Private Practice in Progress

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Consults are in person. Unless they are calling from my old office location and would be suitable for 100% tele.
After seen for the initial consult, its up to the patient to decide future visits for in office or tele. *unless controlled substances, I'll require certain frequency of in office visits. I'd say about 60% opt for tele, 40% prefer in office.
 
Is the Payroll for wages, taxes, and SEP-IRA for your assistant? That together is about 18% of your gross revenue, so pretty big overhead cost.
 
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Yes, those are for the assistant. It is a big piece of the overhead. However, with this being an insurance based practice the amount of work done, its worth every penny. With out that work, I couldn't do it all. Simply impossible. I'm always fortunate her skills are on the upper end of customer service, and she's dependable, and likes the part time nature to current work hours.

If I were say, at ~200 patients and having ~16 clinical hours per week of work, that could in theory equal Gross of ~283K and the overhead would be very similar to that current ~50k mark. So here on up, growth is money in pocket. I just need to get away from this inflection point on the graph of fixed costs. It is a glaring light on why, if doing insurance, people shouldn't think of a light part time practice but focus on a moderate to full time level of practice if doing insurance based, because of the fixed overhead.

I could possibly stop paying monthly website maintenance of $100/month and pocket 1200 more per year, but then if website goes down, I have to figure that out. So as tempting as that is for a low lying fruit, I'll likely not strike it.
 
Your obviously improving year over year esp with the decrease in overhead.

Would you ever consider consolidating your practice into 1-2 days and supplement it with another job till your practice fills up fully?
 
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Those thoughts cross my mind at times.
New rural location just made such options geographically farther; and as I'm the more active parent for kid stuff I can't flip the switch for work-a-holic. Fully capable of doing that, but with me being more the 'soccer mom' I have less possible work time, and need to optimize it, which leaves me right where I am.

Get more patients up to volume "Full"
Then cut out medicare and lower paying insurance
Get back to full.
Re-evaluate what to do. Build office? Go for building equity? Expand to bring on psychologists? Make no changes and just dump money into farming to leave medicine as fast as possible?
 
This looks good especially for essentially starting over in new state. Personally I wouldn’t sell myself short and would instead look at it as $71.8 in my pocket. The tax deferred in SEP plus growth will be in your pocket one day.
 
Sushirolls said:
I could possibly stop paying monthly website maintenance of $100/month and pocket 1200 more per year, but then if website goes down, I have to figure that out. So as tempting as that is for a low lying fruit, I'll likely not strike it.
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That's pretty pricey. What goes into that $100/mo? I pay $20/mo for my website through Wordpress (now transferred to SquareSpace) and it's never gone down.
 
I guess it depends on what you are doing with your website. If it's just a basic HTML website, you don't need to pay that much money. I use Github Pages (with Github Pro) and Namecheap. It costs $48/year for Github Pro (which is necessary to keep your repository private) and $16/year for the domain name on Namecheap.

I just edit the HTML files myself when I want to make a change. This is very easy with the ability to view the changes yourself (because it is HTML, so you can just open the file locally in your browser before you drag it to Github pages to upload it) and the new LLMs. Maybe I'm missing something, but I don't see why it is necessary to pay more than this.

