Private Practice in Progress

[smalltownpsych]

Hey everyone, probably the last real update from me. Probably shutting down the practice at the end of Oct as we're planning to move out of the country. Things have grown at about the rate expected but we've been declining most new patients for a bit in anticipation of the move. Probably would have ended right around $220k for the year if she were still taking all the new patients who have been sending in requests. Anyway, it's been fun but time for a new adventure!

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I need to show my trophywife your p and l statement so she can get that up and running. Too bad she has a full-time job in addition to running the books for our business. Your operating expenses are soooo low, I am envious.

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[randomdoc1]

I need to show my trophywife your p and l statement so she can get that up and running. Too bad she has a full-time job in addition to running the books for our business. Your operating expenses are soooo low, I am envious.

business owner to business owner, the money is at the wise investment part bruh! My overhead is high but the profit made it worth it! ; )
it's about delicate balances, go too low on the overhead and income potential does get limited, but when too high, you p_ss away money. It's the sweet creamy middle.

 

[trophyhusband]

I need to show my trophywife your p and l statement so she can get that up and running. Too bad she has a full-time job in addition to running the books for our business. Your operating expenses are soooo low, I am envious.

Was originally set up as half-day weekend venture. But even so a 2 office suite around here is $800-900 a month (Midwest CoL has its advantages sometimes). We were looking into larger spaces before we decided to make the move.

Quickbooks Online is what we use for the practice. This is just a canned P&L report.

 

[WisNeuro]

I need to show my trophywife your p and l statement so she can get that up and running. Too bad she has a full-time job in addition to running the books for our business. Your operating expenses are soooo low, I am envious.

You should see mine, my office is $500/month. And I don't pay utilities or internet

 

[smalltownpsych]

business owner to business owner, the money is at the wise investment part bruh! My overhead is high but the profit made it worth it! ; )
it's about delicate balances, go too low on the overhead and income potential does get limited, but when too high, you p_ss away money. It's the sweet creamy middle.

lol. I am aiming at the high end as well. Six months in and I‘m beginning to get a return on the investment without accepting insurance so I’m probably doing something right. I actually started out by renting a building with four offices so am dreaming big. Since I’m starting this at this close to retirement age, it’s go big or go home…less. 😁

 

[randomdoc1]

lol. I am aiming at the high end as well. Six months in and I‘m beginning to get a return on the investment without accepting insurance so I’m probably doing something right. I actually started out by renting a building with four offices so am dreaming big. Since I’m starting this at this close to retirement age, it’s go big or go home…less. 😁

Yea, that's the way to live life. It was my husband who gave me the courage and the thought of...one day when I'm a little old lady, wouldn't it be nice to smile at this little adventure we went down versus being a cog in a hospital system? Yea, it can go bust, but the worst that can happen is the situation I'm already in! I started just 3 years out of residency and with so much time ahead, it'll be thrilling to see what else in store. It's a teaching clinic too now. Dreaming of bringing in more training professionals and carving out a little haven <3.

Plus, I may be totally wrong, but when Jeff Bezos started out, wasn't he in some serious debt? Like I think it was h3ll getting started for him. Granted, many many people go bust, but the fast life is kinda fun. You gotta admit it.

 

[smalltownpsych]

Yea, that's the way to live life. It was my husband who gave me the courage and the thought of...one day when I'm a little old lady, wouldn't it be nice to smile at this little adventure we went down versus being a cog in a hospital system? Yea, it can go bust, but the worst that can happen is the situation I'm already in! I started just 3 years out of residency and with so much time ahead, it'll be thrilling to see what else in store. It's a teaching clinic too now. Dreaming of bringing in more training professionals and carving out a little haven <3.

Plus, I may be totally wrong, but when Jeff Bezos started out, wasn't he in some serious debt? Like I think it was h3ll getting started for him. Granted, many many people go bust, but the fast life is kinda fun. You gotta admit it.

Your husband is a smart man. That is such a good point. I also tell people that if it doesn’t work then I’ll have to go back to being just a licensed psychologist. Not a bad fall back plan. lol

 

[GABAtoGLUTAMATE]

WOW. Such a legendary post! I am clueless when it comes to insurance. Any recommendations for insurance credentialing (with good negotiations), and billing too?

 

[Sushirolls]

Insurance negotiations, review has many posts by @randomdoc1

Credentialing, do your self. Outsourcing this will only lead to headaches down the road. Half the time these firms will come back at you to fill in parts, or the extra forms. In other words you still do most of the data entry. Just do it yourself. Save the money, and get it done right the first time.

Billing, is... peppered in this thread. I'm a fan of the integrated clearing houses, like that in Luminello.

 

[Sushirolls]

So I've tried finding a how to guide for relocating your practice. Not much existed, so I created my own list of 'how to.' I tried to put it in order of actual task completion, but I did hop around some. So, here y'all go for those looking to move your practice.


