Private Practice in Progress

[Shufflin]

Are you airway management trained (or someone in your practice)? Or another psychiatrist thinking ketamine is completely safe...

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[TexasPhysician]

Are you airway management trained (or someone in your practice)? Or another psychiatrist thinking ketamine is completely safe...

There is intranasal ketamine.......

 

[Shufflin]

There is intranasal ketamine.......

Yes, but I'd bet that's not what the OP is referring to. Intranasal has barely hit the market, and it's bioavailability is much less that that of IV and the results will reflect this.

Tangent here ~ personally, if something is much more effective for depression you owe it to go for that one in refractory cases. it's faster for the patient too. Intranasal means you sit in the office for 2 hours for monitoring, and it might work.

 

[SourceOfDenial]

Yes, but I'd bet that's not what the OP is referring to. Intranasal has barely hit the market, and it's bioavailability is much less that that of IV and the results will reflect this.

Tangent here ~ personally, if something is much more effective for depression you owe it to go for that one in refractory cases. it's faster for the patient too. Intranasal means you sit in the office for 2 hours for monitoring, and it might work.

Ketamine is already available(and has been for a long time) intranasally through compound pharmacies.

 

[TexasPhysician]

Yes, but I'd bet that's not what the OP is referring to. Intranasal has barely hit the market, and it's bioavailability is much less that that of IV and the results will reflect this.

Tangent here ~ personally, if something is much more effective for depression you owe it to go for that one in refractory cases. it's faster for the patient too. Intranasal means you sit in the office for 2 hours for monitoring, and it might work.

I’ve met psychiatrists using intranasal effectively for years.

 

[TheFuture_22]

Just wanted to pop in and say thanks for doing this! I’m a resident interested in opening a practice one day, and this is very helpful!

 

[Merovinge]

Great post, I have distant dreams of a private practice after I hit several years in a location and know a location well. This definitely helps scratch the itch and is informative as well.

 

[Jules A]

What company are you guys/gals using for credit card processing? What percentage and transaction fees are common now?

 

[Sushirolls]

What company are you guys/gals using for credit card processing? What percentage and transaction fees are common now?

Mine is integrated with the EMR I use. Here are the rates: https://luminello.com/features/credit-card-payments/

 

[Sushirolls]

Great post, I have distant dreams of a private practice after I hit several years in a location and know a location well. This definitely helps scratch the itch and is informative as well.

Why wait? You don't need to know a location well. Google is your reconnaissance friend.
I left one area that was sort of its own location to another adjacent area that's its own location. I knew of the area some rudimentary basics that any one with google and a free afternoon, hot cup of tea, and slippers adorned may have figured out.

-google the hospitals
-google the psychiatric units. Attached to hospitals and free standing.
-google the addiction detox units. The residential programs
-The community mental health centers
-Look up the health systems in the area and see on their websites if they psych providers or mental health department. Call the dept, talk with the secretary, find out how many they really have and what their wait times are.
-look up any large medical groups and see if they have psych people, same thing call up and talk with their front desk.
-look up the smaller independent Psychiatrists, ARNP.
-Look up the methadone clinic locations
-An alternative to google is the psychologytoday website, use this to cross reference the lists you build.
-Look for the closest eating disorder clinic
-Look up the local crisis/911 number
-Establish yourself with a PCP at one of the big box shops in the area for your own healthcare. Then when there, talk with your PCP about local psych referrals and things from their perspective. Talk with the front desk on the way out to see if they have a clinic SW, and if you could get her number. Call and talk with her about the lay of the land and how their referrals go.

-Where to open the office? Where you want. Or go for the usual 'downtown.' Or find a small house you can buy and turn it into an office. Or do what others on here have done and explore embedding yourself within a group of psychologists. Or do some google to find the higher income / house price area of your local area and focus there. Or look at the freeway/highways in your area and choose the best intersection that others will be able to navigate to.

-Once you open your office, send a spam letter (with business cards) to all the PCPs, and therapists in your geographic pull.

*If you have some place that has cable internet, you always have the lifeline of telepsych if you truly choose the worst imaginable location possible.

 

[WisNeuro]

What company are you guys/gals using for credit card processing? What percentage and transaction fees are common now?

Costco offers payment processing that is one of the lowest I have seen. Obviously not integrated with EMR, but has a very low percentage cut.

 

[spaceydaisy]

Thanks so much for doing this! I'm really enjoying following along and I'm picking up a lot of good tips for future since I'm really hoping to set up my own private practice too. I'm just wondering, what's the size of the city/town where you have your practice set up?

