps and keep the delta as your profit. I know I could make money by paying psych nps 110k and making sure they are mostly booked with medicare patients. Get 3-4 of them use your collabs on them, and then keep the delta as your profit.....

It's not anyone's idea of a rewarding practice, but it's the best shot you have to make actual money I think.
How I have been starting a practice may be depressing. There are some things I'm just not optimizing. There are plenty of choices that you could make where profit would be achieved much sooner, and greater. One need not throw in the towel and hire ARNP. I won't be.
 
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How I have been starting a practice may be depressing. There are some things I'm just not optimizing. There are plenty of choices that you could make where profit would be achieved much sooner, and greater. One need not throw in the towel and hire ARNP. I won't be.

thats your choice, but obviously that is the key to making more money. There is nothing wrong with doing it 'your way'.....it just won't make as much money. I commend that though.
 
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Vistaril, no, hiring ARNPs is not the key to making money nor the only way. It is a way.
 
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clausewitz2

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Vistaril, no, hiring ARNPs is not the key to making money nor the only way. It is a way.

Correct me if I'm wrong, but it seems like from what you've posted that if you had known you did not need a ginormo office space for procedures with accompanying steep rent, you would have been profitable waaaaaay earlier. Fair to say?
 
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Sushirolls

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Yes. My lease is $3300, and its possible to find $550 dollar spaces or even $1650 if I want a bathroom for UDS purposes in my area. I also am now in process of changing from a billing service to integration with Luminello and their 3rd party clearing house, ApexEDI which is reducing $5-700/month down to $100/month. I'm also changing my fax from $20/month down to $10/month. I have a few other things I'm looking at reducing.

So last quarter rather than 11.7K I could have had a net income of 22.2K if all those changes were in play (I can't change lease for some time though...). This is for ~9 hours of clinical work by traditional counting.

Nothing like Covid-19 to make you push for more optimization.
 
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Marasmus1

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I say this in a completely non condescending way. If you're unable to think about some of the issues discussed in this thread because your mind isn't geared towards this type of financial thinking (many people aren't), developing a profitable business as a single owner is likely going to be magnitudes more difficult for you .
I was actually referring to joining an established practice. I have no intention to run one.
 
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I was actually referring to joining an established practice. I have no intention to run one.

I would honestly not join any group private practice, because it's going to be predatory. Either go with a solo practice, or do some work for a larger organization, county health authority, private hospital, whatever. Every attending I had told me to avoid group private practices, and they were right. When I was interviewing with some group practices over the phone before I graduated residency (mostly for my own interest, I didn't want to work in that setting), the working environment they described in terms of how much time with patients, how much of the money you kept from what you earned, was all very substandard and almost insulting.

If you're gonna get screwed over a little, have it be from a large corporate hospital where at least it's consistent. If you join a group private practice get ready to get everyones xanax and adderall refills, and watch them go on vacation constantly and make you cover their patients (for no extra money).

During one interview, I asked what the coverage policy was if I joined and the other docs wanted to go on vacation all the time, the head admin guy literally got angry and hung up on me. So yeah.
 

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I would honestly not join any group private practice, because it's going to be predatory. Either go with a solo practice, or do some work for a larger organization, county health authority, private hospital, whatever. Every attending I had told me to avoid group private practices, and they were right. When I was interviewing with some group practices over the phone before I graduated residency (mostly for my own interest, I didn't want to work in that setting), the working environment they described in terms of how much time with patients, how much of the money you kept from what you earned, was all very substandard and almost insulting.

If you're gonna get screwed over a little, have it be from a large corporate hospital where at least it's consistent. If you join a group private practice get ready to get everyones xanax and adderall refills, and watch them go on vacation constantly and make you cover their patients (for no extra money).

During one interview, I asked what the coverage policy was if I joined and the other docs wanted to go on vacation all the time, the head admin guy literally got angry and hung up on me. So yeah.

That’s a broad generalization. I’ve much preferred group pp to any other environment. Small groups can adapt and make your life easier. They also pay better and give more time with patients. You can easily negotiate contracts as well.
 