1) Let patients know you are moving and closing down the practice in the state of origin, and moving to a new state.
2) Let patients know who are taking controlled substances they need a new doc, and point them to their options. DEA doesn't permit prescribing ongoing to patients in different states if you don't have a true physical address in that state. A UPS box / address type of set up doesn't satisfy the DEA.
3) Find an office, sign a lease, and hopefully they don't pay attention to your (P)LLC being out of state and not active in the new state. (suppose, could create the LLC as out of state origin first, in new state, and update both addresses later?)
4) Contacted the medical liability insurance company to let them know what is happening and provided them with whatever information they wanted.
5) Quickly jump online for the Secretary of State website to open a The Same, MD, PLLC corporation and attach any of the the same Doing Business As (DBA) names.
6) I'm keeping the fax and phone number the same, too lazy to change those. But if you were to change, now is the time to do it!!
7) Update the IRS? Not needed, and can be done with annual tax returns. But prep the new W9 form to reflect the new location for the Tax ID number for whatever entities need it.
8) Update CAQH *have W9, licenses, DEA, state CS ready
9) Update Availity
10) Update each insurance company [Besides Google, this is the Biggest pain]
11) Update all State Licenses
12) Get state specific Controlled Substance Registration (first before DEA update, if state requires)
13) Update DEA address
14) Update medical societies & Boards
15) Update NPI type I and II with NPPES
16) Update Medicare at PECOS as new applications....
17) Update Bank address for bank accounts and also which home branch they are attached to
18) Update USPS with address forwarding [credit card for this must match to billing address of card, and not be residential, and not be UPS mailbox address.]
19) Update Google G Suite billing address, and office details listed on Google [THEY REQUIRE A PHOTO OF SIGNAGE OR DIRECTORY BOARD TO UPDATE]
20) Update insurance carrier for business office, make sure new lease is covered, too
21) Update EMR
22) Update billing clearinghouse connected with EMR
23) Update E-prescribing stuff on EMR [DEA and State Controlled Substances number first]
24) Update credit card processing details
25) Update Psychology today profile
26) Get new business cards
27) Get new letterhead
28) Update Website for location and office hours
29) Go through EMR or intake forms or policies (or all of them) and update everything
30) Order new checks for new address
31) Order new stamp with address to stamp checks on the back when depositing
32) Got employees? contact state Labor folks to get all the usual unemployment, taxes, etc stuff taken care of for Payroll.

 

[smalltownpsych]

So I've tried finding a how to guide for relocating your practice. Not much existed, so I created my own list of 'how to.' I tried to put it in order of actual task completion, but I did hop around some. So, here y'all go for those looking to move your practice.


1) Let patients know you are moving and closing down the practice in the state of origin, and moving to a new state.
2) Let patients know who are taking controlled substances they need a new doc, and point them to their options. DEA doesn't permit prescribing ongoing to patients in different states if you don't have a true physical address in that state. A UPS box / address type of set up doesn't satisfy the DEA.
3) Find an office, sign a lease, and hopefully they don't pay attention to your (P)LLC being out of state and not active in the new state. (suppose, could create the LLC as out of state origin first, in new state, and update both addresses later?)
4) Contacted the medical liability insurance company to let them know what is happening and provided them with whatever information they wanted.
5) Quickly jump online for the Secretary of State website to open a The Same, MD, PLLC corporation and attach any of the the same Doing Business As (DBA) names.
6) I'm keeping the fax and phone number the same, too lazy to change those. But if you were to change, now is the time to do it!!
7) Update the IRS? Not needed, and can be done with annual tax returns. But prep the new W9 form to reflect the new location for the Tax ID number for whatever entities need it.
8) Update CAQH *have W9, licenses, DEA, state CS ready
9) Update Availity
10) Update each insurance company [Besides Google, this is the Biggest pain]
11) Update all State Licenses
12) Get state specific Controlled Substance Registration (first before DEA update, if state requires)
13) Update DEA address
14) Update medical societies & Boards
15) Update NPI type I and II with NPPES
16) Update Medicare at PECOS as new applications....
17) Update Bank address for bank accounts and also which home branch they are attached to
18) Update USPS with address forwarding [credit card for this must match to billing address of card, and not be residential, and not be UPS mailbox address.]
19) Update Google G Suite billing address, and office details listed on Google [THEY REQUIRE A PHOTO OF SIGNAGE OR DIRECTORY BOARD TO UPDATE]
20) Update insurance carrier for business office, make sure new lease is covered, too
21) Update EMR
22) Update billing clearinghouse connected with EMR
23) Update E-prescribing stuff on EMR [DEA and State Controlled Substances number first]
24) Update credit card processing details
25) Update Psychology today profile
26) Get new business cards
27) Get new letterhead
28) Update Website for location and office hours
29) Go through EMR or intake forms or policies (or all of them) and update everything
30) Order new checks for new address
31) Order new stamp with address to stamp checks on the back when depositing
32) Got employees? contact state Labor folks to get all the usual unemployment, taxes, etc stuff taken care of for Payroll.

That sounds like a lot of work, no wonder you want to take up farming. 😉
Good work making that list. When I was opening up my practice I was juggling all of the tasks in my head and getting overwhelmed. At one point my partner suggested a checklist. It would have been nice if I could have just cut and pasted yours and just edited to fit.

 

[Sushirolls]

That sounds like a lot of work, no wonder you want to take up farming. 😉
Good work making that list. When I was opening up my practice I was juggling all of the tasks in my head and getting overwhelmed. At one point my partner suggested a checklist. It would have been nice if I could have just cut and pasted yours and just edited to fit.

That's a large part of why I started up this whole thread. Here's the info folks; venture forth and do better than me!

 

[yoloswagpoop42069]

Graduating from residency off cycle in December. Have a locums job in Florida set to start 1/1 until July when I start a fellowship.

I’ll be 1099 with locums.

Should I form a PLLC for the 6 months of income? 200/hr but hopefully some OT at 250/hr. I may pick up a second job. It’s an in person job, and the locums company pays for mileage, but the place is close to where I live so not much traveling. Not sure if I’ll have a lot of write offs since it’s not Telepsychiatry.

My worries are when I move states will have to have to switch the PLLC over to the state. Or what if the state doesn’t recognize PLLCs? I won’t be using it for fellowship most likely anyway, although it’s possible for moonlighting money to go through it? Not sure.

 

[Bartelby]

Graduating from residency off cycle in December. Have a locums job in Florida set to start 1/1 until July when I start a fellowship.

I’ll be 1099 with locums.

Should I form a PLLC for the 6 months of income? 200/hr but hopefully some OT at 250/hr. I may pick up a second job. It’s an in person job, and the locums company pays for mileage, but the place is close to where I live so not much traveling. Not sure if I’ll have a lot of write offs since it’s not Telepsychiatry.