 

[Sushirolls]

Town ~160k
Realistic geographic pull 425k from which patients will actually drive for general psychiatry services.

If ECT is up and running, it will expand to a much larger metro.

 

[Sushirolls]

Month Six:

Week one was strangely low, but also heard from other specialties in area there were schedule dips/cancellations. Suspect the local weather change to summer, graduations, school ending, etc. Also learned that one of the local big box shops is taking internal referrals, again, but yet by week two I’m seeing referrals from them, so not sure what’s going on there, or if that organization is so large not every gets the memo when their internal psych is taking new people. Sent an email to referral source within a big box, about not avoiding their referrals, but limitations of not being able to leave voicemails, etc. Response was highly positive and getting good feedback from mutual patients by this provider. Nice to hear positive feedback. Week two is back on track with follow ups and new consults, hoping to see a power week at some point to make up for those two previous low weeks. Last week Friday no patients, scheduled, so took advantage of it as impromptu day off. Feels odd to embrace such flexibility.

Through grapevine of social circles, I reached out to an anesthesiologist who is disenchanted by hospitals and their delivery of health care – more to share on this person’s journey with a big box shop, but not mine to tell. To my surprise this person is truly interested in collaboration! At least I thought I would be a friendly source to tell of successes/pit falls of entry into private practice, but person is interested in both and with psych overlap. Thus, my apathy towards IV access may be solved with Anesthesiologist starting/doing IV ketamine. I’m also looking into complementing this service line with new FDA approved Esketamine, too. This person has also recharged the idea of looking into Ambulatory Surgery Center (ASC) options for ECT to further our collaborations. Which previously I had relegated to dead end, but if you have an Anesthesiologist working with you, that’s a more attractive option to get foot in the door perhaps. I’m reaching out to one of the better paying insurance companies to ascertain if and which fees they’ll pay in ASC – psychiatrist professional fee, anesthesiology professional fee, and facility fee. Plan A still has privileges application at end of month at local hospital (no attached psych unit at this hospital). A lower paying insurance did say that they would cover Psychiatrist/Anesth/Facility fees in ASC if all were in network. Hard to get excited with that news when just one company, and not in writing. Longshot, but called up ECT device companies, and they knew nothing about intersection of facility/insurance/site delivery to see if there were any hidden ASC based ECT practices out there. Confirmed with state medical board for both anesthesiology and psychiatrist no extra regs/rules with IV ketamine administration. Reached out to a GI owned ASC to see if they’d be interested in adjuncting to their facility ECT, we’ll see if they even respond.

Simply put it is my belief in coming years, most, to all outpatient psychiatry will have Nasal/IV ketamine, and TMS in their office. New TMS protocol that provides remission in 5 days, with 3 min treatments, and speed of Ketamine will redirect psychiatry – to data driven remission rates. We can spend 30 years adjusting, tweaking, adjuncting meds for a patient but we shouldn’t. 2-3 failed trials of med/therapy, should kick start discussion of ECT/TMS/Ketamine options (for depression).

Recent issue with Luminello lead to patients not being able to see demographic section to update it themselves. Fiasco for about 2 weeks, but they eventually fixed it. Another cool feature Luminello now offers is the ability have two or more charts for a patient, i.e. patient has their chart, and key family member has their chart. This is great for those of you who do C&A work, but for me its good for geriatrics, or young schizophrenics who have parents more active in care. The bulk of why I’ll use it, a male spouse who just wants the wife to manage things. It has the ability with being two charts, that if patient ever says, hey, uncheck the permissions for family member, it’s a few clicks and done, they’re now disconnected. Definitely a patient centered feature I like over my years spent on Epic. So far Luminello has been getting back to me, even if months later, even with the minor nit pick things to fix.

Can’t wait for receptionist to start, day 1 of month seven. Slowly chipping away at bringing the work station up to speed with computer, scanner, USB hub, office layout, etc. Slowly coming together, every few days chip away at it for 30-60 minutes. Created the email, created the luminello account, and tinkering with the features, I’m quite happy with the permissions the EMR allows to check or uncheck (could even be a good way to get med students integrated, too). I’m all excited about contemplating work flows and efficient pathways, like Homer Simpson and donuts, “hmm… efficiency!”

Got message from landlord, post office should have everything they need to issue a legit address, and I can pick up the keys for the mailbox! Finally, then I will get google to truly certify my address and get out of this greyzone. Oddly, I check on google address status and with ad feature turned off says I’m truly connected to google maps locations. Confusing. Some search permutations my website pulls up high, others I’m low, but its there on the map. So I’ve stopped the adds again. Have keys in hand, and discovered a few undelivered bill statements I sent out. MISTAKE: minor one; but when lease shopping I wish I had confirmed with agent in writing that the space is legit in the eyes of the local government and post office, can they show proof of a mailbox key for the suite?

