Private Practice in Progress

[WisNeuro]

The businesses that assist you are the clearinghouses I referred to so yes if you submit your claim through a clearinghouse or if your biller does that makes you a covered entity.

I'm not making any claim. I'm just saying it's not for sure illegal like was implied above. I doubt any state has a statute that explicitly denies someone the right to their medical records but does every state have a statute that explicitly states that you have the right to your medical records and under what timeframe? I do not know the answer. I wouldn't assume they all do though.

Considering the possible repercussions as a provider, I would.

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[WisNeuro]

Additionally, from AMA CoE

"

Code of Medical Ethics Opinion 3.3.1​

Medical records serve important patient interests for present health care and future needs, as well as insurance, employment, and other purposes.


In keeping with the professional responsibility to safeguard the confidentiality of patients’ personal information, physicians have an ethical obligation to manage medical records appropriately.


This obligation encompasses not only managing the records of current patients, but also retaining old records against possible future need, and providing copies or transferring records to a third party as requested by the patient or the patient’s authorized representative when the physician leaves a practice, sells his or her practice, retires, or dies.


To manage medical records responsibly, physicians (or the individual responsible for the practice’s medical records) should:

1. Ensure that the practice or institution has and enforces clear policy prohibiting access to patients’ medical records by unauthorized staff.
2. Use medical considerations to determine how long to keep records, retaining information that another physician seeing the patient for the first time could reasonably be expected to need or want to know unless otherwise required by law, including:
   1. Immunization records, which should be kept indefinitely
   2. Records of significant health events or conditions and interventions that could be expected to have a bearing on the patient’s future health care needs, such as records of chemotherapy
3. Make the medical record available:
   1. As requested or authorized by the patient (or the patient’s authorized representative)
   2. To the succeeding physician or other authorized person when the physician discontinues his or her practice (whether through departure, sale of the practice, retirement, or death)
   3. As otherwise required by law
4. Never refuse to transfer the record on request by the patient or the patient’s authorized representative, for any reason.
5. Charge a reasonable fee (if any) for the cost of transferring the record.
6. Appropriately store records not transferred to the patient’s current physician.
7. Notify the patient about how to access the stored record and for how long the record will be available.
8. Ensure that records that are to be discarded are destroyed to protect confidentiality.

 

[trophyhusband]

Considering the possible repercussions as a provider, I would.

I mean I'm assuming people look at their own state laws and figure that out for themselves. Probably giving folks too much credit though.

Anyway, I only bring it up because I'm my wife's assistant and was just recently looking at the statutes for two different states because one doctor's office is give us a hard time about getting records for a patient. His office is in one state so I looked theirs up but then realized the patient was seen in another state. The two statutes were pretty different in the timeframes allowed and lord only knows what the statutes of other stay say or don't say.

 

[WisNeuro]

I mean I'm assuming people look at their own state laws and figure that out for themselves. Probably giving folks too much credit though.

Anyway, I only bring it up because I'm my wife's assistant and was just recently looking at the statutes for two different states because one doctor's office is give us a hard time about getting records for a patient. His office is in one state so I looked theirs up but then realized the patient was seen in another state. The two statutes were pretty different in the timeframes allowed and lord only knows what the statutes of other stay say or don't say.

Yes, timeframes and allowable charges for copying and sending may differ, but I sincerely doubt that any state allows complete withholding of records due to nonpayment.

 

[trophyhusband]

The AMA doesn't have the force of law behind it and if you're not a member of the AMA (which I don't think most docs are) does anyone even care what they think? I honestly don't know.

 

[WisNeuro]

The AMA doesn't have the force of law behind it and if you're not a member of the AMA (which I don't think most docs are) does anyone even care what they think? I honestly don't know.

State boards generally follow these guidelines. I can be brought up for corrective action or license removal by my board for violating either state statutes or my APA ethical codes regardless of whether I am a member of the organization.

 

[trophyhusband]

Yes, timeframes and allowable charges for copying and sending may differ, but I sincerely doubt that any state allows complete withholding of records due to nonpayment.

I work for an insurance company in Operations & Compliance (and before that Finance) after digging through State and Federal statutes for years now I assume nothing.