My worries are when I move states will have to have to switch the PLLC over to the state. Or what if the state doesn’t recognize PLLCs? I won’t be using it for fellowship most likely anyway, although it’s possible for moonlighting money to go through it? Not sure.

I would say nope! Operate as a sole proprietor. You can still tax-deduct business expenses as a sole prop just like you would for a professional corporation.

Also, no corporation ever protects against professional negligence. In other words, if someone sues you for medical malpractice the LLC does nothing for you. It only shields you from liability in more limited circumstances; for example, if you have an employee who sues you then a properly set up corporation may shield you personal assets. But for six months of working a 1099 job, it is hard to imagine what benefit you would get from starting a corporation. You would also need to pay for set up and deal with more complicated record-keeping (corporate minutes, etc.) and tax filings.

 

[yoloswagpoop42069]

Awesome just the information I was looking for.

I guess I was wondering if there are no further tax/income benefits of write offs as a PLLC than a sole proprietor, that would make start up costs of a PLLC worth it.

So as a sole proprietor I wouldn’t need to do anything else aside from filling out the W9 from my contractor, right?

 

[Bartelby]

There are some advanced techniques (like setting up retirement accounts or hiring family members as employees) that might make a corp more tax-advantaged in some circumstances. For the most part, unless you have employees in your practice the corporation probably isn't worth it.

And correct, when you start working and cashing checks you are a sole proprietorship by default. I recommend applying for an EIN do that you don't have to send everyone your social security number. It is also helpful (but not necessary as a sole prop) to open a separate business bank account. But basically having a sole prop is very easy and occurs automatically if you don't form a different legal corporate entity.

If you do end up making a corp also be sure you elect for pass-through taxation. Getting taxed as a C-corp (double taxation) is the default for some types of corporations and is no fun!

 

[Sushirolls]

YEAR FOUR, Q1-Q4, YEAR END SUMMARY:

SUBJECTIVE:

Q1:

Officially off all Medicaid. Can now accept cash pay.

Seeing more politically motivated relocations. People coming here to join their fellow *color state* tribe members, and other patients leaving here to join their tribe in *color state*.

The acquisition of ChangeHealthcare by UHC appears to be getting blocked in the courts. This is good news. [*months later update, nope, it got approved]

Such a low volume this quarter, and mixed with it being deductible season, so much less money coming in. Stark contrast from a record high of December.

Assistant took initiative and pushed to change up scheduling process to give patients an appointment at first, but it is conditional, with requirement they have all paperwork done 1-2 days ahead of the consult appointment. Previously we’d wait to allow any scheduling until all paperwork done. Keeping track of this work flow change. Could be positive. Could be neutral. But seeing as how I have schedule gaps, hard to make an argument of this as a negative change.

Q2:

Little bit of a bounce back of numbers of patients and consults, but still heavy in ‘deductible season’. Looking again at moving to middle of nowhere with the BOSS and this area of interest, has a much more favorable payer mix then the other area I scoped out in past. The insurance reimbursements are lower than current local, but overall, the positively skewed payer mix should be equal. Anticipate best plan would be to truly close office location here, and open new location in that locale, stop accepting new patients from here, and only accept new patient from that locale. Keep the existing patients active with telemedicine. Get new contracts or register new office location with all current insurance companies.

Q3:

Actually moved. The limbo before the move and having assistant explain to some patients, especially those seeking stimulants, drastically cut down on new consults. Normal attrition and lack of new consults slowing drying up the practice. Things are not looking good. Finally decided to keep current patients, but with a future lack of office here, DEA rules – I need to hand off my stimulant and suboxone patients. So far 97%, my estimate, of non controlled substance patients are sticking with me and opting to do telemedicine. Was going to sublease from psychology group, more expensive than what I wanted for this area, but it checked all the boxes and the office is professional. They were suffering front desk staff shortages, and their office is in disarray. Had a superficial glimpse into their work flow. Made me appreciate my positives I’ve built up even more. Their disarray, and their landlord disarray, and the slowness of lawyer all compounded into the delays of getting an actual lease in hand. Craigslist, or driving around, is how you find lease options here. National search firms or brokerages or leasing firms aren’t used. Refreshing, but a different spin for lease locating. Craigslist had a new option, I pounced. Single large room, in suite sink, and a common area bathroom. No waiting room. Cheap, $750/month. I’ll make it work – including the UDS testing. Moving was a pain for personal residence, and moving business office was a pain, too. Just like personal, you don’t realize how much stuff you have accumulated until you have to move. This quarter and next are going to hurt financially really bad. Paying full lease price, as sleep doc isn’t subleasing anymore, and overlapping with this new lease… I’m just hoping to break even this quarter and next. THE BOSS has given me 2 years to make this practice hum, or I have to get back in the WRVUs mine with Big Box Shop. I had a solid contract in hand for local employment. I just couldn’t do it. Not until current lease ends, will I see the lower overhead benefits in 2023. But that should amount to annual gross change of +33.6K (or just +12K if you factored in the sublease previously from Sleep Doc).

Psychologically I’m half dreading all these tasks before me (see the list at post #460 above). But the other half is a boost, a new infusion of excitement and hope with this new location. Such a small town, new landlord already heard about me weeks ago coming to town and was excitedly saying ‘you are the Psychiatrist! I wondered when you’d reach out to me. We so need you here’ I’ve had some experiences in small and smaller towns in the past, but this locale very much so the rules of “watch what you say” and “everyone knows everyone” apply.

I’ve spent too much time thinking about how/when my taxes switch over to the new state. I’m going to stop thinking about this and let the accountant tell me.

I’ve been a few weeks into concentrating my clinical time into 3 days per week, and I’m kicking myself for having not done it sooner. Goals are 3 days clinical, 1 day catch up or new consult overflow, 1 day truly off. Fingers crossed I stick to it.

