Private Practice in Progress

[clausewitz2]

you call the patient during the appt time. I think patients should know how much of a nuisance the prior authorization process is and it does help when talking to the person on the other end of the line for them to know the patient is also in the room.

You probably also generate a lot of positive transference if they witness you fighting The Man on their behalf, I would guess.

---

Members don't see this ad.

 

[WisNeuro]

You probably also generate a lot of positive transference if they witness you fighting The Man on their behalf, I would guess.

Do your billing codes allow including time spent on admin tasks/calling insurance? Or are we talking about cash pay only here?

 

[TexasPhysician]

you call the patient during the appt time. I think patients should know how much of a nuisance the prior authorization process is and it does help when talking to the person on the other end of the line for them to know the patient is also in the room.

How is this process for you? Say you have a 30 minute appt slot. 20-25 minutes in to the appointment, you have chosen a new medication. You consent and eRx it. Are you getting the PA response immediately (I don’t)? So the patient goes home and 1-2 hours later the pharmacy tells you that a PA is needed. Instead of just doing the PA, you work the patient in to another appointment in the next 2 days? They sit in the room while you call the insurance company? I’ve sat on hold for 20 minutes before. So y’all sit and wait and then you answer the questions to get the med approved? The patient is likely bored and frustrated no?

Patients prefer this to your staff doing covermymeds or just checking some boxes on the form given to you by staff? I wouldn’t be exited about a PA fee, but I think I’d pay the $15 over another appointment for my doc to do this.

I’m not arguing that the PA process isnt horrible and a waste of valuable time. I’m just trying to understand your flow without alienating patients.

 

[clausewitz2]

How is this process for you? Say you have a 30 minute appt slot. 20-25 minutes in to the appointment, you have chosen a new medication. You consent and eRx it. Are you getting the PA response immediately (I don’t)? So the patient goes home and 1-2 hours later the pharmacy tells you that a PA is needed. Instead of just doing the PA, you work the patient in to another appointment in the next 2 days? They sit in the room while you call the insurance company? I’ve sat on hold for 20 minutes before. So y’all sit and wait and then you answer the questions to get the med approved? The patient is likely bored and frustrated no?

Patients prefer this to your staff doing covermymeds or just checking some boxes on the form given to you by staff? I wouldn’t be exited about a PA fee, but I think I’d pay the $15 over another appointment for my doc to do this.

I’m not arguing that the PA process isnt horrible and a waste of valuable time. I’m just trying to understand your flow without alienating patients.

I also have trouble seeing how this would work for me. When I am lucky I get a PA response back in 48 hours. The biggest insurers around here don't do PAs over the phone any more. I don't know how I could do this and also see other patients, honestly. I would also rather pay a nominal fee than come back for another appointment (which will trigger at least a copay anyway).

 

[clausewitz2]

Do your billing codes allow including time spent on admin tasks/calling insurance? Or are we talking about cash pay only here?

They will to some extent starting in January, actually.

 

[WisNeuro]

They will to some extent starting in January, actually.

It'll be interesting to see if 3rd party payers fall in line. I know for some of ours, additional documentation spells out that you cannot bill for things such as patient filling out forms, provider filling out forms, or time spent not face to face providing clinical services.

 

[clausewitz2]

It'll be interesting to see if 3rd party payers fall in line. I know for some of ours, additional documentation spells out that you cannot bill for things such as patient filling out forms, provider filling out forms, or time spent not face to face providing clinical services.

I mean, our E&M codes are being redefined to explicitly include time spent on a number of non face-to-face clinical services, so a categorical refusal means they just have to stop accepting basic CPT codes. I do kind of expect more pushback on whether some of those tasks were truly "necessary".

 

[Sushirolls]

@Sushirolls have you hit up local private practice therapists? Maybe search Psychology Today? That is where a majority of my referrals come from and they are thrilled to have someone to refer patients who are in need of med evaluation/management. In my area many of the clinics don't offer medication only and require the patient also receive therapy from their office due to a lack of prescribers.

My local area is the opposite, with less people/groups requiring everything in house and more are open to dual management with therapists. I may need to consider a year 2 anniversary refresh in mailing/spamming the local therapists about services.

 

[Sushirolls]

Is it poor taste to charge money for prior authorization, and excuse letters in a cash practice? What about med changes in between appointments without a visit?

I've got a fee associated with calls/letters/PA. I've so far only charged for a letter 2-3x. Prior auths, are rare in my practice and mostly from meds started by ARNPs that when patients come my way I have to do clean up for.

I often refer patients requesting med changes to schedule an appointment on interval contacts. Unless it was previously discussed and outlined they could message to do a change. I need to thoroughly go over a Risk Benefit discussions and that takes time. Not doing that by messaging.

 

[Sushirolls]

YEAR TWO, Q4​

SUBJECTIVE:
I never got around to doing the epic access stuff with the local Big Box shops. As of today, not planning on doing any follow up with that. Old school fax record requests, or phone calls, or having patient go get records is working well enough.

Got a letter that others on here got, pointed out level 3 and level 4 frequencies in relation to peer numbers. Went in trash.

Took another 1 week vacation, logistically went smooth. And another for the holiday season. Things seamed busier for a while with new consults, but was an artificial feeling as those two weeks of vacations and other routine holidays compressed the schedule down. This is reflected by the 2.8 weekly average of consults – no where near the ~3.7 of pre-covid.