 

[Stagg737]

Yes, timeframes and allowable charges for copying and sending may differ, but I sincerely doubt that any state allows complete withholding of records due to nonpayment.

Actually, just looked up my state laws:

"Health care providers may condition the furnishing of the patient's health care records to the patient, the patient's authorized representative or any other person or entity authorized by law to obtain or reproduce such records, upon the payment of charges not to exceed those established and updated not less than every two years by rules and regulations adopted by the state board of healing arts."

So sounds like records can be legally withheld until certain payments are made. Not 100% sure what specific charges would be included as it's pretty non-descriptive, but it does sound like it's technically legal in my state. Correct me if I'm interpreting the above incorrectly.

 

[trophyhusband]

Actually, just looked up my state laws:

"Health care providers may condition the furnishing of the patient's health care records to the patient, the patient's authorized representative or any other person or entity authorized by law to obtain or reproduce such records, upon the payment of charges not to exceed those established and updated not less than every two years by rules and regulations adopted by the state board of healing arts."

So sounds like records can be legally withheld until certain payments are made. Not 100% sure what specific charges would be included as it's pretty non-descriptive, but it does sound like it's technically legal in my state. Correct me if I'm interpreting the above incorrectly.

That's referring to fees that can be charged to provide the records. Depends on the state but usually around $25 or something. I think HIPAA has a limit on charges that can be assessed as well.

 

[WisNeuro]

Yeah, those sound like the record reproduction fees. Our state sets a limit on how much we can charge for copying and mailing records. Here it's a per page fee.

 

[splik]

Actually, just looked up my state laws:

"Health care providers may condition the furnishing of the patient's health care records to the patient, the patient's authorized representative or any other person or entity authorized by law to obtain or reproduce such records, upon the payment of charges not to exceed those established and updated not less than every two years by rules and regulations adopted by the state board of healing arts."

So sounds like records can be legally withheld until certain payments are made. Not 100% sure what specific charges would be included as it's pretty non-descriptive, but it does sound like it's technically legal in my state. Correct me if I'm interpreting the above incorrectly.

As mentioned above you can only charge for the administrative costs of providing records, not withhold them for unpaid medical bills. Even if your state did have a law allowing you to do so, it would still be illegal. Supremacy clause means federal law trumps state law and HIPAA is very clear on this and HHS will investigate and come after you

 

[TexasPhysician]

As mentioned above you can only charge for the administrative costs of providing records, not withhold them for unpaid medical bills. Even if your state did have a law allowing you to do so, it would still be illegal. Supremacy clause means federal law trumps state law and HIPAA is very clear on this and HHS will investigate and come after you

For those that don’t take insurance, HIPAA does not apply. That said, my state considers medical records to be owned by the patient. We are just in charge of storing them. A few for admin to process them is reasonable, but we can’t withhold them otherwise.

 

[VA Hopeful Dr]

For those that don’t take insurance, HIPAA does not apply. That said, my state considers medical records to be owned by the patient. We are just in charge of storing them. A few for admin to process them is reasonable, but we can’t withhold them otherwise.

Some states (like mine) do not let you charge if another medical provider requests the records.

 

[WisNeuro]

Some states (like mine) do not let you charge if another medical provider requests the records.

Ours lets us charge, but it's like 1.23 a page, so collecting that $15-20 for an odd report here and there is really more trouble than it's worth.

 

[trophyhusband]

Well the wife got her first 1 star Google review from a patient she dismissed due to no showing two appointments and then late canceling her last two appointments.

I let the former patient know that we attached the policy that they signed (stating that 3 missed appointments of any variety was grounds for dismissal) in their chart and that a message was added about the review and noting all of the missed appointments was also added. I let them know that any provider that requests the records will see those notes.

The review has magically disappeared... feels like a small victory and wanted to share.

 

[MedMan80]

Well the wife got her first 1 star Google review from a patient she dismissed due to no showing two appointments and then late canceling her last two appointments.

I let the former patient know that we attached the policy that they signed (stating that 3 missed appointments of any variety was grounds for dismissal) in their chart and that a message was added about the review and noting all of the missed appointments was also added. I let them know that any provider that requests the records will see those notes.