I especially appreciate my assistant. She was openly updated with all the updates and downs, and was starting to put in play contingency plans for new employment if I’d gone employed. Thankfully, she is still willing to stick with me and intends to ride this practice out until she or I retire. She too has disdain of returning back to Big Box shops. We are psychologically preparing that it is now the eye of the storm, and Q4 will be a whirlwind of activity. Time will tell.

Q4:

This caught me by surprise but I had 2nd round of patients drop off form the original office. For some reason being so far away was an issue, despite all or most all of their appointments have been telemedicine anyways. So this dip and just starting to get word out about my practice was more plateau overall - despite the growth from local. Delays with some insurance companies switching over my practice address and on their directories were a big headache and delayed or stopped some patient getting in. Some wanted to see in person and not telemedicine based out of the original office, so they waited until insurance was squared away. In this state, the Blues are split up it, isn’t one regence/blue to rule them all, but two sperate ones. I got my first payment back from one and had distress, a bout of demoralization. Perhaps I had to take that employed job? My reconnaissance on numbers apparently was inaccurate. A bulk of patient panel were in the lump of Blue/regence/cross insurance, and I was going from $200-220/ per 99214 down to Medicare $110ish. That's a solid $100 per encounter, or $200/hr loss! With moving I can't simply do a 180 and be cash only. I can't go back to employed. By default I have to play the volume game. I feel myself needing to review every post by @randomdoc1 However, I still was waiting the entity of this blue/regence/cross whatever dyad, to get me paneled. Perhaps their rates will be what I thought, and I can submit claims to that one? I'm going to put my head in the sand and ignore things for now. Let things simmer, get more data, make decisions in Q1. Still paying lease for both locations really, really hurts. I took home after overhead, and not even paid taxes yet only $5800 for Q4. How deep is the hope well?
[*spoiler, fast forward to Q1 2023, 90% of the blues will go the other entity, I was sending to wrong one, and the other one pays what I originally researched... all is well.]

Assistant notes much more pleasant population to work with here, kinder, more courteous.

OBJECTIVE:

Total Patients:	110	*70 old location	*40 new location
Follow Ups:	590	11.3 (weekly mean)
Consults:	81	1.6 (weekly mean)
Weekly Clinical Hours:	7.2 (annual mean)
Weekly Clinical Hours:	8.0(annual mean)	*updated formula
Overhead Percentage:	59.3%

GROSS PROFIT

$146,216.45​

100.00 %​

Expenses

Accountant	305.00​	0.21 %​
Advertising & Marketing	1,588.25​	1.09 %​

Board Certification Fees	350.00​	0.24 %​
Charitable Contributions	390.00​	0.27 %​

Credit Card Processing Fees	1,470.11​	1.01 %​
Insurance	3,580.00​	2.45 %​

Medical Billing Services	909.56​	0.62 %​
Medical Society Membership Dues	560.00​	0.38 %​

Office Supplies & Software	3,852.49​	2.63 %​
Other Business Expenses	830.83​	0.57 %​

Payroll - Taxes	5,645.67​	3.86 %​
Payroll - Wage Expenses	15,134.21​	10.35 %​

Rent & Lease	47,702.89​	32.62 %​
State Tax	1,768.51​	1.21 %​

State Medical License	1,242.50​	0.85 %​
Taxes & Licenses	291.95​	0.20 %​

Urine Testing Supplies	610.31​	0.42 %​
Utilities	1,388.38​	0.95 %​

Total Expenses	$87,620.66​	59.93 %​
NET OPERATING INCOME	$58,595.79​	40.07 %​

ASSESSMENT:

• Professional Dissatisfaction
• Slow practice growth rate
• Optimization Deficiency
• Infrastructure Deficits
• Retirement Exposure

PLAN:

• In Remission, continue this private practice. Still holding ground on the Never Again policy toward Big Box shops. Test waters with job interview, still couldn't do it.
• Okay with current pace, anything more I get behind on notes. The rate of growth I see with new location and assistant excitedly confirms, is good business decision and the right one. THE BOSS says I have 2 years to get this place humming or I go back to the wRVU mines.
• I had some increased billing of 90833 ups/downs. Can't drop medicare. Not in good place, in fact actively taking again in new location.
• Made positive change of down sized office to a basic suite, but until old office lease drops off I won't see these fruits.
• Very low risk of conversion to retirement at this time. LOL. Retirement? Markets have crashed and we have Lets Go Brandon dynamics in full force, and I didn't have enough income to be able to put any money away. Assistant was okay with no SEP-IRA deposit, thankfully, too.

[**Double spoiler, at almost end of Q1 for 2023, Things are looking so much brighter, rate of growth, patient population, lower overhead, updated policies, improved some work flow, things are looking up, and THE BOSS won't need to intercede.]

 

[randomdoc1]

Hey fellow brother! I'm not sure if this applies to your geographic location. But this may be a game changer for you. I've discovered, hospital systems can have their own self administered insurance and they may say, use BCBS or UMR/United as the third party administrator. What that means is the pay rate aka fee schedule is NOT regular BCBS/UMR/United. All the insurance people, are locally based, employed by the hospital. And you have much better negotiating power, they are super nice and reachable. The busiest hospital system in my state just flat out offered 150% of the Medicare rate which happens to be 150% of the going commercial rates here too. Their insurances pay out bulk of the expense usually leaving the patient with a $30 copay. They audit you way less (so far never). They are often grateful you are helping their employees be well. On a whim, I decided to reach out to the busiest hospital system, their central scheduling department for behavioral health. I heard their waitlist was 12,000 long. They were grateful to meet the clinic and slammed us with referrals of amazing insurance. They were so relieved! Such a stark difference from the non-compete days. They're so saturated with demand, they are trying to refer people out. Going forward, I think this will cause a massive rise in profits. I hope hospital systems in your area have something similar available---you deserve to capitalize on that.

Things aren't always smooth sailing here too. Sometimes the bank account can run tight. Part of it is my laziness because as an expecting mother (with a 7 year old already)...I'm too tired to see that many people, my own clinical work is way down. But that was the goal anyways.