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Overall I agree with Texas, private practice is more likely to have more quality in all facets compared to Big Box Shops. However, several years ago, to your point Basis, I interviewed with a private practice group that only offered like 2-4 weeks vacation. But the worst part was I started out saying I won't even consider moving to that city unless they offered a bare minimum of X. The owner/director was like sure. Let's interview. Their final offer was 50K less than X and no mention of any partnership track. Completely wasted my time. This was also a big city many folks on here would have loved to be in.
 

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Overall I agree with Texas, private practice is more likely to have more quality in all facets compared to Big Box Shops. However, several years ago, to your point Basis, I interviewed with a private practice group that only offered like 2-4 weeks vacation. But the worst part was I started out saying I won't even consider moving to that city unless they offered a bare minimum of X. The owner/director was like sure. Let's interview. Their final offer was 50K less than X and no mention of any partnership track. Completely wasted my time. This was also a big city many folks on here would have loved to be in.

hey if I’m reading it correctly, your blended follow-up average was around 130 per patient? Does this mean if you do 2-3 f/u per hour (Very reasonable in an insurance based practice) you’re essentially grossing 260-390 per hour? With 33 percent overhead you’re on your way to certainly clearing 200 per hour net after you’ve got things worked out, congrats!
 
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hey if I’m reading it correctly, your blended follow-up average was around 130 per patient? Does this mean if you do 2-3 f/u per hour (Very reasonable in an insurance based practice) you’re essentially grossing 260-390 per hour? With 33 percent overhead you’re on your way to certainly clearing 200 per hour net after you’ve got things worked out, congrats!

There are a lot of jobs that you can make 200+/hr on day 1 with no overhead plus benefits and no hassles. The point of all of this is the desire to be your own boss and autonomy but of course it comes with a different sort of price. It is exciting going from residency to attending and see these offers and drooling. The point is it is a short term effect. In the next 5 years how you value and see money will change drastically. Short term if your basing $/hr going with an employed/1099 job is a no brainer if you're looking at simply the short term bottom line. Eventually, everyone realizes that you can't buy time.
 
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Sushirolls

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hey if I’m reading it correctly, your blended follow-up average was around 130 per patient? Does this mean if you do 2-3 f/u per hour (Very reasonable in an insurance based practice) you’re essentially grossing 260-390 per hour? With 33 percent overhead you’re on your way to certainly clearing 200 per hour net after you’ve got things worked out, congrats!
Yes, you connected the dots. And with time, if things go as planned, watch to see how that number should increase.

Finalpsychyear did a good summary of things, too.
 
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Sushirolls, I know you are committed to ECT. I take it you have thought about TMS? Is it saturated in your market and if not, what was your decision process on ECT? My dream if I ever decided to jump academia would be to offer a diverse neuromodulation selection (TMS/ECT/Ketamine).

Apologies, if you had already addressed this question. I did not see it on the thread.
 

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ECT goals are dead. Local hospital kept dragging things out with their CEO staff turn over. I needed to move on, and with family obligations I couldn't commit any longer to 1-2 year start up process for a new service. I need another doc now to pull that off. Positively, with Covid-19 I missed that punch to the gut for a new service line. So definitely a blessing there. My area ECT is not saturated, but TMS probably is.

I could have possibly set up shop with a free standing psychiatric hospital in area, but their quality of care is concerning simply for their main service - inpatient care - and the thought of ECT with sedation/recovery duties there, I just couldn't do it.

TMS is saturated in my market. ARNPs own (lease?) machines in my area, and there are the corporate types of groups popping up, too. Enough saturation to not simply jump in to and will require a good analysis. I simply haven't had the volume of patients to justify my own machine. General adult med check psychiatry is my current trajectory.

If you plan to do a Neurostimulation practice you will need to do your homework if area is viable for ECT or not. And then you will need to figure out if the local hospitals even want to play ball with you... I had one hospital say nope from their medical director because they didn't want any independent third party competition, despite their lack of funds for the next few years to even get their own service going...

I may consider ECT again in the future if I learn about the outcome of 1-2 places I'm aware of that may be doing ECT in ASCs. If the private insurance companies truly will pay for ECT professional fee to Psychiatrist / Professional fee to Anesthesiologist / AND FACILITY fee to an ASC, then that is a game changer. I might consider running the bureacratic gauntlet in a 'Certificate of Need' state to open my own ASC in years to come, and having my own designated ECT suite - even though I won't be able to see any CMS patients there. ECT belongs in ASC, not hospitals.
 