The review has magically disappeared... feels like a small victory and wanted to share.

Nicely done

 

[FlowRate]

Well the wife got her first 1 star Google review from a patient she dismissed due to no showing two appointments and then late canceling her last two appointments.

I let the former patient know that we attached the policy that they signed (stating that 3 missed appointments of any variety was grounds for dismissal) in their chart and that a message was added about the review and noting all of the missed appointments was also added. I let them know that any provider that requests the records will see those notes.

The review has magically disappeared... feels like a small victory and wanted to share.

Was it just obvious which pt it was or did you have to do some sort of sleuthing to figure it out?

 

[trophyhusband]

Was it just obvious which pt it was or did you have to do some sort of sleuthing to figure it out?

Obvious because their name was on it but also obvious because it was the day after she was notified she was dismissed from the practice.

 

[Bartelby]

On the one hand well done! It's nice to see justice served

On the other hand tread carefully. Since the reviewer was identifiable your response could be viewed as disclosing protected health information (information about her appointment attendance with your practice) in a public forum. I doubt anything would come of it, but a person's pattern of attendance at psychiatric appointments would probably be viewed as needing a release to disclose.

 

[Sushirolls]

Here's a good thread over in the IM section about Online Reviews

Patient Online Negative Reviews As A Threat

We all have our fair share of crazy patients, unhappy patients. However, this trend of patients threatening negative reviews in order to get their way is alarming and frustrating. In the past 2 weeks we have had 3 patients all call in and demand something and if they don't get it they threaten...

forums.studentdoctor.net

State I'm in actually passed some laws protecting people who leave bad reviews basically indemnifying the ability to leave a review and say whatever you want negatively.

 

[trophyhusband]

On the one hand well done! It's nice to see justice served

On the other hand tread carefully. Since the reviewer was identifiable your response could be viewed as disclosing protected health information (information about her appointment attendance with your practice) in a public forum. I doubt anything would come of it, but a person's pattern of attendance at psychiatric appointments would probably be viewed as needing a release to disclose.

No, no. I did not reply to the review. I know better than that. I called the patient (several times but they never seem to answer their phone which is consistent with how much they checked their portal messages) and left a voicemail. I had it all typed out before hand and strictly stuck to the facts. It helped that they were being treated for ADHD so their Rx is in the state database and I was able to mention that even if they didn't tell their new provider about her previous doctor that they'd see who was prescribing for them in the database and would likely contact her for info (maybe a slight embellishment). And I noted that my wife always provides records as a matter of courtesy for coordination of care.

 

[Mass Effect]

Here's a good thread over in the IM section about Online Reviews

Patient Online Negative Reviews As A Threat

We all have our fair share of crazy patients, unhappy patients. However, this trend of patients threatening negative reviews in order to get their way is alarming and frustrating. In the past 2 weeks we have had 3 patients all call in and demand something and if they don't get it they threaten...

forums.studentdoctor.net

State I'm in actually passed some laws protecting people who leave bad reviews basically indemnifying the ability to leave a review and say whatever you want negatively.

Is there anything to stop providers from having this in their written formal policy that any threats made of negative reviews will result in dismissal from practice? It wouldn't stop them from writing the review, but it might stop them from using it as a threat to get their way?

 

[Sushirolls]

A lawyer familiar with your state, and your state medical board could probably answer that.

Personally, I'm practicing ignore and forget.

 

[Bartelby]

I imagine a written "discharge for any suggestion of a negative review" policy would also look bad when posted in negative reviews!

 

[MedMan80]

Any reasonable person should presume that any half decent psychiatrist will have atleast some negative reviews..we see and treat unhappy/personality disordered patients all day.

I tried finding a psychiatrist for a family member and one had a spotless record and positive reviews (probably fake), on further investigation she recently had a investigation by the medical board for some bad behavior/boundary violations.

 

[Dr.MONO]

If someone is doing inpatient psychiatry then started doing outpatient cash only, will it be an issue not accepting insurance because the hospital they credentialed accepts insurance?

