Private practice advice needed

[minimooshie]

Hi everyone,

I am a psychiatrist who moved out to southern CA after residency. Loving my life...EXCEPT my job. The work of being a psychiatrist is wonderful and I have no regrets in choosing my specialty, but this specific job is destroying my soul and taking too much of my income.

3 years into attendinghood and I'm finally on SDN. Main reason being - I need some serious advice.

I'm starting a business while transitioning out of a corporate job. I've gleaned a ton of great advice from some colleagues and from threads on here, so thank you all for already contributing to my project greatly. I will continue reading in case these questions are explained elsewhere and I welcome direction to those threads from others.

My business will just be me - offering psych evals, psychotherapy, and med check type appointments. Timeline is to put in my mandatory 60 day notice 11/1 for end of work 12/31, start seeing patients privately in Jan. 2025.

Biggest questions I have right now:

1. How do I keep as many patients as possible, moving from this job into my business?
-I have a ton of patients who love working with me, and I think they'd really want to continue seeing me *IF* it's affordable.

-I am having my lawyer help with dodging the solicitation clause problem - I know there are ways to help patients read between the lines that they can follow me when I end care, and I'm hoping to launch my website in the next month to give them a way to search me up and find my business without having to be explicit with them. I know non-competes/non-solicitations were voided in CA, but federally (like as of this week) there was a rejection to the decision. So waiting for my lawyer to figure out that one.

-I need to decide if I'm going to take insurance (I would have the patient reimburse themselves, not interested in directly making claims to insurance). What are the pros/cons as far as maximizing income with and without insurance? I imagine I'll also have some cash patients but I know if I start my practice just taking cash, most of my current patients will not be able to afford to see me. I feel very wrong about that scenario.

2. Can someone explain some of these aspects of billing/insurance: (some questions are in the 'I never understood this and now I feel really dumb asking' category, so please be kind)
-Do people ever bill their patients exactly what their insurance will cover for certain services or is it a flat fee for all patients? For example, if I charge $700 for an intake but Aetna only reimburses $550 for a 90792 (I'm making up these numbers) do psychiatrists ever just change their fee to accommodate that difference? Is it legal to charge different patients different prices? I will be using fairhealthconsumer.org for guidance on how to price my services.

-Are there downsides to getting credentialed with certain insurance companies? Are there some that are considered high reimbursers that I should prioritize? Anyone in CA with insight on this would be appreciated.

This is enough to start, I think. Jumping quickly from one job to private just seems to be a more specific situation than what I've been reading about here, so I am grateful for thoughts and support. Thank you!

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[reca]

What do you mean by taking insurance but not submitting claims?

 

[splik]

Hi everyone,

I am a psychiatrist who moved out to southern CA after residency. Loving my life...EXCEPT my job. The work of being a psychiatrist is wonderful and I have no regrets in choosing my specialty, but this specific job is destroying my soul and taking too much of my income.

3 years into attendinghood and I'm finally on SDN. Main reason being - I need some serious advice.

I'm starting a business while transitioning out of a corporate job. I've gleaned a ton of great advice from some colleagues and from threads on here, so thank you all for already contributing to my project greatly. I will continue reading in case these questions are explained elsewhere and I welcome direction to those threads from others.

My business will just be me - offering psych evals, psychotherapy, and med check type appointments. Timeline is to put in my mandatory 60 day notice 11/1 for end of work 12/31, start seeing patients privately in Jan. 2025.

Biggest questions I have right now:

1. How do I keep as many patients as possible, moving from this job into my business?
-I have a ton of patients who love working with me, and I think they'd really want to continue seeing me *IF* it's affordable.

-I am having my lawyer help with dodging the solicitation clause problem - I know there are ways to help patients read between the lines that they can follow me when I end care, and I'm hoping to launch my website in the next month to give them a way to search me up and find my business without having to be explicit with them. I know non-competes/non-solicitations were voided in CA, but federally (like as of this week) there was a rejection to the decision. So waiting for my lawyer to figure out that one.

-I need to decide if I'm going to take insurance (I would have the patient reimburse themselves, not interested in directly making claims to insurance). What are the pros/cons as far as maximizing income with and without insurance? I imagine I'll also have some cash patients but I know if I start my practice just taking cash, most of my current patients will not be able to afford to see me. I feel very wrong about that scenario.