From most of my insurance companies I received letters requesting records on specific patients and descriptions saying “these are not audits” but routine CMS mandated chart reviews for diagnosis accuracy … yeah right. These are ‘feeler’ audits as far as I’m concerned meant to trigger a deeper dive if they spot anything of interest. Its in this moment I am reminded why more Psychiatrists don’t take insurance. Its such a pain these behind the scenes paper work dealings.

I came into information that two of my payers that are less than medicare rates, are actually paying another, different specialty doc, who is also in private practice, far more than medicare rates. This person didn’t negotiate or even get fee schedules from these companies simply told ‘you get the usual.’ Frustrating how Psychiatry gets a different usual. Again, another point for the cash only Psychiatry crowd and pay parity is a joke. Once I can personally justify with my finances, I’m going to drop these 2 companies.

Came so very, very close to buying a building with overlap with Sleep Doc. I killed the deal. Sleep Doc displeased, but I am confident better options will present before 2021 is done.

One insurance company stopped doing a carve out for mental health and SUDs that went to another 3rd party insurance company to manage. I suspect this was a violation of parity, and they decided to change before getting caught. Not being paneled with the main insurance, I lost 4-6 patients from this insurance change, but 1-2 opted to pay cash instead. Which this gave me a sample to see how many folks would convert from insurance to cash if they had to. As of now, I suspect 40% conversion rate if this had to happen in the future for any reason.

OBJECTIVE:

Total Patients:	112
Insurance Payor Mix:	36 < Medicare	6 Medicare	70 > Medicare (62.5%)
Follow Ups:	210	16.2 (weekly mean)	range of 0-28 per week
Consults:	37	2.8 (weekly mean)	range of 0-7 per week
Weekly Clinical Hours:	10.9 (quarterly mean)
Blended Payer Mix:	Lazy, didn't calculate this Q4
Overhead Percentage:	58%
Days Off:	14

Profit and Loss by Month
October - December, 2020
	Oct 2020	Nov 2020	Dec 2020	Total
Gross Profit	$15,002.03	$12,331.61	$15,862.23	$ 43,195.87
Expenses
Accountant	0.00	195.00	0.00	195.00
Advertising & Marketing	88.95	88.95	29.95	207.85
Credit Card Processing Fees	95.23	127.01	101.52	323.76
Insurance	0.00	544.00	0.00	544.00
Medical Billing Services	65.48	65.00	65.00	195.48
Medical Society Membership Dues	560.00	0.00	0.00	560.00
Office Supplies & Software	25.85	25.85	1,405.01	1,456.71
Other Business Expenses	252.00	0.00	0.00	252.00
Payroll - Employee SEP-IRA	0.00	0.00	4,714.50	4,714.50
Payroll - Expenses	1,539.21	1,414.15	1,476.68	4,430.04
Payroll - Taxes	0.00	0.00	931.07	931.07
Promotional Meals	138.03	0.00	0.00	138.03
Rent & Lease	3,301.42	3,301.42	3,526.69	10,129.53
State Tax	0.00	0.00	567.63	567.63
Utilities	151.72	145.58	145.50	442.80
Total Expenses	$ 6,217.89	$ 5,906.96	$12,963.55	$ 25,088.40
Net Operating Income	$ 8,784.14	$ 6,424.65	$ 2,898.68	$ 18,107.47
Net Income	$ 8,784.14	$ 6,424.65	$ 2,898.68	$ 18,107.47

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. Never again policy is still enforce for Big Box shop employment. Have cruised job postings and day dreamed about certain locations, but the actual thought of picking up the phone and calling or even interviewing is almost nauseating.
2) Growth rate still low last quarter, and actually reflects a decline in total patients but when counting whose in/out its a bit imprecise and now that I'm posting this almost a month later, that number was likely wrong and probably 116-120 at the end of the quarter with a pinch of panel growth. My assistant and I have noted that we have a core group of solid patients and there's just simply turn over of newer patients who stop follow up for a myriad of reasons. Also had a lot more follow ups with higher acuity patients. Psychology today generated phone calls have slowed down.
3) Not yet time to drop Medicare, nor lower payor insurance until about 20 clinical hours per week achieved. Sublease with Sleep Doc is going well.
4) Still debating on buying a blood pressure cuff, defer until after Covid. Building an office is out - long story. But on hunt for office to purchase.
5) 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. Pay for this quarter will be ~$18.1K, and 20% of that will be put aside for SEP-IRA contribution, and then 20% of that 0.8 put aside for taxes, leaving ~$11.5K to pay personal bills.

 

[Sushirolls]

For 2021 I'm going to skip doing quarterly reports on SDN, and just do a year end report, so this thread might a bit more quiet.

 

[Sushirolls]

Jules you got any updates?

 

[FlowRate]

Any updated thoughts on why you're still not getting new patients very quickly? How often are you seeing most non-acute people back?

 

[Sushirolls]

Any updated thoughts on why you're still not getting new patients very quickly? How often are you seeing most non-acute people back?

There definitely is an uptick since December in calls and inquiries. Assistant relates to being much busier. I'm hopeful to see that trending up in this Year three Q1. I believe my status of not taking on new medicare, being anti benzo, and a saturated market with heavy Big Box shop presence are all factors. Natropaths here also treat mental health.

Positively I have some good consistent referral sources even from the Big Box Shops, and therapists. Getting more word of mouth referrals too.

I let my stable patients pick their follow up from as soon as 4 weeks to at longest 12 weeks. Some want more frequent 6-8, others want the longest 12 week interval.

Telling patients cannabis is bad, doesn't go over well for a lot of people. Some never return after the initial consult, others wait a few visits and when not getting the quick fix results, and not liking to hear the no cannabis encouragement they venture elsewhere. Being in a legal cannabis state is a pain.