 

[Sushirolls]

If someone is doing inpatient psychiatry then started doing outpatient cash only, will it be an issue not accepting insurance because the hospital they credentialed accepts insurance?

Only for Medicaid, and Medicare. All other private/commercial insurance will be linked to the hospital address and the hospital NPI-II and the hospital EIN.

 

[michaelrack]

Medicaid rules vary by state

 

[trophyhusband]

Hello everyone, time for an update.

Looks like as of today she has 167 active patients. So as of the end of 2020 she had 8 patients and as of Q2 2021 she had 73. There have been probably 10 patients that have moved out of state, 5-10 that just dropped off for various reasons, 2 that were fired, and 1 who just let us know she won't be coming back. There are still a few patients on her active list that we're wondering if she'll ever see again but who knows. So all in all she's probably seen somewhere close to 200 patients this year.

She was 1 day a week until July and then went full time in August.

As for the market, the large hospital system still hasn't hired any new Psychiatrists and the one they have works 1 day a week and collaborates with 2 NPs. They aren't taking new referrals for 6 months (and they've been pushing out the six month window every month for a year now). The local CMHC closed their waitlist for C&A patients and we're not sure if they're even taking any new adult patients at this point. There are various NPs around but we don't pay much attention to them.

The local 80 year old Dr. Feelgood that we thought had been shut down apparently was not. She just had a stroke and now all of her patients are calling trying to get appointments. They are very unhappy when I refer them to the CMHC.

Financials to follow in next post. The hope was to gross $85k by the end of the year when she quit and went full time in August. Well, she netted more than that so we're happy.

 

[trophyhusband]

 

[FlowRate]

Wow, your expenses are so low, especially rent. Looks like that rent figure stayed the same even after moving full time so the space you're renting was always a full time rental? Having such low expenses will allow her to scale to a comfortable income without having to work super long hours.

FYI the total general business expenses row is only counting continuing ed, not any of the other business expenses. I don't know if you meant to include other things like EHR in that summary row.

 

[trophyhusband]

Wow, your expenses are so low, especially rent. Looks like that rent figure stayed the same even after moving full time so the space you're renting was always a full time rental? Having such low expenses will allow her to scale to a comfortable income without having to work super long hours.

FYI the total general business expenses row is only counting continuing ed, not any of the other business expenses. I don't know if you meant to include other things like EHR in that summary row.

Yeah, it was an office that she found that she could afford when she was only planning to work a half day on weekends and then the market melted down and she basically had to start seeing more patient and then finally move to full time. The lease has 2 option years at a 3% increase and she's in the first option year now and probably will stay for the final one since everyone is already used to it. Might move to something nicer after 3 years in that one.

The expense row is a Quickbooks thing. I don't really pay attention to it. I just tie out the expenses to the total at the bottom monthly.

 

[calvnandhobbs68]

Wow, your expenses are so low, especially rent. Looks like that rent figure stayed the same even after moving full time so the space you're renting was always a full time rental? Having such low expenses will allow her to scale to a comfortable income without having to work super long hours.

FYI the total general business expenses row is only counting continuing ed, not any of the other business expenses. I don't know if you meant to include other things like EHR in that summary row.

Yeah $258 a month is crazy low rent

 

[Merovinge]

Yeah $258 a month is crazy low rent

What a world where TV/Internet for an office is 50% of the rent!!?!

 

[trophyhusband]

What a world where TV/Internet for an office is 50% of the rent!!?!

That's the thing that kills me. Business internet is crazy expense for what you get. Our home fiber is $72/mo and her business internet is $120 for 100Mbps.

Oh and the best part about her office is it's a 1 minute drive from the house. Our city is a bit overbuilt for office/commercial space since almost every new apartment/condo complex is required to have ground floor commercial space. So there are cheap rents to be had outside of the "city" center in the older buildings. The one she's in now used to be a hotel and they've reconfigured it for offices... it's not the nicest place but her office looks decent and it's got a window unlike most of the offices.

 

[nexus73]

H

View attachment 347816

How many days a week is your wife working? How many patients per day?

 

[trophyhusband]

H

How many days a week is your wife working? How many patients per day?