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

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

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

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

I may consider ECT again in the future if I learn about the outcome of 1-2 places I'm aware of that may be doing ECT in ASCs. If the private insurance companies truly will pay for ECT professional fee to Psychiatrist / Professional fee to Anesthesiologist / AND FACILITY fee to an ASC, then that is a game changer. I might consider running the bureacratic gauntlet in a 'Certificate of Need' state to open my own ASC in years to come, and having my own designated ECT suite - even though I won't be able to see any CMS patients there. ECT belongs in ASC, not hospitals.
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Sushirolls said:
PRIVATE PRACTICE CHECK LIST GUIDE
  1. Chicken and egg stuff here. You need an address.Ideally an actual office, but if you are resident, consider using a UPS store and the suite boxes.
    1. You could actually find some office to sublease from, and ideally get to use the address before you actually get keys in hand and start seeing patients there months in advance. If you are a resident, reach out, network with people.
    2. If you have just left your job, and are doing this in haste, you can possibly pull of a 3 month turnaround, I'm witnessing a Sleep Doc do this in 90 days right now.
  2. Call a lawyer, Form business LLC or PLLC, Get Federal Tax ID number (EIN) and state business number/license. This will need the above address.
    1. Can you be cheap and do this online some how, yeah, but this is going to be your livelihood, go get your questions answered from an expert, pay the lawyer their money. I spent $800-1000 on this.
    2. The lawyer won't care or know anything more than getting you incorporated. Tax structure questions are for your accountant. C, or S, etc
    3. Try to choose your LLC/PLLC name well. You can always have a DBA (doing business as), but its good to choose well right from the start. I didn't...
    4. If you are going to mostly just be solo or only hire employees, save you money and don't bother with the extra cost of 'articles of incorporation.' Unless it is needed for your state. If you plan to have partners or other members with ownership stake in your corporation, then yes, you need those articles of incorporation.
    5. Be aware you may have an email listed on this formation as public knowledge. This document potentially is 'permanent' even if you update your biz details later in coming months years. Sooo, doing step 5 and 6 first be a better order? but then you just made your first payments for your website and Gsuite with personal money. But its easier to update website domain ownership in future to reflect business details and not personal, in coming weeks, compared to the business formation. So, yeah, doing 5 & 6 first might be best.
  3. Once in hand ~1-2 weeks later, Open up bank account and get printed like 2-6 free checks, you'll need these.
    1. Deposit a chunk of money. Depending on what you are doing, 5k at minimum on up to 30K, anything more than that, I hope you have a serious business plan or really know what you are doing?
  4. At a minimum get your Visa debit card that day… Really need this!
    1. Consider getting an actual Business Credit Card, too. Pros and cons to this. It will take another week or so to arrive.
  5. Buy your website domain. Use GoDaddy to locate a domain.
  6. Open a GSuite account and get your email set up so it has [email protected]
    1. Get a Google Voice Number to be your office number. You can always PORT this number away from Google to an actual phone company if needed later. Just get a phone number.
    2. If you don't want to figure out how to set up your domain, you will likely be able to get the website company you contract with to do it for you.
  7. Use SRFax to get a number. You can always PORT this number into your EMR later if it has built in fax or to another service.
  8. Find a small accountant operation. Or a solo accountant. Seriously, your business is not that complicated, and no you don't need the large Big Box Shop accounting firm to rob you of your money. The independent main street Gal will also answer all your ridiculous questions in a timely fashion, too. Go main street. And go meet them in person and get your questions answered. You may learn that until you are bringing in consistent bigger dollars, you won't really need any fancy accounting other than an extra addendum page on your personal taxes. They'll explain your options. Let your accountant know, they'll be happy, you are doing step 17.
  9. Log in to State Department of Revenue or Secretary of State, or Business Whatever Government Bureaucracy Flavor Agency you'll need to report to; to get a business license (and where you pay the state monthly taxes or quarterly taxes). Insert perfect Ron Swanson quote here.
  10. With EIN, mailing address, and PLLC/LLC information in hand, create a type 2 NPI number for your business
    1. Nppes.cms.hhs.gov/
  11. Update your NPI details for your new practice (current residents don't do this until 7/1/FREEDOM year)
  12. Update your DEA details (current residents don't do this until 7/1/FREEDOM year)
  13. if this is your main practice, whatever DEA you have now, you can actually change the state details on and 'port' it to your new location. Save yourself the money and don't get a new one.
  14. Update your details for the Rx PMP program your state has, or start the process to get it for whatever state you are going to.
  15. Update all your society and medical license addresses
  16. START UPDATING YOUR CAQH PROVIEW profile and information with
    1. Pecos.coms.hhs.gov/
    2. Nppes.cms.hhs.gov/
    3. Don't yet sign, or authenticate stuff yet. Just get started on it.
  17. Buy an annual quick books online subscription ~$300/year if paid in advance, link it to your bank account
    1. Send the email invite to your accountant so they can log in and see your numbers when they need to
  18. Target your clinic open date for 90 days from the start of step one above, if you plan to devote resident/moonlighting type hours towards getting this beast up and running. I.E. You will be busy every day, and overwhelmed with the sheer paper work of bureaucracy WTF. Just remember Freedom is your Prize.