There is one Psychiatrist in the area doing cash only, but this person I've seen pop up on notes from a local a for profit psych hospital doing weekend calls/rounding, and has an 'in' with the handful of DPC practices in the area - but I interpret the weekend rounding to reflect not having a robust cash practice. As the only truly cash person in this little area, I would have thought this person to have filled by now. This just adds fuel to the saturated market locally. I also see a lot of the ARNP practices also posting Google Ads locally so I suspect they too are having some lower volumes.

 

[dl2dp2]

Looks like your quarterly growth is pretty healthy despite COVID.

 

[calvnandhobbs68]

There definitely is an uptick since December in calls and inquiries. Assistant relates to being much busier. I'm hopeful to see that trending up in this Year three Q1. I believe my status of not taking on new medicare, being anti benzo, and a saturated market with heavy Big Box shop presence are all factors. Natropaths here also treat mental health.

Positively I have some good consistent referral sources even from the Big Box Shops, and therapists. Getting more word of mouth referrals too.

I let my stable patients pick their follow up from as soon as 4 weeks to at longest 12 weeks. Some want more frequent 6-8, others want the longest 12 week interval.

Telling patients cannabis is bad, doesn't go over well for a lot of people. Some never return after the initial consult, others wait a few visits and when not getting the quick fix results, and not liking to hear the no cannabis encouragement they venture elsewhere. Being in a legal cannabis state is a pain.

There is one Psychiatrist in the area doing cash only, but this person I've seen pop up on notes from a local a for profit psych hospital doing weekend calls/rounding, and has an 'in' with the handful of DPC practices in the area - but I interpret the weekend rounding to reflect not having a robust cash practice. As the only truly cash person in this little area, I would have thought this person to have filled by now. This just adds fuel to the saturated market locally. I also see a lot of the ARNP practices also posting Google Ads locally so I suspect they too are having some lower volumes.

Haha okay are you perhaps in Washington or Oregon? This combo of naturopaths "treating mental health", NP independent state and people loving weed just sounds like one of those states....

 

[FlowRate]

Being in a legal cannabis state is a pain.

I can empathize. Probably 75% chance that any patient I see between ages 18 and 70 is using marijuana at least once a week.

 

[AD04]

Are you doing only medication management or do you do psychotherapy as well? If only the former, I encourage you to add psychotherapy as you'll have better rapport which helps with retention and increases frequency of visits and you're able to increase revenue and profit.

 

[clausewitz2]

@Sushirolls encouraged me to do this ages ago and so I figured I could post a different private practice experience with some numbers.

Working 1099 with a specialized therapy group run by a psychologist with mostly mid-level therapists under him. I'm on their website, get referrals from them when their clients want meds as well. Their receptionist/admin person does my billing and schedules intakes, I schedule my own follow-ups. In principle they also provide office space but with COVID that has obviously been hypothetical. Currently on a 70/30 split agreed to back when I thought I'd be going to an office, but that will likely need renegotiated. Initially started out taking two commercial insurances, dropped one in December. Current mix is probably 75% insurance, 25% self-pay. Pretty much all appointments with a couple of exceptions are medications + psychotherapy in 30 minute slots, with the exception of 5-ish patients at any one time that I see for more traditional 55 minute therapy + meds. Intakes are 60 minutes but I usually try to make sure I have a cushion if it goes over. I have done literally nothing in terms of marketing myself.

I do this 3 days a week, 8-4, giving myself a half hour lunch break, last apptmt of the day is 3:30. I do charge a full-freight no-show fee ($185 for 30 minute appointments, $300 for 60 minute appointments) and a late cancellation fee ($150 if less than 24 hours notice). My no-show rate is maybe 5%. I have access to medical records of biggest local health system and so reviewing notes and lab results is pretty easy, which helps with documenting based on MDM. I also put in 8 hours a week as 1099 at a general CMHC clinic and 6 hours a week in a grant-funded hyper-specialized program (hoping to get more hours at the later due to recent developments). $150 an hour for the general clinic and $180 an hour for the grant clinic. The grant clinic especially has been great when I wasn't super full because they had me do some trainings that they paid me the same rate for.

I probably end up spending 60-90 minutes per PP day doing notes, documentation, calling collateral etc. I do end up doing some prior auths, maybe 2-3 per week, but quite honestly they don't take more than 10 minutes a piece because the one insurer I have has a functional online portal. I have an account with Quest for lab orders although still have to use doximity fax to send scans of orders for things like sleep studies to patients, which is kind of annoying for everyone involved. I do order stimulants when clinically indicated and do not burn with the hate of a thousand suns towards Z-drugs like some people on this board but benzo scripts I write are almost 100% part of a taper.

In terms of revenues, it looks like this (post-split):

Month 1: 622.30 (wasn't credentialed with main payer yet)
Month 2: 2274.98
Month 3: 8941.82
month 4: 10956.97
Month 5: 13787.06

Malpractice with tail covering me for here and grant clinic is about 3K per year. Health insurance for me + dependents is ~800 a month. Life insurance + disability insurance = ~300 a month. I am currently using Luminello for free because of an offer I've discussed on this board before. I am paid through an LLC so had some legal start up costs but have more than made up for that with deductions so far at tax time due to pass-through. Have already talked to owner about an 80/20 split when contract is up for renewal in the summer and he seems open. If he goes for it I probably drop my general CMHC clinic job and put in another day or half-day in PP.