Variable, she's open 3.5 days a week and occasionally has a full week but has other weeks where there are only a handful of patients. Max # of patients in a week would be 49. She's only been open for 3.5 days a week for four months and has been adding so many patients I couldn't even hazard a guess on what the average patients per day would be at this point.

 

[Sushirolls]

Well done! [Continued applause]

 

[romanticscience]

That's the thing that kills me. Business internet is crazy expense for what you get. Our home fiber is $72/mo and her business internet is $120 for 100Mbps.

Oh and the best part about her office is it's a 1 minute drive from the house. Our city is a bit overbuilt for office/commercial space since almost every new apartment/condo complex is required to have ground floor commercial space. So there are cheap rents to be had outside of the "city" center in the older buildings. The one she's in now used to be a hotel and they've reconfigured it for offices... it's not the nicest place but her office looks decent and it's got a window unlike most of the offices.

If you want to consider another lower cost, I finally broke down and got in-office Wi-Fi (v. using my hotspot) for $50/mo from T-mobile.

Reliable 5G Home Internet service | T-Mobile

Check your internet availability for T-Mobile's fast, in-home 5G internet by address. We're working hard to deliver our 5G internet across the country.

www.t-mobile.com

 

[nexus73]

Variable, she's open 3.5 days a week and occasionally has a full week but has other weeks where there are only a handful of patients. Max # of patients in a week would be 49. She's only been open for 3.5 days a week for four months and has been adding so many patients I couldn't even hazard a guess on what the average patients per day would be at this point.

Thanks for the info. 49 in 3.5 days, Would that be up 14 patients per day?

 

[trophyhusband]

Thanks for the info. 49 in 3.5 days, Would that be up 14 patients per day?

Correct, 30 min per and 7 hour days. She has some patients that want to see her for an hour (even though she doesn't really do therapy) so it'd usually be a few less patients than that.

 

[InvestingDoc]

This is amazing. Contracts! This is professional level keeping costs low, good work! Amazing that you are able to have such low rent. We pay $11,000 a month for a 3k sq ft office.

 

[trophyhusband]

If you want to consider another lower cost, I finally broke down and got in-office Wi-Fi (v. using my hotspot) for $50/mo from T-mobile.

Reliable 5G Home Internet service | T-Mobile

Check your internet availability for T-Mobile's fast, in-home 5G internet by address. We're working hard to deliver our 5G internet across the country.

www.t-mobile.com

BTW, thank you for all the help when she was initially setting this up. The guidance has been invaluable. Just the auto attendant on Google Voice has save I dunno hundreds maybe thousands of dollars for her.

 

[Sushirolls]

Did some quick math, just looking at the Gross for Q4 to further extrapolate. $37,950
Estimating of the current 3.5 days per week, at most that's 21.5 clinical hours per week from what's posted above.
But guessing not 100% filled, probably an average for Q4, say 16 clinical hours?
Assuming 6 weeks vacation, puts 1.5 weeks into Q4?

$37,950 / 16 hours per week / 11.5 weeks worked in quarter = estimated hourly gross rate of ~$206.25/hr

Extrapolating that out to say 32hrs per week (full time?) it would be $206.25 x 32hours x 46 weeks = $303,600
$303,600 - Overhead ~$30,000? = ~270K net take home before taxes and retirement with full time work.

Does that match your projections?

 

[trophyhusband]

Did some quick math, just looking at the Gross for Q4 to further extrapolate. $37,950
Estimating of the current 3.5 days per week, at most that's 21.5 clinical hours per week from what's posted above.
But guessing not 100% filled, probably an average for Q4, say 16 clinical hours?
Assuming 6 weeks vacation, puts 1.5 weeks into Q4?

$37,950 / 16 hours per week / 11.5 weeks worked in quarter = estimated hourly gross rate of ~$206.25/hr

Extrapolating that out to say 32hrs per week (full time?) it would be $206.25 x 32hours x 46 weeks = $303,600
$303,600 - Overhead ~$30,000? = ~270K net take home before taxes and retirement with full time work.

Does that match your projections?