  19. And pre-pay for your part time liability insurance to start on this date. I suggest using PRMS, and opt for their Part Time, Occurrence based. Seriously, don't be cheap, get occurrence based, don't do claims made.
  20. Pay/sign up for your EMR, and for Psychiatry or Child/adolescent Psychiatry it is hands down, LUMINELLO. No debates. Using their integrated ApexEDI billing feature and even their new Invoice Tracker. Dollar for Dollar, this is the MMA note fighter that will get you the championship belt.
  21. Go back into the PECOS, CAQH, NPPES, etc and update them again with your liability stuff, etc. Now you can probably ‘authenticate’ or ‘complete’ your applications/data.
  22. Start the process of filling out forms to get paneled with insurance companies. Use your shiny new email address. This part sucks.
    1. Keep an excel list and save all communications received from them. Depending on if you are only doing 1-2 or 10+ you will still feel a bureaucracy headache. I had paid people to do this in the past. I wish I hadn't. I'm helping a Sleep Doc get up and running, and this person took my advice and doing it 100% themselves. So much easier and no data mistakes. Wish I had saved myself the money and done it myself.
    2. You'll need a fee schedule. Come up with your fee schedule and all the CPT codes you plan or even think you'll bill for in the future. Some want this fee schedule, most don't care. But you'll need anyways for step 28.
  23. Start working on your logo for your website. Go to 99designs.com, and pay their $500-1000 or whatever it is to get a logo. Kind of a daunting process to figure out, but if you stick with it, and call the company when you got questions you'll be happy you did. But spend 2-3 days digging around the internet, and reflecting an thinking about What Do You Really Want - before you sign up. My logo is meh. The Sleep Doc I'm helping, took my advice and just WOW, got a quality logo, and one that reflects that doc. Really professional and amazing. At the end make sure you get the .AI, .JPG, .GIF, .SVG, .PNG files in light and dark forms of your logo +/- any clinic name text that coincides. They will also have options for things like letter head, business cards, etc.
  24. Use VistaPrint to use those logo images to create your own PDF to form your own business card, or use the ones created by 99designs. Order up 500 at a minimum. Also get maybe 500 of your letter head too. Treat yourself, get something cheesy too, maybe mugs, post it notes, pens, whatever.
  25. Open up some Word Documents. Start typing your website content. This part sucks. I know you want to procrastinate at this point, but don't flake out now, you've made it this far. Pretend you are back in a college humanities 101 class with barely a care in the world, or if you are an IMG, pretend you are entering the American undergrad experience and start typing. You need the meat, the stuff you plan to put on your website. Dig around other peoples sites for inspiration if you are having writers block.
    1. Save the websites, and make notes of the cool sites you come across that make you think 'wow I want that'
  26. Call a professional photographer. No, not Auntie Shruti or Uncle Nguyen, to come snap a photo of you by the shrubs in your front lawn. Go get an appointment and pay a pro to get your mug shot. Actually get yourself looking nice - definitely more than you've been doing during Covid-19. And a contract that you get full ownership of the images, and don't need to quote/reference them on any digital media they are used in...
  27. Reach out to a website firm. Google up your local main street options for website developers. There are so many website development options. But count on spending 2.5-4K just for the website. Talk with them about their SEO, and also ask them about their website maintenance/hosting packages ($50/60) a month. Review these contracts. You want something that is dual functional for ol' lappy and for the smart phones.
    1. Be like hey, I'm on top of this, I already content for you! They will be happy.
    2. Also be like hey, I came across 25.1 above, and these will help you with your creativity and creating something that is pleasing to me.
  28. Keep chipping away at the EMR to make it your own with note templates. Start creating your policies and privacy practice forms, etc. To get incorporated into your website and/or EMR.
    1. Start working on getting the E-prescribing activated with the EMR
    2. Start working on getting the lab integration, (low priority honestly) with the EMR
    3. Start working on getting the ApexEDI clearing house integrated with Luminello and as the Insurance contracts come thru, the ERA/EFT enrollments.
    4. Integrate with Doxy.Me for your telemedicine. You know, Covid-19, this thing going on that forced every one into telemedicine?
    5. Buy a webcam. Something. Don't over think it.
  29. Got an empty office? Look for the closest big city and see if they have a second hand office warehouse. Basically when other businesses go bankrupt, or upgrade, their stuff goes here. Even plants! Which, actually are expensive. Good prices, good products, and won't break the bank for getting the office filled with stuff.
    1. You also need a computer or lap top. Microsoft word/ppt/excell/etc package. A fujitsu scansnap ix500 scanner or whatever the current version is. OMG don't skimp here, get this. Antivirus software. A printer, I highly suggest Brother. Don't get color. Just cheap, basic black white 2 sided printer. It will be your Massey Ferguson tractor, and just keep on plowing. Remember to use your business debit (or credit card) to buy all this stuff.
    2. If you haven't, update your quickbooks for all these purchases. Get used to this new behavior. Stay on top of it.
    3. Don't forget to save every receipt. Dump it into your GSuite Google Drive for your business. Come up with a filing/organization system. I suggest folders of whatever label and using year, like 2020-07-12 Another Business Expense.PDF
  30. If you haven't realized it yet you need to store your logins and passwords some where, some how. They are piling up. Don't lose them.
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Great post. I used the invaluable information in this to start my own practice. Highly recommend bookmarking it for any fellows looking to start on their own. Thanks for posting this long ago Sushirolls 👍
 