Interestingly a late career psychiatrist in the area, had updated website 1-2 months ago. Not sure if my entry into local area had anything to do with it. Site looks good, though.

Got a heads up from the local hospital psych doc that mine and the other doc’s credentials packet got approved. However, I’ll believe it once I get a formal letter in mail saying I have privileges. Then the next step, how do I liaise with the right people to improve odds of getting ECT up and running there?

Medicare advantage plans… another doc, learned from a SW or patient, can’t recall, apparently doesn’t take any medicare advantage but just straight medicare. Perplexing at first impression when I learned this. Fast forward a few months, I’m starting understand why, I had my first ‘test’ patient with medicare which was an HMO version, and another HMO person slipped in recently. The patient is medically complex and reminds what my upper level training is capable of. However, no prior auth was done and I’m getting stiffed several visits worth. I was able to get the big box shop SW army to do some PA on my behalf, but they only did it for the next 90 days in future, not retro. My calls to insurance were unproductive and the only way to do their appeal is thru their online forms, no paper. I’ve got so many online accesses and so many websites bookmarked, I’m contemplating cutting my loses and just saying no to any future HMO medicare and possibly medicare advantage. Really need to reflect more on this before decidiing. But next three months for sure I’m going to do what I can for patient.

Year-to-date Business Income -8.6K, balance 3.8K (still no personal income)
Q1 profit/loss -7.7k
Q2 profit/loss -0.8k
If this trend continues, Q3 should be in positive, but receptionist starts day 1 for Q3 (month 7) adding additional overhead expense.

 

[eaglepsych]

“Simply put it is my belief in coming years, most, to all outpatient psychiatry will have Nasal/IV ketamine, and TMS in their office.”

If that’s the case then I fear ketamine dependence could become a massive public health problem... hope I’m wrong.

 

[Sushirolls]

“Simply put it is my belief in coming years, most, to all outpatient psychiatry will have Nasal/IV ketamine, and TMS in their office.”

If that’s the case then I fear ketamine dependence could become a massive public health problem... hope I’m wrong.

I hope a novel oral pill is derived from Ketamine that lacks any addiction potential *fingers crossed*.

 

[TexasPhysician]

“Simply put it is my belief in coming years, most, to all outpatient psychiatry will have Nasal/IV ketamine, and TMS in their office.”

If that’s the case then I fear ketamine dependence could become a massive public health problem... hope I’m wrong.

I have a hard time believing TMS will ever get big. The results are very minimal and not close to ketamine.

 

[FlowRate]

I have a hard time believing TMS will ever get big. The results are very minimal and not close to ketamine.

I'm skeptical on both but the opioid dependence I suspect we'll foster with daily ketamine will take a while to settle out. Hopefully I'm wrong and we'll have two miracle cures for "depression"--whatever that is.

 

[Sushirolls]

I have a hard time believing TMS will ever get big. The results are very minimal and not close to ketamine.

What will propel it forward is the time. Remission in 5 days for TMS. 3 minute treatments and not the usual 20-40min treatments. Even if people don't respond, or remit, a 5 day trial for such a low risk procedure will drive its utilization. Can still do business as usual with SSRI, CBT, etc

 

[TexasPhysician]

What will propel it forward is the time. Remission in 5 days for TMS. 3 minute treatments and not the usual 20-40min treatments. Even if people don't respond, or remit, a 5 day trial for such a low risk procedure will drive its utilization. Can still do business as usual with SSRI, CBT, etc

We must have very different populations. I’ve yet to see a single patient improve with TMS. I’ve found things like Deplin to be more effective.

 

[Sushirolls]

~6 months of true open doors, patient panel is 64 patients. And to my surprise 47% is the more preferred payers, which is up from an earlier 25% several months ago.

 

[AD04]

What are you doing for market? My friend is growing a practice from scratch and it is growing at a nice pace. And that's with an inept secretary turning patients away for a few months saying he's not on whatever insurance panel when he is.

What are you doing when you're not seeing patients?

 

[dl2dp2]

~6 months of true open doors, patient panel is 64 patients. And to my surprise 47% is the more preferred payers, which is up from an earlier 25% several months ago.