2. Can someone explain some of these aspects of billing/insurance: (some questions are in the 'I never understood this and now I feel really dumb asking' category, so please be kind)
-Do people ever bill their patients exactly what their insurance will cover for certain services or is it a flat fee for all patients? For example, if I charge $700 for an intake but Aetna only reimburses $550 for a 90792 (I'm making up these numbers) do psychiatrists ever just change their fee to accommodate that difference? Is it legal to charge different patients different prices? I will be using fairhealthconsumer.org for guidance on how to price my services.

-Are there downsides to getting credentialed with certain insurance companies? Are there some that are considered high reimbursers that I should prioritize? Anyone in CA with insight on this would be appreciated.

This is enough to start, I think. Jumping quickly from one job to private just seems to be a more specific situation than what I've been reading about here, so I am grateful for thoughts and support. Thank you!

So non competes have been illegal in CA for over 100 years but non solicitation clauses are allowed. However they can’t stop the patients continuing with you. You must follow your practice guidelines regarding terminating with your patients but you could tell them you are going into op and you can’t solicit them however if they happened to find you you would be happy to see them.

However if you’re at an insurance practice most patients will want to see someone who takes insurance. If you are really good and have a good relationship with them and do therapy you could have as many as 60% follow you but expect it to be far fewer than 40 especially with the non solicitation (probably way less).

If you accept insurance you have to file claims. That is what it means to accept insurance. Perhaps you’re talking about being OON which is effectively the same as cash only and you give pts a superbill to try to get reimbursed. Almost every cash psychiatrist does OON and gives pts a superbill some even file claims on the pts behalf. Some pts can get most of the money back if they have a good employer sponsored plan but if they have an Obama care plan or something like United/optum or a high deductible plan they won’t get much if anything back until they’ve met their deductible (which could be $5000+ for OON)

You should assume you will be starting from scratch and take it as an added bonus if some of your pts follow you.

 

[minimooshie]

What do you mean by taking insurance but not submitting claims?

Giving the patient a super bill each month to get reimbursed by insurance on their own. I'd take cash up front from the patient.

 

[minimooshie]

If you accept insurance you have to file claims.

Okay this is helpful - so I thought by being credentialed with insurance companies, I'd be considered in network and I'd negotiate some amount of reimbursement that would be higher than if I was OON, so patients could then get a higher amount reimbursed even on their own. Thank you for clearing that up for me.

Wondering if it'd be worth just taking the top 1-2 insurances used by my panel to get started. If I do that, I could still charge cash rates/do OON superbill process for new patients, correct?

 

[splik]

Okay this is helpful - so I thought by being credentialed with insurance companies, I'd be considered in network and I'd negotiate some amount of reimbursement that would be higher than if I was OON, so patients could then get a higher amount reimbursed even on their own. Thank you for clearing that up for me.

Wondering if it'd be worth just taking the top 1-2 insurances used by my panel to get started. If I do that, I could still charge cash rates/do OON superbill process for new patients, correct?

I’d you accept insurance you can’t charge those pts privately. If you say took Aetna but didn’t take UHC you could charge a pt with UHC cash and they could undertake the sometimes painful process of trying to get reimbursement from UHC.

 

[minimooshie]

Got it. Thank you! I think this will need to be my approach to have a best of both worlds scenario.

Appreciate the basic education about this stuff, everyone. Have learned so much from your previous posts, too.

 

[clozareal]

1. How do I keep as many patients as possible, moving from this job into my business?
-I have a ton of patients who love working with me, and I think they'd really want to continue seeing me *IF* it's affordable.
-I am having my lawyer help with dodging the solicitation clause problem - I know there are ways to help patients read between the lines that they can follow me when I end care, and I'm hoping to launch my website in the next month to give them a way to search me up and find my business without having to be explicit with them. I know non-competes/non-solicitations were voided in CA, but federally (like as of this week) there was a rejection to the decision. So waiting for my lawyer to figure out that one.

You would tell them you are leaving your current employer and starting off on your own. You tell them that you're not technically allowed to tell them to leave the employer and follow you, but nothing is stopping them from looking you up on their own and reaching out to your private practice to become a new patient there. You let them know of your fees and that you'll be out of network, and for them to look at their out of network benefits. Then you wait until they contact you. Like splik said, it's really a bonus if they follow you as most people who are at an insurance practice want to use their insurance.