I don't really look at it that way. I tend to look at it as a $ per patient per year equation which an easier way to look at it when you're charging cash and everyone is paying the same rate. So when she's full the average patient will pay ~$1k a year and we'll probably consider her full when she gets to 350 patients. For right now the average patient won't be paying $1k because she had a decent amount follow her from her old job and they follow up at 1/2 the frequency as her other PP patients so she'll probably carry 400 or so patients to compensate until they cycle out (they're all college students).

Now, everyone should remember that I'm her assistant so I answer her phones and deal with all the admin stuff so the expenses are less than they would be because of that.

 

[Jules A]

I'm still plugging along a few hours a week. Again inpatient/ED/CL are what make me happy and my primary jam but I have a nice group of concierge patients and I like the additional retirement contribution from having self-employment income. My rent is cheap, one day a week in the office of a psychologist although mostly telemedicine now. I have been doing this just short of three years, no website only psychology today listing. Most of my referrals are from therapists I have worked with over the years, a psychiatrist in town who is always booked two months out or from current clients. Fee is $300 per hour although with texts, calls, PAs, not documenting during session I average about $200 per hour.
Grossed $39,300
Expenses $6,453
Net $32,847 (before taxes, retirement contribution)

 

[Sushirolls]

YEAR THREE, Q1-Q3 SUBJECTIVE:

Q1:
Attempted to renegotiate with a lower than medicare insurer in January, emailed a specific person, as was instructed, and told will respond in 30-90 days or something like that. Found the fax number – after given wrong fax number – for another insurance company, and faxed them the same. This will supposedly take 45 days to process. I have no hope that any of this will yield anything positive, but will go thru motions now to facilitate an “I tried” cancelation later in the year.

Stumbled across an employed addiction posting in a rural community that caught my eye. Called up for details. Had I stumbled into this position fresh from residency I would probably have been happy, still there, and helping to make a dent in that community with large needs. However, now I can’t go back to being on call weekends or weeknights. Yes, I am on call 24/7 now, but in the past 3 years I have only been called twice. It’s a different, realistic kind of call. Or the notion of doing C/L work or even having a pinch of C&A requirements. Nope. I believe this was my final ‘what if’ for employed work. I am better off managing this practice to optimization and then doing a telecommute from where ever I want to live rather than strive to work/live in same location. Also, the thought of closing up shop and letting my assistant go would be so very hard to do. Waiting on Starlink internet from Elon Musk. This will open up the ability to work from home, or to even see if THE BOSS wants to move to middle of nowhere, as this will be the gateway to idealized rural living. Que in song lyrics “Green Acres is the place to be!...”

My tech setup is using a plugable port / hub that all things connect to. The cable to the internet, the printer, the scanner, the wireless USB for mouse/keyboard, large monitor, headset, webcam – everything. From this a single USB cable springs forth to connect to the lap top where the magic happens. I choose this tech set up to be portable, to take the lap top when on vacation or at home or wherever. Also allows easy replacement of parts. If a lap top breaks, replace it. Instead of a classic desk top computer that you try to have remote login access to. About 2.25 years into the practice, my hub just died and wouldn’t be recognized by my lap top. Had to get a new one.

A local Big Box shop, like a tiny version of Cleveland Clinic, a pseudo doctor run multispecialty clinic (but not an HMO) has amazing contracted rates. I looked over my personal EOBs from past few years and one insurance company had a 99214 at $292, and another insurance company had $303 and the 99213 at $205. Mind boggling. This payment variance for such a large organization compared to us main street independents, essentially preferences these large entities and pushes us out … or into cash only in order to survive.

Had the determination of the PPP and EIDL loans last December, paid it off, since the EIDL was deducted. Well, got a letter saying the government wised up and decided to not deduct the EIDL from PPP. Got the refund check for that. So, I fed from the government trough for about ~6K in conclusion. Probably could have applied and got a lot more, but I didn’t.

Q2:
Received a message from my land lord that the reconciliation for 2020 common area expenses (as I’m on a triple net lease) warrants a payment of ~$1500 more. I can’t wait to leave this building the exorbitant lease costs are brutal. Discovered my current office is also being sold, so will have a new landlord. See how that goes. Also, convenient how this large additional bill for expenses is just before the building gets sold…

Sleep Doc now has an employee/MA and growing in similar fashion as my practice. Also, in a saturated market.