With Medicare rate of about ~$200 per visit we are looking at $150k revenue already for med mgmt only, and more if you do more intensive (> 12 visits per year) psychotherapy. In about 1.5 years you'll be at > $450k revenue. This sounds about right.

 

[FlowRate]

With Medicare rate of about ~$200 per visit we are looking at $150k revenue already for med mgmt only, and more if you do more intensive (> 12 visits per year) psychotherapy. In about 1.5 years you'll be at > $450k revenue. This sounds about right.

99214+90834? Hour long visits once a month? I don't know much about billing/coding but does billing all 99214 potentially put you out of the norm / in the sights of auditing?

 

[splik]

99214+90834? Hour long visits once a month? I don't know much about billing/coding but does billing all 99214 potentially put you out of the norm / in the sights of auditing?

90834 is a psychotherapy code, not an add on code. in my area (which has the highest reimbursement for medicare in the country), a 99214+90833 visit would be over $200 (assuming you were able to capture this). bear in mind most private practices don't take medicare for a variety of reasons, including that you don't necessarily get back what you bill (it may be much less), they are very slow about paying vs commercial insurance (it takes months vs a few days with some commercial insurances), medicare reimbursement decreases pretty much yearly (i.e. you got more 5 yrs ago than today!), and if you have >100 medicare pts/collect more than $30k/yr, then you have to participate in MIPS, which in addition to being tedious and leading to possibly having to repay money to CMS, you have to have an expensive EMR to do it right. in short, its not practical for most psychiatrists in private practice to take medicare. to add insult to injury, in many parts of the country, the common commercial insurances pay less than medicare rates for psychiatry!

billing more than 2-5% of your visits as a level 5 follow up might lead to an audit (99205 is fair game for most new visits if you are spending >60 mins with the pt), but 99214 is the standard/default code for most psychiatrists (is for pts with 2 more stable problems, which most patients in an insurance based practice would meet). I have pts I see weekly or twice weekly with not that great insurance and have not had any problems with 99214.

 

[dl2dp2]

90834 is a psychotherapy code, not an add on code. in my area (which has the highest reimbursement for medicare in the country), a 99214+90833 visit would be over $200 (assuming you were able to capture this). bear in mind most private practices don't take medicare for a variety of reasons, including that you don't necessarily get back what you bill (it may be much less), they are very slow about paying vs commercial insurance (it takes months vs a few days with some commercial insurances), medicare reimbursement decreases pretty much yearly (i.e. you got more 5 yrs ago than today!), and if you have >100 medicare pts/collect more than $30k/yr, then you have to participate in MIPS, which in addition to being tedious and leading to possibly having to repay money to CMS, you have to have an expensive EMR to do it right. in short, its not practical for most psychiatrists in private practice to take medicare. to add insult to injury, in many parts of the country, the common commercial insurances pay less than medicare rates for psychiatry!

billing more than 2-5% of your visits as a level 5 follow up might lead to an audit (99205 is fair game for most new visits if you are spending >60 mins with the pt), but 99214 is the standard/default code for most psychiatrists (is for pts with 2 more stable problems, which most patients in an insurance based practice would meet). I have pts I see weekly or twice weekly with not that great insurance and have not had any problems with 99214.

Everything's spot on. Generally to see Medicare patients you'd need to for a government sponsored facility. I see Medicare pts in private and only have private contracts and people pay full fee. It's fine. A lot of retirees can handle once a month psychopharm visits out of pocket if they think your service is worth it.

 

[AD04]

Can someone provide a summary of MIPS requirements or a link that explains it simply?

 

[Jules A]

Everything's spot on. Generally to see Medicare patients you'd need to for a government sponsored facility. I see Medicare pts in private and only have private contracts and people pay full fee. It's fine. A lot of retirees can handle once a month psychopharm visits out of pocket if they think your service is worth it.

Am I correct in that you have to formally opt-out of medicare, at all jobs, for medicare patients to be able to pay cash for services? I have heard if you accept cash from medicare patients at private practice location but bill medicare at your side gig like a local hospital for example you could be liable to reimburse the cash payments you have received.

 

[dl2dp2]

Am I correct in that you have to formally opt-out of medicare, at all jobs, for medicare patients to be able to pay cash for services? I have heard if you accept cash from medicare patients at private practice location but bill medicare at your side gig like a local hospital for example you could be liable to reimburse the cash payments you have received.

This is correct. You must opt out of all Medicare if you opt out.

However, Medicare does not forbid concierge (i.e. membership fee-based practice). Prior to opting out I had for a while charged a membership for Medicare patients in my practice as a non-par provider (which is different from opt out). Turns out this is more complication than it's worth, since patients would then have to file claims to their Medicare plan, which is a huge pain for everyone involved, so I formally opted out so they just pay me cash.