EDIT: my one hesitation about dropping general CMHC job is that it gives me a toehold in Major Health System, and having an internal email address has been super helpful in discussing a few mutual cases with other docs/therapists which is now also super helpful for billing purposes. I am volunteer faculty and do some didactics teaching but I am not sure that will be enough to let me keep the email. I am going to see if there are any even more part-time roles I could have in the system that would still let me keep that access (also the sweet free UptoDate/journal subscriptions are pretty nice).

 

[dl2dp2]

Month 1: 622.30 (wasn't credentialed with main payer yet)
Month 2: 2274.98
Month 3: 8941.82
month 4: 10956.97
Month 5: 13787.06

You are growing nicely, and I don't mean just revenue. The knowledge-base speaks for itself.

 

[Techmed07]

@Sushirolls encouraged me to do this ages ago and so I figured I could post a different private practice experience with some numbers.

Working 1099 with a specialized therapy group run by a psychologist with mostly mid-level therapists under him. I'm on their website, get referrals from them when their clients want meds as well. Their receptionist/admin person does my billing and schedules intakes, I schedule my own follow-ups. In principle they also provide office space but with COVID that has obviously been hypothetical. Currently on a 70/30 split agreed to back when I thought I'd be going to an office, but that will likely need renegotiated. Initially started out taking two commercial insurances, dropped one in December. Current mix is probably 75% insurance, 25% self-pay. Pretty much all appointments with a couple of exceptions are medications + psychotherapy in 30 minute slots, with the exception of 5-ish patients at any one time that I see for more traditional 55 minute therapy + meds. Intakes are 60 minutes but I usually try to make sure I have a cushion if it goes over. I have done literally nothing in terms of marketing myself.

I do this 3 days a week, 8-4, giving myself a half hour lunch break, last apptmt of the day is 3:30. I do charge a full-freight no-show fee ($185 for 30 minute appointments, $300 for 60 minute appointments) and a late cancellation fee ($150 if less than 24 hours notice). My no-show rate is maybe 5%. I have access to medical records of biggest local health system and so reviewing notes and lab results is pretty easy, which helps with documenting based on MDM. I also put in 8 hours a week as 1099 at a general CMHC clinic and 6 hours a week in a grant-funded hyper-specialized program (hoping to get more hours at the later due to recent developments). $150 an hour for the general clinic and $180 an hour for the grant clinic. The grant clinic especially has been great when I wasn't super full because they had me do some trainings that they paid me the same rate for.

I probably end up spending 60-90 minutes per PP day doing notes, documentation, calling collateral etc. I do end up doing some prior auths, maybe 2-3 per week, but quite honestly they don't take more than 10 minutes a piece because the one insurer I have has a functional online portal. I have an account with Quest for lab orders although still have to use doximity fax to send scans of orders for things like sleep studies to patients, which is kind of annoying for everyone involved. I do order stimulants when clinically indicated and do not burn with the hate of a thousand suns towards Z-drugs like some people on this board but benzo scripts I write are almost 100% part of a taper.

In terms of revenues, it looks like this (post-split):

Month 1: 622.30 (wasn't credentialed with main payer yet)
Month 2: 2274.98
Month 3: 8941.82
month 4: 10956.97
Month 5: 13787.06

Malpractice with tail covering me for here and grant clinic is about 3K per year. Health insurance for me + dependents is ~800 a month. Life insurance + disability insurance = ~300 a month. I am currently using Luminello for free because of an offer I've discussed on this board before. I am paid through an LLC so had some legal start up costs but have more than made up for that with deductions so far at tax time due to pass-through. Have already talked to owner about an 80/20 split when contract is up for renewal in the summer and he seems open. If he goes for it I probably drop my general CMHC clinic job and put in another day or half-day in PP.

EDIT: my one hesitation about dropping general CMHC job is that it gives me a toehold in Major Health System, and having an internal email address has been super helpful in discussing a few mutual cases with other docs/therapists which is now also super helpful for billing purposes. I am volunteer faculty and do some didactics teaching but I am not sure that will be enough to let me keep the email. I am going to see if there are any even more part-time roles I could have in the system that would still let me keep that access (also the sweet free UptoDate/journal subscriptions are pretty nice).

How did you get around the corporate of medicine ethics issues? I thought fee splitting was illegal.

 

[splik]

How did you get around the corporate of medicine ethics issues? I thought fee splitting was illegal.

fee splitting is not illegal in the US (it is in many other countries) unless it is a kickback and that is only for medicare patients. It is generally considered unethical but it is also pretty standard set up and I think most people would disagree that is prima facie unethical though it could be depending on the set up. However I do not see anything unethical about a set up where you a contracted to provide a service to someone else who is doing your advertising, billing, scheduling, and providing office space etc.

 

[calvnandhobbs68]

How did you get around the corporate of medicine ethics issues? I thought fee splitting was illegal.

1) Anti-kickback laws only apply for Medicare/Medicaid patients (unless very specific instances for private insurance)
2) Anti-kickback laws also have an exception for a direct employer-employee relationship (although you could argue how much a 1099 is an employee)

 

[clausewitz2]

fee splitting is not illegal in the US (it is in many other countries) unless it is a kickback and that is only for medicare patients. It is generally considered unethical but it is also pretty standard set up and I think most people would disagree that is prima facie unethical though it could be depending on the set up. However I do not see anything unethical about a set up where you a contracted to provide a service to someone else who is doing your advertising, billing, scheduling, and providing office space etc.