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PRIVATE PRACTICE CHECK LIST GUIDE
  1. Chicken and egg stuff here. You need an address. Ideally an actual office, but if you are resident, consider using a UPS store and the suite boxes.
    1. You could actually find some office to sublease from, and ideally get to use the address before you actually get keys in hand and start seeing patients there months in advance. If you are a resident, reach out, network with people.
    2. If you have just left your job, and are doing this in haste, you can possibly pull of a 3 month turnaround, I'm witnessing a Sleep Doc do this in 90 days right now.
  2. Call a lawyer, Form business LLC or PLLC, Get Federal Tax ID number (EIN) and state business number/license. This will need the above address.
    1. Can you be cheap and do this online some how, yeah, but this is going to be your livelihood, go get your questions answered from an expert, pay the lawyer their money. I spent $800-1000 on this.
    2. The lawyer won't care or know anything more than getting you incorporated. Tax structure questions are for your accountant. C, or S, etc
    3. Try to choose your LLC/PLLC name well. You can always have a DBA (doing business as), but its good to choose well right from the start. I didn't...
    4. If you are going to mostly just be solo or only hire employees, save you money and don't bother with the extra cost of 'articles of incorporation.' Unless it is needed for your state. If you plan to have partners or other members with ownership stake in your corporation, then yes, you need those articles of incorporation.
    5. Be aware you may have an email listed on this formation as public knowledge. This document potentially is 'permanent' even if you update your biz details later in coming months years. Sooo, doing step 5 and 6 first be a better order? but then you just made your first payments for your website and Gsuite with personal money. But its easier to update website domain ownership in future to reflect business details and not personal, in coming weeks, compared to the business formation. So, yeah, doing 5 & 6 first might be best.
  3. Once in hand ~1-2 weeks later, Open up bank account and get printed like 2-6 free checks, you'll need these.
    1. Deposit a chunk of money. Depending on what you are doing, 5k at minimum on up to 30K, anything more than that, I hope you have a serious business plan or really know what you are doing?
  4. At a minimum get your Visa debit card that day… Really need this!
    1. Consider getting an actual Business Credit Card, too. Pros and cons to this. It will take another week or so to arrive.
  5. Buy your website domain. Use GoDaddy to locate a domain.
  6. Open a GSuite account and get your email set up so it has [email protected]
    1. Get a Google Voice Number to be your office number. You can always PORT this number away from Google to an actual phone company if needed later. Just get a phone number.
    2. If you don't want to figure out how to set up your domain, you will likely be able to get the website company you contract with to do it for you.
  7. Use SRFax to get a number. You can always PORT this number into your EMR later if it has built in fax or to another service.
  8. Find a small accountant operation. Or a solo accountant. Seriously, your business is not that complicated, and no you don't need the large Big Box Shop accounting firm to rob you of your money. The independent main street Gal will also answer all your ridiculous questions in a timely fashion, too. Go main street. And go meet them in person and get your questions answered. You may learn that until you are bringing in consistent bigger dollars, you won't really need any fancy accounting other than an extra addendum page on your personal taxes. They'll explain your options. Let your accountant know, they'll be happy, you are doing step 17.
  9. Log in to State Department of Revenue or Secretary of State, or Business Whatever Government Bureaucracy Flavor Agency you'll need to report to; to get a business license (and where you pay the state monthly taxes or quarterly taxes). Insert perfect Ron Swanson quote here.
  10. With EIN, mailing address, and PLLC/LLC information in hand, create a type 2 NPI number for your business
    1. Nppes.cms.hhs.gov/
  11. Update your NPI details for your new practice (current residents don't do this until 7/1/FREEDOM year)
  12. Update your DEA details (current residents don't do this until 7/1/FREEDOM year)
  13. if this is your main practice, whatever DEA you have now, you can actually change the state details on and 'port' it to your new location. Save yourself the money and don't get a new one.
  14. Update your details for the Rx PMP program your state has, or start the process to get it for whatever state you are going to.
  15. Update all your society and medical license addresses
  16. START UPDATING YOUR CAQH PROVIEW profile and information with
    1. Pecos.coms.hhs.gov/
    2. Nppes.cms.hhs.gov/
    3. Don't yet sign, or authenticate stuff yet. Just get started on it.
  17. Buy an annual quick books online subscription ~$300/year if paid in advance, link it to your bank account
    1. Send the email invite to your accountant so they can log in and see your numbers when they need to
  18. Target your clinic open date for 90 days from the start of step one above, if you plan to devote resident/moonlighting type hours towards getting this beast up and running. I.E. You will be busy every day, and overwhelmed with the sheer paper work of bureaucracy WTF. Just remember Freedom is your Prize.
  19. And pre-pay for your part time liability insurance to start on this date. I suggest using PRMS, and opt for their Part Time, Occurrence based. Seriously, don't be cheap, get occurrence based, don't do claims made.