All said, the regulations are very unclear in this area (Medicare based concierge), and there's a dearth of litigation (that would come from the government) that might have clarified these things by case law, but so far the govt isn't interested in suing individual providers. This could change if a lot of people refuse to take insurance (i.e. in a M4A scenario).

Secondarily, in theory you can be denied moonlighting/jobs when you opt out of Medicare. In practice, 1) people don't check; 2) hospitals often bill medicare using some number that's not yours--which is technically is a form of fraud (or at least negligence), but hey who's checking? 3) in many scenarios, your name doesn't even appear during the audit, should such audits ever occur, because the hospitals that hire moonlighters are so disorganized and the moonlighters change so frequently they have a hard time tracking them. They might appear if there's a lawsuit, but people don't get sued often, and even if they do, the court wouldn't care if they paid you $1000 extra when you billed Medicare 5 years ago with someone else's number. Rememeber, institutional responsibilities are diffuse. It's not your fault that the clerk who's supposed to check all this at credentialing didn't know the finer differences between tiers of Medicare participation.

State and CHMC jobs are somewhat different because SMI patients are almost always on Medicare, so you need to be par on Medicare to get those jobs. If it ever get to a point though I'll have to wait 2 years before I can opt back into Medicare.

 

[Sushirolls]

Some organizations will have you sign a statement if you have opted out.
Locums has the ability, to my understanding, to piggy back off of other clinicians numbers or its institutional numbers for their claims submissions to insurance companies for a permissible 90 day period. I wonder though how places get away with this for more than 90 days.

Many psychiatrists have opted out of medicare in the outpatient arena. In my local area I think there are 4-5 who have.
I've stayed in because of the ECT prospect. If that dream dies, I'll likely opt out.

 

[calvnandhobbs68]

Yeah criteria for 99214 is actually not that hard to hit. If you’re doing mostly 99213s you’re probably under-billing or should be cranking those out in under 15 minutes. Most psych patients are gonna hit 99214 criteria unless you’re literally just reordering their Zoloft.

 

[Sushirolls]

What are you doing for market? My friend is growing a practice from scratch and it is growing at a nice pace. And that's with an inept secretary turning patients away for a few months saying he's not on whatever insurance panel when he is.

What are you doing when you're not seeing patients?

See the previous posts for what's been done with marketing. That's fantastic for the friend, hope it keeps excelling. I suspect most locations people will or can have the potential for faster growth than what I'm experiencing. When not seeing patients I'm charting often, or doing residual 'office manager duties.' Like right now, rather than posting on SDN, I should be creating a CMS happy 'Business Associate Agreement' for my receptionist to sign. Basically says follow HIPAA. Or coordinating with anesthesiolgist about possible Ketamine plans, or following up on certain things are easier if I just do it with insurance company than receptionist. As she gets more situated with practice, I'll start to punt these complex issues to her. For instance I got a denial from insurance company saying I'm out of network, when I have a contract saying I am. Why is that? There goes 20-30 minutes of your day. So many other random little things that pop up that suck up your time. And a pinch of my simply poor time management. Or I'm leaving a little early to get to the grocery store in order start making a quality dinner.

 

[Sushirolls]

Month Seven (posted one day early):
Week one, busiest yet! Eight consultations this week! Things already look solid for week 2 & 3.

Finally have a receptionist. Part time, 20 hrs per week, 4 hrs per day. As my schedule is picking up it fuels greater need for her services, but also requires my training for work flow. So lately notes are getting delayed completion with work/life balance. Training takes longer than expected. So many nuances and little tricks for efficiency. New/rusty topic for her has been billing side of things with EOB statements and entering them in Luminello. Catching on quickly. Stellar with phones, nice relief to be more hands off with phones. $21/hr, and additional payroll taxes are ~$1.60/hr. Needed to sit down with accountant and get ‘idiots guide’ to understanding pay roll taxes and reassure that I was enrolling in the right state websites and federal websites to submit required quarterly reports. Positively my operation is small enough that I won’t trigger the certain dollar values that will require monthly reports for some of these agencies. Paying receptionist monthly on final business day of month. Using Luminello calendar in work around way to document time card. Trying to use my EMR to its fullest. I’m optimistic I can handle this amount of payroll, but if things expand, might need to revisit this. Conceptually its strange to place so much trust in someone with duties and logins, etc. But I’m glad I’ve had prior working experience with this person to do so. This fear comes from those stories of office managers ruining a dental practice and absconding with money. First pay day will be end of month, see how that goes. Accountant is willing to review all my math and calculations just before I finalize.