 

[Sushirolls]

Good advice on finding a way to integrate with the Hospital or other large employers.

My previous location had several large health systems, and they were just dumb. An approach like you recommended would go nowhere. 3 of them had flavors sub networks with the bigger insurance companies, and 2 even got themselves on the state exchange with a flavor specific to their hospital system. I was in with 2 of the 3. Didn't make much of difference even with their lack of ability to accommodate demand. They simply referred internally. That was it. Patients would simmer with long wait list ... and that was it. Another entity changed its behavior, and started hiring/expanding psych services, and that dried up one of my referral sources.

With moving, my new office location kicked me out of the local area and I'm no longer in with those sub networks, had to refer off a few patients as a result of that discovery.

Now my new area... there is a larger business/employer with some internal medical services. I met with them, and a regional local psych group is backed up ~5 months. I'm getting their people in 1.5-2.5 weeks, and maintain open communication. They keep sending people, and I keep getting them in. Well paying private insurance, great population that wants to work.

My new area medical/hospital entities are Critical Care access hospitals, they don't have their own insurance. Since I didn't take a job at one of them, I'm it. I'm still getting all their referrals. But thankfully they aren't the only PCP source so even IF someone else were to show up and work for them, I still have other entities referring.

I'm glad your local health system had some brains and was able to work with you and the insurance subnetwork. My former area... shaped my views on Big Box shops.

Congrats on the family growth!

 

[Jules A]

Would love an update on how things are going in your new area. Are you happy with the move?

 

[Sushirolls]

So much happier. No longer see homeless people out my window anymore. My overhead is so much lower and has skewed my Percent overhead lower. I'm getting steady growth from local folks. Patients are less entitled than the deep Blue area I came from. Barely any cannabis, and when I counsel / assist with cessation, people actually stop, want to get off the cannabis rather than debate how its a miracle cure for everything. Thankfully the insurance panel has been equivocal or a small percent better in pay and even payer mix. Had a very brief scare on that. Had another round of people who dropped me from original area, which was odd, but I guess the psychology of being further away got to some people, despite telemedicine and excellent responsiveness and availability for folks. Currently building up out of that dip now. But I now have more patients from this new area than my old area. My assistant loves working with patients from this area too, and sees the same thing, nice population more courteous, etc.

 

[SeniorWrangler]

I hope it's not rude to throw in a private practice question here: I'm thinking of joining a clinic space with other providers with the idea that we can collaborate on complex patients, but everyone will have their own practice. The other providers are all using DrChrono for their EHR, however it's pretty expensive ($249/month for the basic version) and seems like a lot more than I would need initially for a small cash-based practice. Is it worth it to sign up for a year trial to facilitate sharing patient information with my colleagues, or should I go with a cheaper basic EHR?

 

[Jules A]

I hope it's not rude to throw in a private practice question here: I'm thinking of joining a clinic space with other providers with the idea that we can collaborate on complex patients, but everyone will have their own practice. The other providers are all using DrChrono for their EHR, however it's pretty expensive ($249/month for the basic version) and seems like a lot more than I would need initially for a small cash-based practice. Is it worth it to sign up for a year trial to facilitate sharing patient information with my colleagues, or should I go with a cheaper basic EHR?

If only space sharing I would use whatever EMR I preferred.

 

[Sushirolls]

Ditto.
If you need to share records, that's what a fax is for.
Not rude. The thread has already all sorts of side topics.

 

[allantois]

I hope it's not rude to throw in a private practice question here: I'm thinking of joining a clinic space with other providers with the idea that we can collaborate on complex patients, but everyone will have their own practice. The other providers are all using DrChrono for their EHR, however it's pretty expensive ($249/month for the basic version) and seems like a lot more than I would need initially for a small cash-based practice. Is it worth it to sign up for a year trial to facilitate sharing patient information with my colleagues, or should I go with a cheaper basic EHR?

I haven’t heard anything good about DrChrono, but then they are all expensive and terrible.. some less so. Even if they are newer and not as expensive, they will eventually raise the prices to market level. Personally, I hate dealing with faxes so would just suck up the cost

 

[calvnandhobbs68]

I hope it's not rude to throw in a private practice question here: I'm thinking of joining a clinic space with other providers with the idea that we can collaborate on complex patients, but everyone will have their own practice. The other providers are all using DrChrono for their EHR, however it's pretty expensive ($249/month for the basic version) and seems like a lot more than I would need initially for a small cash-based practice. Is it worth it to sign up for a year trial to facilitate sharing patient information with my colleagues, or should I go with a cheaper basic EHR?

I mean depending on how good of note writers other people are, it might not even be worth it for that purpose. Especially if you're talking about psychologists or therapists who often write very little in their notes about what's actually going on with people for privacy purposes.

I mean things like an entire note can be something similar to "processed trauma reactions utilizing TF-CBT approaches, discussed safety concerns and ways to manage" when really what they're saying is "patient is having severe stress from his insomnia due to nightmares, punched a hole in the wall and threatened his wife after having combat flashbacks daily".

 

[Sushirolls]

*grumble*
Liability insurance has gone up.
~2700 to ~3700 for part time.

 

[jbomba]

How do you recommend to do the billing when you also take insurance. So a patient has a co-pay or co-insurance. Do you just run the card at the time of the visit for what you anticipate their responsibility should be? Is this something an EMR can make clear in terms of what the charge should be at the time of the visit? I will be using luminello for what its worth.

 

[allantois]

How do you recommend to do the billing when you also take insurance. So a patient has a co-pay or co-insurance. Do you just run the card at the time of the visit for what you anticipate their responsibility should be? Is this something an EMR can make clear in terms of what the charge should be at the time of the visit? I will be using luminello for what its worth.