Thoughts on starting a private practice in PGY4? Could this turn a profit/attract patients? Would it have to be cash only because insurance wouldn’t reimburse me as non board eligible for the first 6 months? I don’t know how I would advertise myself, don’t feel comfortable saying I am a psychiatrist just yet (though my understanding is that’s incredibly not a protected term). I do feel like I could do a decent job if selecting patients carefully once done with my outpatient year, and have money to get it going from other moonlighting. Alternatively, could look at working with a company during pgy4 for outpatient. I just like the idea of getting a small (1 day a week ideally) private practice set up asap. Would love to hear if anyone did this during residency.

As others have echoed, really appreciate the blue print for getting things set up, regardless.
 
Cath Up said:
Thoughts on starting a private practice in PGY4? Could this turn a profit/attract patients? Would it have to be cash only because insurance wouldn’t reimburse me as non board eligible for the first 6 months? I don’t know how I would advertise myself, don’t feel comfortable saying I am a psychiatrist just yet (though my understanding is that’s incredibly not a protected term). I do feel like I could do a decent job if selecting patients carefully once done with my outpatient year, and have money to get it going from other moonlighting. Alternatively, could look at working with a company during pgy4 for outpatient. I just like the idea of getting a small (1 day a week ideally) private practice set up asap. Would love to hear if anyone did this during residency.

As others have echoed, really appreciate the blue print for getting things set up, regardless.
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You are a psychiatrist with 3 years of experience who is finishing their final year of residency and will become board-eligible in X months. Don't sell yourself short.
 
Say you are a Psychiatric trained physician, or Psychiatric Focused Physician.

Solicit the same way as others, provide your card when you are on inpatient unit - get approval from PD first before soliciting from training populations. Or even the residency clinic.

The bigger issue, is this just a small time block clinic for moonlighting goals? Or is this your home where you plan to stay after training and will continue the clinic? A PD is more likely to give their blessing if you are staying, i.e. patient continuity. But if you are leaving you need to have another younger resident on standby to take over July 1st. There was PGY3 years ago, at CCF, who got a cash suboxone clinic going during the era of DEA X waivers, and that resident did the clinic on weekends and handed off to younger resident once finished training.

You'll need a website, office space, etc. By opening it up now, you will get the headache of establishing it done, and working out some kinks early, so once you are done with training its ready to blossom. So lower expectation of it being money maker, and assume it will lose money, but your prep work will be complete, and that's something!
 
Stagg737 said:
You are a psychiatrist with 3 years of experience who is finishing their final year of residency and will become board-eligible in X months. Don't sell yourself short.
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Much appreciated.
 
Sushirolls said:
Say you are a Psychiatric trained physician, or Psychiatric Focused Physician.

Solicit the same way as others, provide your card when you are on inpatient unit - get approval from PD first before soliciting from training populations. Or even the residency clinic.

The bigger issue, is this just a small time block clinic for moonlighting goals? Or is this your home where you plan to stay after training and will continue the clinic? A PD is more likely to give their blessing if you are staying, i.e. patient continuity. But if you are leaving you need to have another younger resident on standby to take over July 1st. There was PGY3 years ago, at CCF, who got a cash suboxone clinic going during the era of DEA X waivers, and that resident did the clinic on weekends and handed off to younger resident once finished training.

You'll need a website, office space, etc. By opening it up now, you will get the headache of establishing it done, and working out some kinks early, so once you are done with training its ready to blossom. So lower expectation of it being money maker, and assume it will lose money, but your prep work will be complete, and that's something!
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I appreciate this.

I would like to have 1-2 days a week of a private practice alongside locums once I graduate so this would work towards that. One issue is that I don’t currently live where I will be practicing (though do have a state license there and in the state I am training in) so visits would need to be virtual until I move.

I am not concerned with my PD’s permission, they are very likely to approve, very supportive.

Also not a huge concern that it wouldn’t be a money maker- interested in the process and getting the paperwork done while I may have some time to twiddle my thumbs during fourth year. Though, I’d hope to at least bring something in. Would any insurance/medicaid/medicare reimburse for this, or would it make most sense to stick to only cash?
 
Short answer stick to cash, maybe explore slowly one insurance at a time. But you will most likely need an office lease in that area.
A lot of things will tie back in to needing an address / office in that location.
 
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