I’m not in network with HMO medicare plans. New policy, not going to accept or do the Prior Auth for these.

Picked up another patient who was disgruntled from ARNP essentially saying she didn’t know what do for patient anymore and find another doctor. In summary no med trials were maximized and med classes were currently prescribed for indications that have no evidence for it. If records come, maybe there might be some decent justification but not holding my breath. I am dreading my geriatric years when the likely treatment for my ailments will be by mid-levels. There have been 2 possible ARNPs I could have started a branch office in a very in demand area. As a business model this makes sense to hire mid-levels, but I just can’t do it. Quality simply isn’t there, if I myself don’t get care from mid-levels how I can offer it to others? Oh, and another former ARNP patient never had 100mg Zoloft increased because of serotonin syndrome fears with PRN use of Maxalt…

*Positively 6+ months into this I have ZERO patients I’m prescribing any benzos/ambien for.
*Positively for past 6 months my designated after hours on call phone has only rang twice.
*Positively for past 6 months I have only done 1 CT Head prior auth, and 2 medication prior auths.
*As mentioned in an above post, panel is about 64 patients. Quality insurance payers are 47% of the mix. This caught me by surprise when a few months back it was 25%.

Mid way thru the month the receptionist has resolved old things that piled up in month six like old bills not yet processed by insurance, following up on those. Or old small dollar values needing phone calls to patients about balances do. About to finish up all the policies for MSDS, safety plans, etc. Supply survey and restocking. And another round of letter advertising, this time to focus on urgent cares. Breathing lighter with this help, and actually have down time where she says, ‘do you have anything else to do?’ She has now even expressed some guilt about being here and logging hours without being constantly busy. I’ve expressed to her not her concern and being able to answer phones is a positive. Already she has captured at least one pt that I might not have. She has recouped dollars from old bills I conceptionally thought wouldn’t have. Also just nice to have another person in the office to talk with on occasion. She hedged her bets, and stayed on as relief with previous job, too. Comments that having seen the greener grass on this side of the fence that if I were to shut this down, etc, she would expend her effort to find a similar set up – i.e. she is happy here.

Good friend (also here on SDN) told me about his need for some telepsych outpatient, and I was very tempted to explore this further and add 8-12 clinical hours to stabilize the finances. But THE BOSS is being very supportive and told me to stay the course without side gigs. I’ve exhausted all personal finances as of 1-2 months ago, and am now dependent on THE BOSS with the expenses on the home front. Potential trade is she might open her own business in coming years and I’ll reciprocate thru her starvation period. She does not want me to unleash the workaholic Kraken and is very supportive of this practice being ‘second tier’ to her career for our personal life obligations.

Receptionist is conceptually struggling with permission to solve things as she sees fit. At this time I’m not sending people to collections or working with a collections agency, so as it starts to look like we won’t collect the full balance due, I’ve given her permission to offer/haggle reduced, or even payment plans for those remaining balances. She has already captured more money then what I would have. (MISTAKE: not being 100% aggressive and having a collection agency contracted with to chase down every dollar of services owed, after adhering to a strict practice policy of unpaid bills. This goes against quality business management, is an affront to the business cycle imperative to not do so – but I’m choosing not to…) Our intake process can actually go 2 different ways presently, I’ve told her to choose/triage as she sees fit to get people in door. She is used to years of being told ‘this is what you do.’ Nope, she has the experience, she believes the vision here, and is fully capable of making that decision herself – and I’m encouraging some of this. I want to use her to her fullest skill set, and a rigid intake process will miss out on some people. She is expressing joy of working with Luminello EMR system compared to her years on Epic – I concur.

I got a phone call from the replacement CEO at the local for-profit psych hospital I was working at in month -1 and month 0. They are in big need of “providers” and now for a medical director. Briefly entertained the idea with a face to face meeting, but the larger corporate entity still hasn’t changed their tune and push patient volume above all else. Despite the possible role of being Med Dir to fight that entropy, and this CEO sounding better, I said no. Long story short it was a good test of the proverbial forbidden fruit to stroke money, ego, and possibly academia with potential to push for student presence. However, this practice dream is the superior plan, and like I said in early postings – I’m not going back. Feels good to have passed a temptation test. To quote some other person on SDN and internet land “The hospital won’t love you back…”

Did my first payroll at end of month. Thankfully the new accountant made a beautiful excel spread sheet with all the with holdings and made it so easy to plug in the hours and *bam* withholdings calculated. Also have an easy to generate pay stub, too. Having spent years with more routine employment, its odd to write a pay check out by hand. Receptionist was surprised to have check on final day of pay period, too, but happy. Thought it was going to be day after.