You should run their insurance ASAP. You can do it on the website for most insurances, but you may have to call (you probably need a biller as this takes a lot of time)

 

[jbomba]

You should run their insurance ASAP. You can do it on the website for most insurances, but you may have to call (you probably need a biller as this takes a lot of time)

So I will have a biller. So essentially all I need to do when I have a new appt is run their insurance and then charge them accordingly at the time of the visit? I'm assuming running them on the insurance website will tell me what is owed at the time of appt..

 

[Merovinge]

*grumble*
Liability insurance has gone up.
~2700 to ~3700 for part time.

Given they are on the hook for 1 mill/3mill and the legal defense that seems imminently reasonable to me. Docs pay 6 figures for full-time work in high risk specialties. At $2700/year I don't even understand how they can stay in business even with the very low rates of lawsuits for psychiatrists.

 

[calvnandhobbs68]

Given they are on the hook for 1 mill/3mill and the legal defense that seems imminently reasonable to me. Docs pay 6 figures for full-time work in high risk specialties. At $2700/year I don't even understand how they can stay in business even with the very low rates of lawsuits for psychiatrists.

Depends on the state too though, the cheapest quotes I was getting quoted was $5745 full time claims made through the Doctors Company with 15% claims free discount at maturity. $1436 for my first year going up to $5745 by year 5.
So I could see how someone feels like $3700 is rough for part time.

 

[Sushirolls]

So I will have a biller. So essentially all I need to do when I have a new appt is run their insurance and then charge them accordingly at the time of the visit? I'm assuming running them on the insurance website will tell me what is owed at the time of appt..

This is a weak area for my practice.
I had tried in early years to adequately run the insurance, and/or view the insurance card to predict what the Co-Pay was at time of insurance and get it then.
But I kept having some insurance after the claim was processed, procure a number that was different... sometimes more. Sometimes less. And then having discussion/messaging with patient about 'whoops.' Overcharged, do you want us to carry this forward or refund... When patients wanted the refund it was a pain to print/write up a check and mail it off.

So instead, I don't bother with copays at service time anymore. Instead, I get it on the back end after the insurance company has processed it.

Do I get stiffed with some patients and never collect that co-payment as they don't follow up? Yes.

I've kept track of my 'bad debt' non-collected money, and it continues to be in a low enough percentile that I don't bother aggressively chasing that down on front end. I've got a bunch of long term patients who will let them stack up over 6-12 months, and then they finally pay them all off in one fell swoop.

I use the luminello feature of creating invoices. Once the insurance has posted / uploaded their ERA/EOB for that claim/encounter, my assistant will package that all up into an Invoice, and send to the portal. We do that on the back end after the insurance uploads. I used to have a 60 day overdue, but changed to 30 day.

 

[Sushirolls]

The profile tab on Luminello has entry fields to be reminder for Co-Pay and Deductible, too.

 

[allantois]

So I will have a biller. So essentially all I need to do when I have a new appt is run their insurance and then charge them accordingly at the time of the visit? I'm assuming running them on the insurance website will tell me what is owed at the time of appt..

We always run the insurance because it may be termed and the patient may not want to self-pay or they may have a very high deductible. If the deductible is very high, we started to collect $200 deposit as that is around what the insurance would pay for the first visit.

It is complicated with co-insurance as you may not know the exact code that you will bill so you will not know exactly what to collect upfront. But you should have all the rates for different codes available to you. We do not accept any HMOs as that is another layer of added complexity which we do not have the staff to deal with

 

[jbomba]

We always run the insurance because it may be termed and the patient may not want to self-pay or they may have a very high deductible. If the deductible is very high, we started to collect $200 deposit as that is around what the insurance would pay for the first visit.

It is complicated with co-insurance as you may not know the exact code that you will bill so you will not know exactly what to collect upfront. But you should have all the rates for different codes available to you. We do not accept any HMOs as that is another layer of added complexity which we do not have the staff to deal with

I will be running a lean, solo private practice. Maybe 10-15 hours a week max. Are these issues a biller could help with?

In my mind, having not done this before, I'm imagining a process like this; 1. check insurance for coverage and co-pay. 2. have visit. 3. run card for co-pay or co-insurance after the visit so I know what the code will be.

Is that pretty much it?

 

[allantois]

I will be running a lean, solo private practice. Maybe 10-15 hours a week max. Are these issues a biller could help with?

In my mind, having not done this before, I'm imagining a process like this; 1. check insurance for coverage and co-pay. 2. have visit. 3. run card for co-pay or co-insurance after the visit so I know what the code will be.

Is that pretty much it?

you bill your initials as 90792 so you run the insurance and see if patient has copay (that's easy). If it's coinsurance you have to see what the contracted rate for 90792 is and calculate patient's part. We collect payment upfront. If it is a small coinsurance amount, we usually will wait for the EOB to see the owed amount. Are you employing the biller or is it third party? You can negotiate with them whether they can check patients' insurance upfront. They usually will, but I am only familiar with in-house billers

 

[Psychresy]

How do you guys determine when you are full? And by this I mean, how many new patients do you figure you'll need to fill out?

I'm hoping for 15 hours of private practice a week. Of this I will surely have patients who come for follow up q4-12 weeks. How many new intakes do you think I'll need before I close the door to new intakes?

 

[TexasPhysician]

you bill your initials as 90792 so you run the insurance and see if patient has copay (that's easy). If it's coinsurance you have to see what the contracted rate for 90792 is and calculate patient's part. We collect payment upfront. If it is a small coinsurance amount, we usually will wait for the EOB to see the owed amount. Are you employing the biller or is it third party? You can negotiate with them whether they can check patients' insurance upfront. They usually will, but I am only familiar with in-house billers

In most non-academic places, 90792 isn’t used and pays much less than E&M options.

 

[DOswag]

In most non-academic places, 90792 isn’t used and pays much less than E&M options.

I noticed this when reviewing coding guidelines recently. I'm active duty and have just been using 90792 for intakes because that's what I was taught to use. Getting out soon though so will need to start using 99201-05. Do you typically use E&M or time for coding?