In this case I would argue it is ethically equivalent to me billing insurance for services I provide and then paying the other entity in question for the services they are providing for me. The main difference is the number of steps involved in moving money around. It doesn't provide any incentives for me apart from seeing more patients and any incentives for them apart from facilitating me seeing more patients. I struggle to see the moral quandry.

 

[Sushirolls]

Clausewitz, That's awesome! Good stuff you posted and definitely can show the residents and others how different a practice start up can go. Hope you keep adding to this thread in months to come.

Curiosity, with your last month, how full was your schedule? So out of 24 potential clinical hours, are you at 8 or 20 hours?

 

[clausewitz2]

One bitter lesson for PP: if you're going to have a no-show fee, don't schedule people without a CC on file. Just don't.

 

[Sushirolls]

Are you doing only medication management or do you do psychotherapy as well? If only the former, I encourage you to add psychotherapy as you'll have better rapport which helps with retention and increases frequency of visits and you're able to increase revenue and profit.

Absolutely right.

I mostly am a med management with pinch of supportive therapy. Pre-Covid I'd do hypnotherapy for a few patients, as that is more my orientation / training strength, but even at that, not something I'm seeking to do every day.

 

[throw-away-go-away]

Absolutely right.

I mostly am a med management with pinch of supportive therapy. Pre-Covid I'd do hypnotherapy for a few patients, as that is more my orientation / training strength, but even at that, not something I'm seeking to do every day.

how/where do you get great training in Hypnotherapy?
I have no training in hypnotherapy

 

[Sushirolls]

how/where do you get great training in Hypnotherapy?
I have no training in hypnotherapy

ASCH | American Society of Clinical Hypnosis

www.asch.net

 

[Stagg737]

3) Not yet time to drop Medicare, nor lower payor insurance until about 20 clinical hours per week achieved. Sublease with Sleep Doc is going well.

Maybe I missed it, but how much do you get from the sub-lease? Or did you just subtract that out from your cost in rent?

I can empathize. Probably 75% chance that any patient I see between ages 18 and 70 is using marijuana at least once a week.

Same, as soon as I start asking about substances more than a few of my patients start talking about getting their medical marijuana card.

my one hesitation about dropping general CMHC job is that it gives me a toehold in Major Health System, and having an internal email address has been super helpful in discussing a few mutual cases with other docs/therapists which is now also super helpful for billing purposes. I am volunteer faculty and do some didactics teaching but I am not sure that will be enough to let me keep the email. I am going to see if there are any even more part-time roles I could have in the system that would still let me keep that access (also the sweet free UptoDate/journal subscriptions are pretty nice).

Any chance of sticking with the CMHC and working 1-2 days per month or acting as coverage if someone takes a vacation?

One bitter lesson for PP: if you're going to have a no-show fee, don't schedule people without a CC on file. Just don't.

I thought CC meant chief complaint at first and was going to ask you what diagnoses to avoid. Clearly I'm still a resident, lol.

 

[Sushirolls]

Sublease is $1650, and that gets added as income. 'Top line'

Can't put sublease income on bottom line as a deduction to my existing rent. Wanted to, but that's now how the IRS sees it.

 

[Jules A]

Hi, Happy New Year!
Here is a rough draft of what my year looked like before taxes. I bill $300 hour. I believe the current availability of psychiatrists and NPs offering telemedicine now who take insurance has had an impact on my growth. When I opened in 2019 many of my clients weren't inclined to pay cash but couldn't get in with someone accepting their insurance in this area. My goal remains to grow to about 6h a week. Inpatient work which has been especially plentiful this year is my real love. I bill $300 an hour so after expenses and the minimal admin time I'm putting in I'd estimate my gross to be around $200 an hour.

Rent	$2,100​
Credit Card Fees	$929​
EMR	$1,584​
Misc	$1,000​
Total:	$5,613​
Gross:	$24,900​
Net:	$19,287​

 

[futuredo32]

how is your billing so low?

 

[clausewitz2]

how is your billing so low?

Working less than 6 hours per week'll do that.

 

[Sushirolls]

	Total​
	Jan - Dec 2020​	% of Income​
Total Income	$ 157,290.53 ​	100.00%​
Gross Profit	$ 157,290.53 ​	100.00%​
Expenses
Accountant	710.00​	0.45%​
Advertising & Marketing	1,101.03​	0.70%​
Bank Charges & Fees	0.00​	0.00%​
Board Certification Fees	350.00​	0.22%​
Continuing Medical Education	1,408.12​	0.90%​
Credit Card Processing Fees	1,316.15​	0.84%​
Insurance	3,031.00​	1.93%​
Legal & Professional Services	600.00​	0.38%​
Medical Billing Services	3,651.64​	2.32%​
Medical Society Membership Dues	765.00​	0.49%​
Office Supplies & Software	3,286.87​	2.09%​
Other Business Expenses	378.00​	0.24%​
Payroll - Employee SEP-IRA	4,714.50​	3.00%​
Payroll - Expenses	17,277.64​	10.98%​
Payroll - Taxes	3,509.49​	2.23%​
Promotional Meals	401.64​	0.26%​
Rent & Lease	40,023.64​	25.45%​
Repairs & Maintenance	27.10​	0.02%​
State Tax	2,279.04​	1.45%​
State Medical License	443.50​	0.28%​
Taxes & Licenses	941.00​	0.60%​
Utilities	1,617.02​	1.03%​
Total Expenses	$ 87,832.38 ​	55.84%​
Net Operating Income	$ 69,458.15 ​	44.16%​

 

[Sushirolls]

2020 Stats (Year Two):

24.5 days vacation for the year - fell short of my goal for 6 weeks. Need to fix that.
137 consults
727 follow ups
9.6 clinical hours per week on average
2.6 consults per week on average
14.0 follow ups per week on average

Still glad to not be a part of a Big Box Shop - PRICELESS.