A C&A doc who expressed interest in joining has again reached out… See what happens here.

Local hospital granted privileges to myself and back up doc. Now to start the networking to see if they'll play ball for ECT, got a meeting for mid/late month 8 to elicit political support with their psychiatry heads.

Covered my overhead for the month including the expense of the receptionist. I am pleased. Onward to the next month!

 

[Sushirolls]

Monthly income (actual collections):
1: $78
2: $1700
3: $1772
4: $4042
5: $6449
6: $6334
7: $7457
Upward trend is continuing. Still no paychecks to me. Still meeting overhead with receptionist in month 7, too.

 

[Sushirolls]

Excell spreadsheet has an interesting extrapolation feature. Kind of cool. Curious to see how the future months match out to these data points.

Timeline	Values	Forecast	Lower Confidence Bound	Upper Confidence Bound
1​	78​
2​	1700​
3​	1772​
4​	4042​
5​	6449​
6​	6334​
7​	7457​	7457​	7457.00​	7457.00​
8​		9099.8438​	7917.36​	10282.33​
9​		10388.71​	9206.22​	11571.20​
10​		11677.575​	10495.08​	12860.07​
11​		12966.441​	11783.93​	14148.95​
12​		14255.307​	13072.77​	15437.84​

 

[MedMan80]

Thanks for the posts Sushirolls, is it typical that most people go 1 year in PP without netting any profit? Just wondering how sustainable this can be, aren't there bills to pay?

 

[Merovinge]

Thanks for the posts Sushirolls, is it typical that most people go 1 year in PP without netting any profit? Just wondering how sustainable this can be, aren't there bills to pay?

Most people I knew who set up a PP did not just go headstrong into it full-time. Sushi has noted doing this related to his significant other/lifestyle considerations. Generally people are working other jobs that help funnel some patients or just pay the bills during this time frame.

 

[TexasPhysician]

Thanks for the posts Sushirolls, is it typical that most people go 1 year in PP without netting any profit? Just wondering how sustainable this can be, aren't there bills to pay?

It’s not typical, but all practices are designed differently.

My understanding is that the above practice just hired a PT secretary 6 months in. MD is doing own billing and navigating insurance issues. That stuff is complicated. I had a FT secretary a month BEFORE I opened. I was advertising a month before as well. I spent more time on networking, marketing, and advertising than medicine. In the end, I’m sure Sushi’s practice will thrive. It’s just a matter of how you want to get there and where you want to spend your money.

 

[Armadillos]

We must have very different populations. I’ve yet to see a single patient improve with TMS. I’ve found things like Deplin to be more effective.

What treatment settings are they getting? Sounds like pts being under-doses or coil placement is not good

As an aside, I want to start trying some folks on deplin. Looks expensive, does insurance cover? Are these OTC generics claiming to be same legit?

 

[Sushirolls]

It’s not typical, but all practices are designed differently.

My understanding is that the above practice just hired a PT secretary 6 months in. MD is doing own billing and navigating insurance issues. That stuff is complicated. I had a FT secretary a month BEFORE I opened. I was advertising a month before as well. I spent more time on networking, marketing, and advertising than medicine. In the end, I’m sure Sushi’s practice will thrive. It’s just a matter of how you want to get there and where you want to spend your money.

Exactly. My approach is quite different from TexasPhysician. That's the fun and beauty of this whole process. Plan out every minutiae or just dive in. You've got options and a range of how to do things. Don't draw any conclusions from my story as truth. Just consider it for what it is, an N of 1, an extra data point.

The benefits for others with my story is the ability to see what an almost 40 hour work week practice growth can look like in a mid size market with decent ARNP penetration. Perhaps a better placement of my practice trajectory is on the conservative side, a bench mark, that if people want faster growth they do things differently to achieve it.

MISTAKE: The other aspect of my practice that is limiting growth is calling in doesn't lead to an automatic appointment. This is a barrier on my referrals from Inpatient discharges and some inquiries for sure. I divert people to my website to start the process of doing an online Luminello intake with all the policies, questionnaires etc. In other words people who are technologically functional are getting in the door. By emphasizing Luminello I can have more robust consults and spend less time on the factoids. A previous job I had, the intake packets were mailed to patients, and often the weren't filled out. With requiring it be completed on Luminello first, I can wait to open the online booking until after its done. To simply get patients, this is a MISTAKE.