Did some geographic exploration to move to a different state or even have dual office, and discovered this area would be completely wide open to a new Psychiatrist and fill within 3 months – especially when this rural area has already lost their one Psychiatrist. Sadly, the commercial insurance there pays markedly less as does Medicare compared to my current location. Full pros/cons weighed with THE BOSS, and we opted to not make this change, so staying the course with slower growth here.

Recently there have been too many denials and coding issues with claims for one of the insurance companies that reimburses less than Medicare. I am now united in my decision to drop them. I called, which took a while, and eventually got the email of who/how to state my intent to drop them. Got a response back same day asking if I’ve done their process for rate increase. Yes, I had and heard nothing. Told them they would have to substantially increase their rates and cover the various codes they conveniently deny as not covered. Will potentially lose ~28 patients with this change, ~12K for the year. Positively the reimbursement is so low that it won’t be too much of a hit, but it’s necessary when I’m possibly the only entity taking this insurance in the local area. The Big Box shops do too but they are full or filter who get in their doors. I estimate maybe 10 patients will stay with the practice and pay the cash out of network rate. (MISTAKE: from an admin perspective this was NOT the time to drop this insurance company; counter transference won out)

A past building I looked at many months ago, was a dead end due to real estate agent unable to get ahold of owner. Great location, and when factoring in population growth, great investment just for that. For sale by owner goes up. Make contact fast, and doing financials with various banks to explore financing options. Financials coming back with banks want 10% down and a lien on personal home to float - that’s a no go. So back to looking at tiny little rickety offices.

Discovered two more ARNP offices in local area. Learned one big box shop was hiring a Psychiatrist. Another Big Box shop was actually looking to increase their outpatient presence and shuffled people from other parts of the metro to staff, and hiring an ARNP. Third Big Box shop also hiring an ARNP. One ARNP office also hiring an ARNP in few months. Plus, a discovery of two recent ARNP grads opening up telemedicine only practices anchored in local area. Saturation and competition in local area appears to be getting worse in the Fee for Service (FFS) market (both the independents and Big Box shop side of things). Cash only practice would be considered but the one Psychiatrist in town doing it hasn’t shown signs of flourishing. Another deeper in the metro continually has Google ads posted.

Response back for pay rate increase of one insurance company that was less than Medicare, essentially just increased their rates to match Medicare rates locally. So that little bit helps, and delays the likely dropping of this company. Figure once schedule is fuller and impacts the rate of getting people in quickly, will drop this company to open up more slots, likely mid late ~2022.

Q3:
Smaller office in small town popped up. Put in offer well below asking price, needs multiple repairs / updates. I’m using a lawyer, however seller has real estate agent. My lawyer forgot to send key emails (left out their email) to the seller. Terminated services with lawyer for such ineptitude. Seller wants a broker-to-broker transaction and forms. Lesson from this is, lawyers communicate to lawyers, agents/brokers communicate to agents/brokers and they just don’t mix! House sold with cash offer for $15k more than my offer before I could square aware with an agent/broker.

Started the process of porting the main office line away from the Telecom company to Google Voice (MISTAKE: should never have gone with a telecom company in first place, wish I did Google Voice right from the start). So, this should save a few dollars with overhead, and provide greater flexibility for assistant, to use own cell phone or work computer and turn off/on whichever is preference when working. Also allows greater flexibility for any future work-from-home Covid moments. I’m also excited to integrate the phone tree prompts others on SDN have discussed. Plus, the transcription feature of calls is an added bonus, too. This also needs to be done in preparation of the lease ending at the end of the year, and if I change offices, I need this flexibility and ease of bringing my phone number with me. Too many insurance companies and other entities have this number, I loathe the thought of needing to update any of them. I’ve been apprehensive about this change because I believe the Telecom has a fixed multiyear contract with me, so I wanted to reduce the likelihood of getting double billed for a service that I wasn’t even using with one servicer. I have a second line for just my office I had also got, but in hindsight, really wasn’t needed unless I had a bunch of other docs working in this practice. So, it’s been at best a mild convenience but really a hassle of extra costs and a number patients call because they store it – not the main line – which is a pain if you are ever out of the office. Because you know, that’s when people call and leave a VM on the line that’s not checked, when you are out…

Just learned one of the insurance companies that has a larger percentage of my panel, recently reverted to POS 02 and modifier GT (was POS 11 with 95) for telemedicine. So got a bunch of claims that need to be resubmitted. If it were up to me it would be POS 11 with GT – done, no other combos or permutations, just 11 with GT.