 

[hamstergang]

I noticed this when reviewing coding guidelines recently. I'm active duty and have just been using 90792 for intakes because that's what I was taught to use. Getting out soon though so will need to start using 99201-05. Do you typically use E&M or time for coding?

99205 by time is 1 hour on the day of service, and that includes face-to-face with the patient, record review (including any scales or forms you have the patient complete), and note writing. Seems easy to hit every single time.

 

[Psychresy]

99205 by time is 1 hour on the day of service, and that includes face-to-face with the patient, record review (including any scales or forms you have the patient complete), and note writing. Seems easy to hit every single time.

does 99205 by time pay better than a 99204 + 90836? I'd guess it makes more sense to bill the latter, no?

 

[calvnandhobbs68]

does 99205 by time pay better than a 99204 + 90836? I'd guess it makes more sense to bill the latter, no?

It's more documentation to do the latter for sure. Most of my intakes are child and I often don't start a med on the first visit (I split intakes across a 60 min initial and a 30 min followup), so can be hard to hit 99204 plus then have to document for a 90836 and doesn't pay THAT much more.

I much rather just go "60 minutes of face to face time with patient, 99205" at the end and leave it at that.

 

[Sushirolls]

99205 + 99417 + 99417 for 90min consult Face to Face, and front end chart review, and back end documenting. PDMP look up. etc.
Forget 90792 unless it was a very short/quick consult missing most routine elements.

~15 clinical hours per week, with Q4-Q12 week follow up frequency, general adult, will likely take 200 patients. 8 hours = 100 patients

Being full and declaring that to say, no new patients, is own process, and hard to say when to do. I've not yet got to that point.

Intake needs to fill are ... relative. Of the consults you do, how many stick with you? What is the attrition rate? You, location, insurance, prescribing habits, etc all impact that attrition rate.
*you give most patients a benzo, and ambien, low threshold for dispensing stimulants, you will fill lightening fast. Heck, talk about only the benefits of cannabis, you will be a God.

I moved to middle of nowhere. Over oh, we'll say 9 months, I have ~70 patients from this local area. My previous patients who followed me (telemedicine) is dropping from upper 60's to low 50's now. Rate of filling can be much, much faster, so many variables.

Yet, again, I had a newer patient, already working towards depression/anxiety symptoms, want to be "tested for ADHD" and upon having the discussion that no they don't have ADHD, and depression/anxiety/insomnia/OSA workup need to be completed first or in remission before doing a review - is met with disdain, and I've likely lost this patient - "because what I read on the internet about ADHD just sounds like me."

ARNPs in my observation will just say sure, do an Adult ADHD Rating scale, and give the adderall. I've lost a lot of patients this way who were already convinced they have ADHD. I've tried different approaches to these discussions, none seem to better than the other. Now I just stick with blunt truth.

 

[Sushirolls]

This post was originally in this thread, but I wanted to cross post into this one for the added value to the theme of this one.

I have an excel spread sheet that I started when I opened.
Rows are the 52 weeks of the year. Color coded for each Quarter.

Column 1 "week"
Column 2 "consults"
Column 3 "follow ups"
Column 4 Date, basically the Monday of that week 7/17, 7/24, etc
Column 5&6 is for data, I have one spot that sums the consults, sums the follow ups, and averages the consults, and averages the follow ups.
Column 7 "clinical hours" Is where you do this math (1.5 x avg consult) + (0.5 x avg follow up) = avg clinical hours per week

*If you take a vacation week, you enter 0 and 0 and it pulls your average. But even if you worked less days, it still pulls your average. Is what it is.
*I do 90 minute consults, hence the 1.5 multiplier. I do 30 min follow ups, hence the 0.5 multiplier.

See my cut paste of this 2023 Q2:

	4	11	3-Apr	Q2
15	4	6	10-Apr
	3	18	17-Apr
	2	9	24-Apr
	4	6	1-May
	3	13	8-May
20	4	5	15-May
	3	9	22-May
	1	11	29-May
	1	14	5-Jun
	4	11	12-Jun
25	4	5	19-Jun	39	135
	2	17	26-Jun	3.0	10.4	9.7

 

[MedMan80]

Bump for update

 

[Sushirolls]

You're right. I've got the numbers and what not. I just need to sit down and crank it all out here for a post.

 

[Sushirolls]

YEAR FIVE, Q1-Q4, YEAR END SUMMARY:

SUBJECTIVE:

Q1:
The old office lease has finally dropped off. No longer hurting my overhead. All the insurance companies are dialed in except… Aetna. Don’t get me going on this company. No real complaints historically, not great, not bad. Middle of road. But you can’t ever get a live person. I faxed/messaged/emailed everything, of and Availity, updated my address several times. Buried deep on their website found a place that said you have to request to terminate your old contract and request a new one. You guessed it… a new contract means time, means delays, means patients are OON. Strongly considered just dropping them. But we’ll see how it shakes down. Staying honest with patients about this cluster fun and some temporary paying cash, others dropped me. Thankfully Aetna is minor % of the total income coming in. See how this shakes down.

Assistant continues to sing praises of patient population here and how so much nicer in Deep Red state compared to our previous Deep Blue location.

I had sent out letters to closer notable places in Q3 last year with business cards to alert of my presence. Even at that, slow penetrance. Just takes time to get word out. I have 3 main referral sources, which are basically PCP type groups. Rare smattering of therapist referrals, similar numbers of self-referral, and family related word of mouth referrals. Psychology today generated calls are much, much less here in rural-ville. Maybe considering dropping psychology today listing. Not even bothering with Google ads anymore.