 

[FlowRate]

Hoping you get some patient flow--if you bill/work 30 clinical hours at those rates that leaves you netting ~300k per year with a reasonable schedule.

 

[Attending1985]

2020 Stats (Year Two):

24.5 days vacation for the year - fell short of my goal for 6 weeks. Need to fix that.
137 consults
727 follow ups
9.6 clinical hours per week on average
2.6 consults per week on average
14.0 follow ups per week on average

Still glad to not be a part of a Big Box Shop - PRICELESS.

Do you do therapy and meds or just meds?

 

[Sushirolls]

Do you do therapy and meds or just meds?

Heavy on the meds, some supportive, pinch of hypnotherapy with a handful of patients during non-covid times.

 

[PikminOC]

2020 Stats (Year Two):

24.5 days vacation for the year - fell short of my goal for 6 weeks. Need to fix that.
137 consults
727 follow ups
9.6 clinical hours per week on average
2.6 consults per week on average
14.0 follow ups per week on average

Still glad to not be a part of a Big Box Shop - PRICELESS.

So youre only working 10 hours a week? What do you do for the rest of the time?

 

[Sushirolls]

I'm working a solid 40 hours for sure. I chart, and am an over documenter, send messages to patients, refills, payroll. Prep documents for taxes. Basically I'm the office manager; process stats for the practice. Search online for possible office to purchase / move to. Help with questions for Sleep Doc. And as already evidenced, spend too much time on SDN. But over documenting is the biggest time suck. Bathroom breaks. Snacks. Trouble shoot tricky issues with assistant. Adjust/develop things like business cards and then order them for practice. Supply purchases as needed for the practice. Saving / storing receipts for the practice in case of any IRS audits. Reviewing the sea of insurance letters and contract addendums. Draft marketing like letters to be mailed out, that assistant then executes. Read up on CME like stuff when tricky things present. CME. Check compliance with Board certifications. Read emails on Covid 19 vaccine roll outs in state, or emails for labor laws and medical offices with Covid. Review DEA delays on rules due to Covid. Staying on top of patient list with assistant for who needs letters to be exited from the practice. Even a quick nap once in awhile. Talk with neighbor tenants to learn the building gossip and nuances of lease contracts. Dealing with bank account/card fraud - this one has happened twice now. Helping assistant troubleshoot claim denials or odd processing, but doing much less now as she is excellent at this. Prep all the finance documents need for a bank to authorize business loan for a building purchase - earlier in year reviewing loan/construction side of things which not planning on doing at this time point. Then there was the SBA PPP and EIDL loans, filing for that, and then filing for the loan forgiveness and even talking with the servicer on nuances. Researching PCP offices, calling them, keeping track of whom I've called, and ordering catering for their office, picking up the food and then meeting with them - did that 2-4x in 2020. Texting friends/family/work colleagues. Scheduling family type appointments, dentists, dr appointments, vehicle repairs, etc. Reviewing business optimization decisions, like when to switch over land line phones to Google voice, and how existing utility contract will respond, how many portings can google voice do, which service level with google do I need, how to integrate that into the infrastructure of the office, how will it impact work flow for assistant. Open and process the daily mail - deposit the few paper checks that still come as not 100% EFT.

And one of my least favorite, figuring out the Cluster Fun of faxes and pharmacy requests and when they dropped their ball or if their ridiculous auto refill requests are running rampant etc. As patient refills - or lack of them - can be a source of patient satisfaction.

 

[kopftonmd]

I'm working a solid 40 hours for sure. I chart, and am an over documenter, send messages to patients, refills, payroll. Prep documents for taxes. Basically I'm the office manager; process stats for the practice. Search online for possible office to purchase / move to. Help with questions for Sleep Doc. And as already evidenced, spend too much time on SDN. But over documenting is the biggest time suck. Bathroom breaks. Snacks. Trouble shoot tricky issues with assistant. Adjust/develop things like business cards and then order them for practice. Supply purchases as needed for the practice. Saving / storing receipts for the practice in case of any IRS audits. Reviewing the sea of insurance letters and contract addendums. Draft marketing like letters to be mailed out, that assistant then executes. Read up on CME like stuff when tricky things present. CME. Check compliance with Board certifications. Read emails on Covid 19 vaccine roll outs in state, or emails for labor laws and medical offices with Covid. Review DEA delays on rules due to Covid. Staying on top of patient list with assistant for who needs letters to be exited from the practice. Even a quick nap once in awhile. Talk with neighbor tenants to learn the building gossip and nuances of lease contracts. Dealing with bank account/card fraud - this one has happened twice now. Helping assistant troubleshoot claim denials or odd processing, but doing much less now as she is excellent at this. Prep all the finance documents need for a bank to authorize business loan for a building purchase - earlier in year reviewing loan/construction side of things which not planning on doing at this time point. Then there was the SBA PPP and EIDL loans, filing for that, and then filing for the loan forgiveness and even talking with the servicer on nuances. Researching PCP offices, calling them, keeping track of whom I've called, and ordering catering for their office, picking up the food and then meeting with them - did that 2-4x in 2020. Texting friends/family/work colleagues. Scheduling family type appointments, dentists, dr appointments, vehicle repairs, etc. Reviewing business optimization decisions, like when to switch over land line phones to Google voice, and how existing utility contract will respond, how many portings can google voice do, which service level with google do I need, how to integrate that into the infrastructure of the office, how will it impact work flow for assistant. Open and process the daily mail - deposit the few paper checks that still come as not 100% EFT.