-I need to decide if I'm going to take insurance (I would have the patient reimburse themselves, not interested in directly making claims to insurance). What are the pros/cons as far as maximizing income with and without insurance? I imagine I'll also have some cash patients but I know if I start my practice just taking cash, most of my current patients will not be able to afford to see me. I feel very wrong about that scenario.

You'll have to do an analysis about the market conditions in your area. Are most people offering insurance and thus will be competition to get private pay patients? What are the cash rates? What are the insurance rates? Do you want to deal with the hassle of submitting claims, following-up on them (called revenue cycle management)? Feeling wrong about the scenario is different than feeling unfamiliar and thus uncomfortable with how it works. You'll have to manage that feeling with learning more about the freedom being untied to insurance can give to you.

2. Can someone explain some of these aspects of billing/insurance: (some questions are in the 'I never understood this and now I feel really dumb asking' category, so please be kind)
-Do people ever bill their patients exactly what their insurance will cover for certain services or is it a flat fee for all patients? For example, if I charge $700 for an intake but Aetna only reimburses $550 for a 90792 (I'm making up these numbers) do psychiatrists ever just change their fee to accommodate that difference? Is it legal to charge different patients different prices? I will be using fairhealthconsumer.org for guidance on how to price my services.

People do all kinds of things. You can learn about all the different models or just do what's easiest for you. Here are some.

1. Flat hourly rate. Let's say $500/hr. A 90 minute intake would be $750 and a 30 min follow up would be $250.
2. Less hourly (therapy) than med mgmt. $300 for weekly therapy, $200 for 30 minute follow-up.
3. Lower intake rate since it's just a one time fee to get people in the door. $375 for intake then $500/hr for follow-ups.
4. Retainer fee. Patients need to pay $2,000 up front to be a patient then get 4 free appointments per year, then pay for each additional appointment.
5. Membership fee. Patients pay $300/month for one visit a month whether they use it or not, with additional appointments paid for.

You can't balance bill the patient for the remaining amount over what insurance will pay. You can charge $700 per hour for your OON rates for other insurances even if your rate with Aetna would be $550. Psychiatrists often have different fee schedules depending on the patient, particularly if they increase their rates and haven't increased it for legacy patients.

-Are there downsides to getting credentialed with certain insurance companies? Are there some that are considered high reimbursers that I should prioritize? Anyone in CA with insight on this would be appreciated.

It's going to depend on your local market. Some people go for market volume (a bigger percentage of the population with that insurance) but they may pay less than smaller insurances who want to entice providers to take their patients. You can ask Anthem/Magellan, Aetna, Cigna/Evernorth, UHC/UBH to send you the rates based on your metro area. Don't sign with them unless you're comfortable with their rates, even if they say you can't negotiate until after you sign with them.

This is enough to start, I think. Jumping quickly from one job to private just seems to be a more specific situation than what I've been reading about here, so I am grateful for thoughts and support. Thank you!

You should start on the first steps of starting a private practice, in this order:

1. Getting malpractice
2. Getting a sole proprietor EIN
3. Getting an office
4. Getting a phone/email/fax
5. Finding an EMR

All of those can come before even thinking about marketing. Only the last step would you need to consider whether you'll take insurance since the EMR can help tremendously with claims filing. You can start taking private pay patients and then add insurance later on if you wanted to.

 

[minimooshie]

You would tell them you are leaving your current employer and starting off on your own. You tell them that you're not technically allowed to tell them to leave the employer and follow you, but nothing is stopping them from looking you up on their own and reaching out to your private practice to become a new patient there. You let them know of your fees and that you'll be out of network, and for them to look at their out of network benefits. Then you wait until they contact you. Like splik said, it's really a bonus if they follow you as most people who are at an insurance practice want to use their insurance.


You'll have to do an analysis about the market conditions in your area. Are most people offering insurance and thus will be competition to get private pay patients? What are the cash rates? What are the insurance rates? Do you want to deal with the hassle of submitting claims, following-up on them (called revenue cycle management)? Feeling wrong about the scenario is different than feeling unfamiliar and thus uncomfortable with how it works. You'll have to manage that feeling with learning more about the freedom being untied to insurance can give to you.

People do all kinds of things. You can learn about all the different models or just do what's easiest for you. Here are some.