 

[Sushirolls]

Thanks for the posts Sushirolls, is it typical that most people go 1 year in PP without netting any profit? Just wondering how sustainable this can be, aren't there bills to pay?

I originally planned and prepared financially for 6 months of nothing, with expectation that in months 4-6 I would start to see money in my pocket. I have used up my reserve funds on the personal home front, and now am being floated by The Boss. When side gigs have presented I consider them, and present them to The Boss, who at this point is telling me to stay the course and not add extra gigs. Historically I have functioned in the capacity of working long and hard, like husky wanting and yearning to pull the sled, embodying the classic physician paradigm, work before family. The Boss is saying otherwise.

 

[FlowRate]

To simply get patients, this is a MISTAKE.

The upside being an implicit screening for, at least in some ways, higher functioning patients, if that's something you'd like in the long run.

IIRC you're paying way more for space in hopes of doing TMS/Ketamine than you would be otherwise, so you probably would have been making a profit by now if you were more a single room + waiting area, right?

I wonder if that CAP (or anyone else) would jump at renting space as a way of defraying that cost.

 

[Sushirolls]

The upside being an implicit screening for, at least in some ways, higher functioning patients, if that's something you'd like in the long run.

IIRC you're paying way more for space in hopes of doing TMS/Ketamine than you would be otherwise, so you probably would have been making a profit by now if you were more a single room + waiting area, right?

I wonder if that CAP (or anyone else) would jump at renting space as a way of defraying that cost.

Yeah, my overhead really hurts. And I would be in profit if the lease were less of a budget consumption.
The subleasing is tempting, but there are pages in my lease contract that are a barrier, and essentially means the landlord gets their fingers involved heavily with any subleasing, that its almost an incentive to do employed or partner with folks just to avoid that. MISTAKE: lease contract details unfriendly to subleasing

 

[MedMan80]

It’s not typical, but all practices are designed differently.

My understanding is that the above practice just hired a PT secretary 6 months in. MD is doing own billing and navigating insurance issues. That stuff is complicated. I had a FT secretary a month BEFORE I opened. I was advertising a month before as well. I spent more time on networking, marketing, and advertising than medicine. In the end, I’m sure Sushi’s practice will thrive. It’s just a matter of how you want to get there and where you want to spend your money.

Did you have a FT or another PT gig to supplement while you were building your PT? What part of TX are you in if you dont mind me asking? I'm looking towards TX in the next 3-5 years

 

[TexasPhysician]

Did you have a FT or another PT gig to supplement while you were building your PT? What part of TX are you in if you dont mind me asking? I'm looking towards TX in the next 3-5 years

I did work PT elsewhere to support my expenses at the beginning.

For the sake of anonymity, I’ll keep my location a secret. That said, I don’t think my specific location is that special. Any reasonably sized city outside of NYC, Cali, and Boston probably could use more psychiatrists.

 

[MedMan80]

I did work PT elsewhere to support my expenses at the beginning.

For the sake of anonymity, I’ll keep my location a secret. That said, I don’t think my specific location is that special. Any reasonably sized city outside of NYC, Cali, and Boston probably could use more psychiatrists.

Fair enough, although tbh..after training in NYC seems that there's never enough CAP to meet the demand

 

[TexasPhysician]

Fair enough, although tbh..after training in NYC seems that there's never enough CAP to meet the demand

Probably true. I just always here about fellow intelligent minds moving to NYC, Boston, and the west coast so I assume it’s harder to start there. I never hear groups of psychiatrists flocking to Ok City, Little Rock, Fort Worth, etc.

 

[WisNeuro]

Probably true. I just always here about fellow intelligent minds moving to NYC, Boston, and the west coast so I assume it’s harder to start there. I never hear groups of psychiatrists flocking to Ok City, Little Rock, Fort Worth, etc.

From a bunch of recent articles, apparently Oregon has a pretty severe shortage. We're looking a shortage in our system, with our hospital in particular here in the Midwest. Last rumors I hear was to try to just get a psychiatrist in and then fill in with some midlevel prescribers to supplement given the difficulty in recruitment and retention with those positions here.

 

[deleted736562]

Fair enough, although tbh..after training in NYC seems that there's never enough CAP to meet the demand

Beg to disagree. Maybe in Manhattan but everywhere else in nyc shortage is severe for cap.

Edit: nevermind I think I misread your post.

 

[AD04]

I spent more time on networking, marketing, and advertising than medicine.

What did you do for marketing and advertising?