And one of my least favorite, figuring out the Cluster Fun of faxes and pharmacy requests and when they dropped their ball or if their ridiculous auto refill requests are running rampant etc. As patient refills - or lack of them - can be a source of patient satisfaction.

My favorites were definitely the naps and building gossip. Hope to get there someday.

 

[Bartelby]

As your volume picks up (which seems very likely in the medium to long-term) do you think that will mean you have to work well over 40 hours? Or do you see yourself mastering these tasks/details such that as your clinical time goes up you can still hold to a 40-hour week? It seems like with the current numbers you might have a lot on your plate to get up to the take-home equivalent of a $250k/yr + benefits salaried job (which I think is pretty average these days).

 

[clausewitz2]

I'm working a solid 40 hours for sure. I chart, and am an over documenter, send messages to patients, refills, payroll. Prep documents for taxes. Basically I'm the office manager; process stats for the practice. Search online for possible office to purchase / move to. Help with questions for Sleep Doc. And as already evidenced, spend too much time on SDN. But over documenting is the biggest time suck. Bathroom breaks. Snacks. Trouble shoot tricky issues with assistant. Adjust/develop things like business cards and then order them for practice. Supply purchases as needed for the practice. Saving / storing receipts for the practice in case of any IRS audits. Reviewing the sea of insurance letters and contract addendums. Draft marketing like letters to be mailed out, that assistant then executes. Read up on CME like stuff when tricky things present. CME. Check compliance with Board certifications. Read emails on Covid 19 vaccine roll outs in state, or emails for labor laws and medical offices with Covid. Review DEA delays on rules due to Covid. Staying on top of patient list with assistant for who needs letters to be exited from the practice. Even a quick nap once in awhile. Talk with neighbor tenants to learn the building gossip and nuances of lease contracts. Dealing with bank account/card fraud - this one has happened twice now. Helping assistant troubleshoot claim denials or odd processing, but doing much less now as she is excellent at this. Prep all the finance documents need for a bank to authorize business loan for a building purchase - earlier in year reviewing loan/construction side of things which not planning on doing at this time point. Then there was the SBA PPP and EIDL loans, filing for that, and then filing for the loan forgiveness and even talking with the servicer on nuances. Researching PCP offices, calling them, keeping track of whom I've called, and ordering catering for their office, picking up the food and then meeting with them - did that 2-4x in 2020. Texting friends/family/work colleagues. Scheduling family type appointments, dentists, dr appointments, vehicle repairs, etc. Reviewing business optimization decisions, like when to switch over land line phones to Google voice, and how existing utility contract will respond, how many portings can google voice do, which service level with google do I need, how to integrate that into the infrastructure of the office, how will it impact work flow for assistant. Open and process the daily mail - deposit the few paper checks that still come as not 100% EFT.

It seems like you might be better off taking fewer insurances. If you are literally spending 3 times as much on admin stuff as on clinical hours something is going badly wrong and this is going to hobble you no matter how big your panel grows.

And one of my least favorite, figuring out the Cluster Fun of faxes and pharmacy requests and when they dropped their ball or if their ridiculous auto refill requests are running rampant etc. As patient refills - or lack of them - can be a source of patient satisfaction.

I always write my scripts with the intention that they will not be due for renewal until on or after the day I plan to see the patient next; that way it's pretty easy to remember whose scripts i have to refill (who did I see today?) If rescheduling means that doesn't work out, I make it clear it is on them to contact me for refills because ain't nobody got time for that mountain of auto-generated fax nonsense. If you are insisting folks have the ability to do on-line scheduling anyway it seems like requiring them to shoot you a message through luminello when they want meds filled is a reasonable expectation.

I have to call my medical specialist for refills on medications, or at least use an app to request one. None of my patients have had a problem with this (well, one did, but mostly did not accept that I was not going to write 90 days of controlled substances routinely for someone I had just met).

 

[Sushirolls]

I see myself spending the same time I currently am as things progress with greater clinical hours. Time requirements for new intakes is substantial, but as the patient panel increases in stable patient numbers, they have less paperwork/admin to process. Goal is still 30 clinical hours and no more. Goal is to drop the lower paying insurance in coming year or two.

I have been targeting the refills to next appointment, but not a 100% full proof management. I have unofficially been having patients message me on luminello for refill issues, but plan to make it more official in the future. Still have a handful of patients that re-iterate multiple times to message me and then they don't and then they go several days/weeks with no prescription and wonder why the pharmacy refill request was denied. Definitely room to improve the work flow there.

 

[clausewitz2]

I have been targeting the refills to next appointment, but not a 100% full proof management. I have unofficially been having patients message me on luminello for refill issues, but plan to make it more official in the future. Still have a handful of patients that re-iterate multiple times to message me and then they don't and then they go several days/weeks with no prescription and wonder why the pharmacy refill request was denied. Definitely room to improve the work flow there.

If they are not able to use a free and easy electronic messaging system to ask for a refill despite being told to do this multiple time and/or can't keep track of when they are low on the medications they take regularly, I feel like you gotta ask: are they really functioning at a high enough level for outpatient? And if someone else is responsible for keeping track of their meds, do they really have adequate supports for you to handle their case all by your lonesome?

 

[Sushirolls]

These people are definitely functional. Its forgetful and grumpy.

 

[clausewitz2]

These people are definitely functional. Its forgetful and grumpy.