I’m really glad I made change some time back, for a solid 3 day work week with one day flex for new consults. Should have done that from the start. Contrast to the low of demoralization at end of Q4, not experienced since year one, I am not on the highest I’ve been with morale. Growth is happening here. Work flow is solid with assistant, our dynamics, the patient experience from first contact to consult, I believe now is The Moment. This is the year, I hope, I believe, that by the end of the year will be in a different phase. Where it will be harder to get in new consults. Currently I’m consistently book 1.5-2.5 weeks out with consults. Will use my flex day to release that pressure at times and get folks in sooner. This is perfect for me and my work life balance.

Small town, everyone knows everyone. Can’t share those stories. But wow, have to be extra mindful of that.

I dropped UHC like more than a year ago. Just got a phone call from patient at old location, saying was informed I’m still in network with them and wanted a consult… [insert tirade about UHC here].

I’m no longer doing UDS testing in office. Logistically awkward with an executive suite I currently have and where bathroom is. I so miss the convenience of onsite stat results. But conversely, nice not dealing with urine and supplies. Wasn’t even a money maker.

Q2: (I didn't journal anything) This is a retro entry.
Briefly was taking on some new medicare again, to get patients in, but all it took was 1-2 who are substantial time utilizers for myself and assistant to close that down again.

Q3: (I didn't journal anything)

Q4: (I didn't journal anything) This is a retro entry.
Through out this year, the growth I was having was mitigated by the loss of patients from original Blue State location, deciding they wanted local person - despite their preference for telemedicine even when I was local. The only thing that changed was the backdrop behind me. Baffling. I had 81 consults in 2022. 115 consults in 2023. Essentially a wash of a year. Consults over the year had ups/downs. One referral source that was sending numerous, dried up, and again resumed again around this 4th quarter. Unsure of why things slowed from that location for awhile. One of the local CCAH has a high medicare rate as one would expect, and if I opened up to medicare could fill very fast. But the time involvement of some geriatrics not being able to do anything with online EMRs and if any neurocog + Anxiety; the time utilization is massive. Can't do it with my assistant and I. Interestingly, this year I finished with less patients than last year... and less follow ups than last year, but I think the payer mix and higher consults, and the lower overhead is what gave the higher income compared to the pain of last year.

OBJECTIVE:

Total Patients:	103 active at end of year	~25 or so from original location	~78 new location
Insurance Payor Mix:	12 = to Medicare rates	4 Medicare	87 > Medicare (84.5%)
Follow Ups:	529 annual	10.2 (weekly mean)	range of 0-23 per week
Consults:	115 annual	2.2 (weekly mean)	range of 0-5 per week
Weekly Clinical Hours:	8.4 annual	<updated formula
Blended Payer Mix:	$ (oops) per follow up	<Secret sauce formula
Overhead Percentage:	34.48%
Days Off:	(oops)

GROSS PROFIT	$143,094.94 ​	100.00%​
Expenses
Accountant	745	0.52%
Advertising & Marketing	1,669.27	1.17%
Board Certification Fees	350	0.24%
Charitable Contributions	440	0.31%
Credit Card Processing Fees	1,367.57	0.96%
Insurance	3,743.22	2.62%
Medical Billing Services	962.62	0.67%
Medical Society Membership Dues	-60	-0.04%
Office Supplies & Software	3,215.36	2.25%
Other Business Expenses	72	0.05%
Payroll - Employee SEP-IRA	4,729.27	3.30%
Payroll - Taxes	6,493.51	4.54%
Payroll - Wage Expenses	13,369.93	9.34%
Rent & Lease	9,834.30	6.87%
State Medical License	441	0.31%
Taxes & Licenses	1,008.00	0.70%
Utilities	956.42	0.67%
Total Expenses	$49,337.47	34.48%
NET INCOME	$93,757.47	65.52%

93K - ~17.3k SEP-IRA - ~21.2k taxes? = ~54.5k in my pocket

ASSESSMENT:

• Professional Dissatisfaction
• Slow practice growth rate
• Optimization Deficiency
• Infrastructure Deficits
• Retirement Exposure

PLAN:

• In Remission, continue this private practice. Still holding ground on the Never Again policy toward Big Box shops. THE BOSS is starting to push that I take the local Big Box shop job; getting an earful at times and being told wRVU mines build character and the community really needs good miners.
• Okay with current pace, anything more I get behind on notes. Really didn't expect the second wave of original patients dropping off; which ruined the growth experienced from local area. Disappointment that I didn't get to 150+ patient panel size, but actually lower than previous year!
• Still need to bill 90833. Doing great on 96127. Can't drop medicare yet. Get the win for reducing overhead % down.
• Saw positives of old lease drop off and just current cheap lease, that's a win.
• Very low risk of conversion to retirement at this time. Able to resume SEP-IRA deposit for assistant and I again this year. Positively this deposit is close to what it might be at a Big Box shop, so that's an almost win.

[Spoilers for 2024, currently up to ~137 patients, and +11k gross compared to this date 1 year ago. Biggest best insurance is nudging up rates a pinch in few months, that's nice.]

 

[FlowRate]

PLAN:

• In Remission, continue this private practice. Still holding ground on the Never Again policy toward Big Box shops. THE BOSS is starting to push that I take the local Big Box shop job; getting an earful at times and being told wRVU mines build character and the community really needs good miners.
• Okay with current pace, anything more I get behind on notes. Really didn't expect the second wave of original patients dropping off; which ruined the growth experienced from local area. Disappointment that I didn't get to 150+ patient panel size, but actually lower than previous year!
• Still need to bill 90833. Doing great on 96127. Can't drop medicare yet. Get the win for reducing overhead % down.
• Saw positives of old lease drop off and just current cheap lease, that's a win.
• Very low risk of conversion to retirement at this time. Able to resume SEP-IRA deposit for assistant and I again this year. Positively this deposit is close to what it might be at a Big Box shop, so that's an almost win.

Thanks for the update. Did your assistant change physical locations with you, or does she work remote? Given the low pay I was almost assuming the latter. Sorry to hear that growth still isn't as robust/sustained as one would hope.

 

[Sushirolls]

Remote. Part time, stayed in original location.