1. Flat hourly rate. Let's say $500/hr. A 90 minute intake would be $750 and a 30 min follow up would be $250.
2. Less hourly (therapy) than med mgmt. $300 for weekly therapy, $200 for 30 minute follow-up.
3. Lower intake rate since it's just a one time fee to get people in the door. $375 for intake then $500/hr for follow-ups.
4. Retainer fee. Patients need to pay $2,000 up front to be a patient then get 4 free appointments per year, then pay for each additional appointment.
5. Membership fee. Patients pay $300/month for one visit a month whether they use it or not, with additional appointments paid for.

You can't balance bill the patient for the remaining amount over what insurance will pay. You can charge $700 per hour for your OON rates for other insurances even if your rate with Aetna would be $550. Psychiatrists often have different fee schedules depending on the patient, particularly if they increase their rates and haven't increased it for legacy patients.


It's going to depend on your local market. Some people go for market volume (a bigger percentage of the population with that insurance) but they may pay less than smaller insurances who want to entice providers to take their patients. You can ask Anthem/Magellan, Aetna, Cigna/Evernorth, UHC/UBH to send you the rates based on your metro area. Don't sign with them unless you're comfortable with their rates, even if they say you can't negotiate until after you sign with them.

You should start on the first steps of starting a private practice, in this order:

1. Getting malpractice
2. Getting a sole proprietor EIN
3. Getting an office
4. Getting a phone/email/fax
5. Finding an EMR

All of those can come before even thinking about marketing. Only the last step would you need to consider whether you'll take insurance since the EMR can help tremendously with claims filing. You can start taking private pay patients and then add insurance later on if you wanted to.

Thank you for this! I am glad to know I can say so much to patients without it being true solicitation - I'm going to work on a script of some kind to this effect.

I do not want to deal with claims, really. But I think with the position I'm in, I do want to maintain some of my panel so I don't have to start completely from scratch. I will be offering online appts so I could see folks from all over CA, technically - so the market conditions could vary widely. In my direct area, it seems like there is a long wait list to see folks taking insurance. I only know of 5-6 private pay docs around here, but I am unable to know the total, exactly. Just doing search engine research to understand who is here.

Thanks for explaining the "balance bill" concept, too. Is it worth it to contact some major insurance co's in the area and understand how much they'll reimburse for OON in order to give potential patients an idea of what they'd have to pay? Is that even information that is readily available? I will definitely reach out to some of the companies who cover larger numbers of my patients to see what their rates are.

I think I feel stuck on the insurance thing early in this process because in order to know my timeline for transitioning out of my current job, I need to be able to give the company 60 days notice and be credentialed while I transition out my panel so I can tell those patients that I accept their insurance when I say goodbye. From what I understand, credentialing can take a few months so I'll need to get started on that ASAP. Am I overthinking this? I guess it's more a fear of a major financial loss to have a gap of minimal income if my cash only panel takes forever to fill.

I've already started on the EIN, website, email...I have been reading other threads about EMR's and seems like a few favorites were recently bought out - so haven't chosen or tested any yet. I have a friend who likes PracticeQ. Lots of options for offices in the area so hoping I can find something affordable. Have not compared malpractice plans yet but have some good suggestions from SDN, friends.

 

[clozareal]

Thanks for explaining the "balance bill" concept, too. Is it worth it to contact some major insurance co's in the area and understand how much they'll reimburse for OON in order to give potential patients an idea of what they'd have to pay? Is that even information that is readily available? I will definitely reach out to some of the companies who cover larger numbers of my patients to see what their rates are.

You won't know how much they'll reimburse OON because the maximum allowable amount and what percentage is covered OON depends on that insurance plan from the individual. This is information you get after the fact.

I think I feel stuck on the insurance thing early in this process because in order to know my timeline for transitioning out of my current job, I need to be able to give the company 60 days notice and be credentialed while I transition out my panel so I can tell those patients that I accept their insurance when I say goodbye. From what I understand, credentialing can take a few months so I'll need to get started on that ASAP. Am I overthinking this? I guess it's more a fear of a major financial loss to have a gap of minimal income if my cash only panel takes forever to fill.

There will be a gap in income that you need to plan for. You won't take forever to fill. You can always take cash pay patients while waiting for insurance credentialing.