  20. Pay/sign up for your EMR, and for Psychiatry or Child/adolescent Psychiatry it is hands down, LUMINELLO. No debates. Using their integrated ApexEDI billing feature and even their new Invoice Tracker. Dollar for Dollar, this is the MMA note fighter that will get you the championship belt.
  21. Go back into the PECOS, CAQH, NPPES, etc and update them again with your liability stuff, etc. Now you can probably ‘authenticate’ or ‘complete’ your applications/data.
  22. Start the process of filling out forms to get paneled with insurance companies. Use your shiny new email address. This part sucks.
    1. Keep an excel list and save all communications received from them. Depending on if you are only doing 1-2 or 10+ you will still feel a bureaucracy headache. I had paid people to do this in the past. I wish I hadn't. I'm helping a Sleep Doc get up and running, and this person took my advice and doing it 100% themselves. So much easier and no data mistakes. Wish I had saved myself the money and done it myself.
    2. You'll need a fee schedule. Come up with your fee schedule and all the CPT codes you plan or even think you'll bill for in the future. Some want this fee schedule, most don't care. But you'll need anyways for step 28.
  23. Start working on your logo for your website. Go to 99designs.com, and pay their $500-1000 or whatever it is to get a logo. Kind of a daunting process to figure out, but if you stick with it, and call the company when you got questions you'll be happy you did. But spend 2-3 days digging around the internet, and reflecting an thinking about What Do You Really Want - before you sign up. My logo is meh. The Sleep Doc I'm helping, took my advice and just WOW, got a quality logo, and one that reflects that doc. Really professional and amazing. At the end make sure you get the .AI, .JPG, .GIF, .SVG, .PNG files in light and dark forms of your logo +/- any clinic name text that coincides. They will also have options for things like letter head, business cards, etc.
  24. Use VistaPrint to use those logo images to create your own PDF to form your own business card, or use the ones created by 99designs. Order up 500 at a minimum. Also get maybe 500 of your letter head too. Treat yourself, get something cheesy too, maybe mugs, post it notes, pens, whatever.
  25. Open up some Word Documents. Start typing your website content. This part sucks. I know you want to procrastinate at this point, but don't flake out now, you've made it this far. Pretend you are back in a college humanities 101 class with barely a care in the world, or if you are an IMG, pretend you are entering the American undergrad experience and start typing. You need the meat, the stuff you plan to put on your website. Dig around other peoples sites for inspiration if you are having writers block.
    1. Save the websites, and make notes of the cool sites you come across that make you think 'wow I want that'
  26. Call a professional photographer. No, not Auntie Shruti or Uncle Nguyen, to come snap a photo of you by the shrubs in your front lawn. Go get an appointment and pay a pro to get your mug shot. Actually get yourself looking nice - definitely more than you've been doing during Covid-19. And a contract that you get full ownership of the images, and don't need to quote/reference them on any digital media they are used in...
  27. Reach out to a website firm. Google up your local main street options for website developers. There are so many website development options. But count on spending 2.5-4K just for the website. Talk with them about their SEO, and also ask them about their website maintenance/hosting packages ($50/60) a month. Review these contracts. You want something that is dual functional for ol' lappy and for the smart phones.
    1. Be like hey, I'm on top of this, I already content for you! They will be happy.
    2. Also be like hey, I came across 25.1 above, and these will help you with your creativity and creating something that is pleasing to me.
  28. Keep chipping away at the EMR to make it your own with note templates. Start creating your policies and privacy practice forms, etc. To get incorporated into your website and/or EMR.
    1. Start working on getting the E-prescribing activated with the EMR
    2. Start working on getting the lab integration, (low priority honestly) with the EMR
    3. Start working on getting the ApexEDI clearing house integrated with Luminello and as the Insurance contracts come thru, the ERA/EFT enrollments.
    4. Integrate with Doxy.Me for your telemedicine. You know, Covid-19, this thing going on that forced every one into telemedicine?
    5. Buy a webcam. Something. Don't over think it.
  29. Got an empty office? Look for the closest big city and see if they have a second hand office warehouse. Basically when other businesses go bankrupt, or upgrade, their stuff goes here. Even plants! Which, actually are expensive. Good prices, good products, and won't break the bank for getting the office filled with stuff.
    1. You also need a computer or lap top. Microsoft word/ppt/excell/etc package. A fujitsu scansnap ix500 scanner or whatever the current version is. OMG don't skimp here, get this. Antivirus software. A printer, I highly suggest Brother. Don't get color. Just cheap, basic black white 2 sided printer. It will be your Massey Ferguson tractor, and just keep on plowing. Remember to use your business debit (or credit card) to buy all this stuff.
    2. If you haven't, update your quickbooks for all these purchases. Get used to this new behavior. Stay on top of it.
    3. Don't forget to save every receipt. Dump it into your GSuite Google Drive for your business. Come up with a filing/organization system. I suggest folders of whatever label and using year, like 2020-07-12 Another Business Expense.PDF
  30. If you haven't realized it yet you need to store your logins and passwords some where, some how. They are piling up. Don't lose them.
 