If it's not beyond their capabilities or an undue burden (clearly isn't for most of your patients), seems like running out of medications is a reasonable natural consequence of not requesting a refill.

 

[Stagg737]

If they are not able to use a free and easy electronic messaging system to ask for a refill despite being told to do this multiple time and/or can't keep track of when they are low on the medications they take regularly, I feel like you gotta ask: are they really functioning at a high enough level for outpatient? And if someone else is responsible for keeping track of their meds, do they really have adequate supports for you to handle their case all by your lonesome?

Eh, I've inherited quite a few patients who run out of meds and then just don't ask for a refill. Sometimes because they have an appointment in a week, sometimes they forget, sometimes they just have crappy insight into how much the med actually works. I actually give my patients enough refills to get to the next appointment +1 refill in case they need to reschedule or they accidentally miss. Exceptions being patients whose insurance requires 90-day refills and I'm still adjusting meds or controlled substances. I started doing this around September and it's made my inbox a lot more manageable for the last month or so.

 

[Stagg737]

	Total​
	Jan - Dec 2020​	% of Income​
Total Income	$ 157,290.53 ​	100.00%​
Gross Profit	$ 157,290.53 ​	100.00%​
Expenses
Accountant	710.00​	0.45%​
Advertising & Marketing	1,101.03​	0.70%​
Bank Charges & Fees	0.00​	0.00%​
Board Certification Fees	350.00​	0.22%​
Continuing Medical Education	1,408.12​	0.90%​
Credit Card Processing Fees	1,316.15​	0.84%​
Insurance	3,031.00​	1.93%​
Legal & Professional Services	600.00​	0.38%​
Medical Billing Services	3,651.64​	2.32%​
Medical Society Membership Dues	765.00​	0.49%​
Office Supplies & Software	3,286.87​	2.09%​
Other Business Expenses	378.00​	0.24%​
Payroll - Employee SEP-IRA	4,714.50​	3.00%​
Payroll - Expenses	17,277.64​	10.98%​
Payroll - Taxes	3,509.49​	2.23%​
Promotional Meals	401.64​	0.26%​
Rent & Lease	40,023.64​	25.45%​
Repairs & Maintenance	27.10​	0.02%​
State Tax	2,279.04​	1.45%​
State Medical License	443.50​	0.28%​
Taxes & Licenses	941.00​	0.60%​
Utilities	1,617.02​	1.03%​
Total Expenses	$ 87,832.38 ​	55.84%​
Net Operating Income	$ 69,458.15 ​	44.16%​

Congrats on the growth and thank you for sharing! Seeing the quarterly numbers are sometimes discouraging, but looking at the whole year seems much more optimistic in terms of take-home and growth. Seems like rent/lease is kind of killer for a small/1-person practice. Any new plans for moving to a cheaper space or buying an office?

I'm working a solid 40 hours for sure. I chart, and am an over documenter, send messages to patients, refills, payroll. Prep documents for taxes. Basically I'm the office manager; process stats for the practice. Search online for possible office to purchase / move to. Help with questions for Sleep Doc. And as already evidenced, spend too much time on SDN. But over documenting is the biggest time suck. Bathroom breaks. Snacks. Trouble shoot tricky issues with assistant. Adjust/develop things like business cards and then order them for practice. Supply purchases as needed for the practice. Saving / storing receipts for the practice in case of any IRS audits. Reviewing the sea of insurance letters and contract addendums. Draft marketing like letters to be mailed out, that assistant then executes. Read up on CME like stuff when tricky things present. CME. Check compliance with Board certifications. Read emails on Covid 19 vaccine roll outs in state, or emails for labor laws and medical offices with Covid. Review DEA delays on rules due to Covid. Staying on top of patient list with assistant for who needs letters to be exited from the practice. Even a quick nap once in awhile. Talk with neighbor tenants to learn the building gossip and nuances of lease contracts. Dealing with bank account/card fraud - this one has happened twice now. Helping assistant troubleshoot claim denials or odd processing, but doing much less now as she is excellent at this. Prep all the finance documents need for a bank to authorize business loan for a building purchase - earlier in year reviewing loan/construction side of things which not planning on doing at this time point. Then there was the SBA PPP and EIDL loans, filing for that, and then filing for the loan forgiveness and even talking with the servicer on nuances. Researching PCP offices, calling them, keeping track of whom I've called, and ordering catering for their office, picking up the food and then meeting with them - did that 2-4x in 2020. Texting friends/family/work colleagues. Scheduling family type appointments, dentists, dr appointments, vehicle repairs, etc. Reviewing business optimization decisions, like when to switch over land line phones to Google voice, and how existing utility contract will respond, how many portings can google voice do, which service level with google do I need, how to integrate that into the infrastructure of the office, how will it impact work flow for assistant. Open and process the daily mail - deposit the few paper checks that still come as not 100% EFT.

And one of my least favorite, figuring out the Cluster Fun of faxes and pharmacy requests and when they dropped their ball or if their ridiculous auto refill requests are running rampant etc. As patient refills - or lack of them - can be a source of patient satisfaction.

Aaaaaaaand this is discouraging again, lol. I do realize building a practice from the ground requires a lot of admin work, but 25+ hours per week towards the end of the second year sounds awful. It's probably not as bad as it sounds as your post seems very comprehensive and maybe during/after 4th year I'll feel different, but that much time on admin for an outpatient practice would not be something I think I could maintain. Thank you again for this thread though, it really is an awesome resource and I've learned a ton about the non-clinical aspects of outpatient psych. Hope things keep growing and improving and that you're enjoying the freedom from the big boxes!