I've already started on the EIN, website, email...I have been reading other threads about EMR's and seems like a few favorites were recently bought out - so haven't chosen or tested any yet. I have a friend who likes PracticeQ. Lots of options for offices in the area so hoping I can find something affordable. Have not compared malpractice plans yet but have some good suggestions from SDN, friends.

Get quotes from different liability insurances now. PRMS, MIEC, CAP-MPT, APA, etc.

 

[Therapist4Chnge]

You can't balance bill the patient for the remaining amount over what insurance will pay. You can charge $700 per hour for your OON rates for other insurances even if your rate with Aetna would be $550. Psychiatrists often have different fee schedules depending on the patient, particularly if they increase their rates and haven't increased it for legacy patients.

To clarify, a provider needs to have ONE fee schedule for clinical work. You can have a separate fee schedule for legal work.

If you choose to take insurance, then your fee schedule (what you charge) is the same for every insurance and cash pay. What you are reimbursed (what they pay you) is negotiated with each insurer. You may charge $600 for an intake, but the “negotiated rate” for Cigna might be $350 and for UHC it is $375. You still charge your fee, but you are PAID the negotiated rate.

For cash rate you might charge $600 bc that is on your fee schedule, or you might use a sliding scale if there are economic limitations. This still uses *one* fee schedule on your end, but the negotiated rate can be different.

 

[splik]

You would tell them you are leaving your current employer and starting off on your own. You tell them that you're not technically allowed to tell them to leave the employer and follow you, but nothing is stopping them from looking you up on their own and reaching out to your private practice to become a new patient there. You let them know of your fees and that you'll be out of network, and for them to look at their out of network benefits. Then you wait until they contact you. Like splik said, it's really a bonus if they follow you as most people who are at an insurance practice want to use their insurance.

No - this is solicitation. Don't tell them your fees or tell them how to reach out to contact you. Tell them you're leaving, refer them back to the practice, let them know you are going into pp and leave it at that. If they ask if they can continue seeing you, then you can tell them they could look you up if they wish. The good news is fee splitting is illegal so they can't ask you to pay to take those patients with you.

 

[minimooshie]

No - this is solicitation. Don't tell them your fees or tell them how to reach out to contact you. Tell them you're leaving, refer them back to the practice, let them know you are going into pp and leave it at that. If they ask if they can continue seeing you, then you can tell them they could look you up if they wish. The good news is fee splitting is illegal so they can't ask you to pay to take those patients with you.

Thanks - I'm asking for very specific advice on this with my lawyer currently. Ideally it'd be nice to be able to communicate something to my patients in writing (I won't get an appt with everyone in my panel in the next 2 mo) but of course that makes it even more important I write exactly what I can get away with! My company did send a notice about non-solicitation clauses no longer being pursued legally but...still. I don't want to step on a rake here.

 

[Jules A]

Thanks - I'm asking for very specific advice on this with my lawyer currently. Ideally it'd be nice to be able to communicate something to my patients in writing (I won't get an appt with everyone in my panel in the next 2 mo) but of course that makes it even more important I write exactly what I can get away with! My company did send a notice about non-solicitation clauses no longer being pursued legally but...still. I don't want to step on a rake here.

Communicating something in writing to your clients when you are moving to a new practice sounds like a lousy idea.

 

[minimooshie]

So my lawyer surprisingly was cavalier in her take on this - basically my company did send out a notice this year saying they wouldn't pursue any legal action around non-compete or non-solicitation clauses in our contracts, after employment has ended. Lawyer said that the bill referring to recent CA changes does not state any difference between before/after termination when interpreting the invalidation of these clauses statewide. So she said it'd be very, very unlikely my company would pursue any action, regardless of my decisions to solicit.

That being said, I'm not interested in playing games, potentially. I do believe this company is highly disorganized and would not even know what I was up to, frankly. But I don't like risks so I'm going to find a middle ground of some kind, likely just making sure all searchable web pages with my name and current business contacts are updated to include my new website or email address so patients can just easily look me up. Then I'll verbally let them know during these final visits that I'm doing PP and they can stay with my current clinic or find me on their own if they want to continue care.

 

[minimooshie]

Sliding scale question - read that there is a risk of insurance companies decreasing their reimbursement amount/percentage to full charge patients if someone brings them a bill with a lower fee (like a sliding scale patient might). Anyone know if this is true or even a likely occurrence? If so, is there a way to get around this?