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clozareal

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Chicken and egg stuff here. You need an address.Ideally an actual office, but if you are resident, consider using a UPS store and the suite boxes.

Any thoughts about using Traveling Mailbox for this? It's an actual address and not a PO box from the mailroom store.

Call a lawyer, Form business LLC or PLLC, Get Federal Tax ID number (EIN) and state business number/license. This will need the above address.

Would you recommend forming the business entity in the state that the practice is located in? Is it even legal to have an out of state LLC (presumably for better tax benefits)?

  1. Use SRFax to get a number. You can always PORT this number into your EMR later if it has built in fax or to another service.

Is paying for SRFax better than using the free Doximity fax service?

Reach out to a website firm. Google up your local main street options for website developers. There are so many website development options. But count on spending 2.5-4K just for the website. Talk with them about their SEO, and also ask them about their website maintenance/hosting packages ($50/60) a month. Review these contracts. You want something that is dual functional for ol' lappy and for the smart phones.

I've heard of people using SEO firms, such as SEO Tuners, but if there's an SEO service built into website firms, probably better to not have to do both.
 

liquidshadow22

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Quick question re: luminello. Does the site itself act as a lead generator and patients will come to request appointments from you directly through your profile?
 

TexasPhysician

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Keep in mind that Luminello is designed for a 1 person practice. If you plan to grow with 1+ additional counselor, psychiatrist, or whatever, Luminello is a terrible option.
 

Sushirolls

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Clozareal - I've stayed away from doximity for their free fax because I just didn't want to be on doximity. 500 pages, annual subscription for SRFax is like $110/year. Good, clean professional, funcitonal interface, and it allows accounts for future employees and you can set their access level too. Good call on the state specific nature of businesses, probably best to establish where the practice is going to be. I know nothing about traveling mailbox, might be a better option? SEO is truly wide, you might have nailed a better option too. SEO ongoing can be pricey for some places and is a monthly fee to capture the changing Google.

LiquidShadow - I wouldn't say Luminello is a lead generator. But its profile page could be a default website in a pinch until people get a more prnounced presence up and running. The luminello profile is an entry point, if people use this feature, for folks to request a consultation. I defnitely use this, and point all my prospective patients towards this entry point.

Texas - you are right, as of today Luminello doesn't have a group/clinic option and "terrible" is an appropriate adjective. So far every update they've done with features I've been pleased with. And they've been saying 'soon' a group/clinic feature will come out. When it does, I'm optimistic and really excited to see how this feature will role out. Just a matter of time.

In grand summary that check list is a guide, lots of truth in it, but it's definitely not the truth for starting a practice. But I remember before I got started there was a pittance of information I could easily find, so hopefully it helps someone.
 
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