Eventually got a contract with pay update from the insurance company I dropped. Thought I’d be able to write about not having any issues dropping the insurance company and why do other people post about it taking forever… now I know. This company differentiates their medical from their behavioral health. Positively I have email records of contact with both entities, so there is no reason for me still being in network. The pay increase they sent to me 2 months after the official end of contract, was about 10% more than local medicare rates, similar to what I’ve seen other post on SDN getting from this company. Probably as good as it gets. But compared to the headaches of working with this company for me and my assistant, no thanks, not going to bite. So emailed off to another person who supposedly makes decisions outlining the past events and instructing them to get me off their demographic lists – and stop sending me mailings or requests. Eventually got another confirmation email they will back date their contract end to the original/actual termination date. However, I look myself up on their directory and they still show me as in network for several more months…

 

[Sushirolls]

Q4:

Continue to get letters from ChangeHealthcare reflecting differences of 99214, 99213 billing numbers compared to their belief of norms. They even show people billing 99212! Who even bills that? Unfortunately, these letters are in reference to a company that is my biggest billings.

Met with an FM and Psychiatrist and able to learn that the Psychiatrist was full and transitioning more to TMS consult type practice and looking to deflect and even transition existing patients. PCP then in need of new referral pattern. Previous attempts over past few years to communicate with both were silence or told simply not needed. This could be a right time / lucky moment of networking that will yield more referrals. From this encounter learned there is a C/L doc about to transition off Visa and able to make more open career decisions – and wants to pursue ECT. And the other Psychiatrist has connections to a surgeon and ASC wherein the procedure could be done, skipping the bureaucracy of the hospital. Once more, after I thought ECT was a dead dream, it’s now popping up again. Do I even want to venture back into this? A recent post in a different thread by @TexasPhysician where he lambasted private docs that didn’t have a plan, didn’t strive to have a growth of service with either people or service lines – made me reflect. Is my current drastically simplified plan the right course? I remember back in college some business snippet about the business cycle and the imperative to always grow, always invest, always expand, etc. As I’ve aged, I’ve thought there is room for companies that cautiously (slug pace) do this imperative and simply emphasize more of sustainability. I know I’ve thought about years to come maybe pairing up with another doc or adding psychologists to the practice but this was maybe like 5 years down the road. Maybe now is the time? Sometimes you just have to act and not over think it?

Crunch time for my overly expensive lease. Bolt or stay? I was able to lock in the same contract for a 1 year extension. Still working with Sleep Doc who subleases with me and the idea of a next step in tandem is still on the table. The issue is simply money. When your 2020 income only reflects a net income of ~70k, banks aren’t as keen to lend. So having the tax documents for a completed 2021 (higher net income) the prospect for an office move is more likely in 2022. However, I still may just keep things simple and revert to a tiny cheap office presence and focus on building up the telemedicine side of things?

Well, the official count is in, of the 28 patients from the insurance company I dropped in Q1: 2 had serendipitous insurance change to stay in network, and 5 opted to pay cash. Not counting the insurance changes, 5 of 28 retention is about a ~17.8% conversion to cash only. Huh.

One of the larger national insurance companies, that few take elsewhere in the country, has very low penetrance in my locale. Consistently patients who come from across country are surprised that I’m paneled with the company and fully expected to pay cash. This company was better than Medicare but not as robust as others. Recently got a letter showing a decrease in rates, cutting ~$10-30 off, code depending. Frustrating. I’ll now lump this one with another company to cut out when the time comes. But fearful mind, I worry this is the start of the trend of the better insurance companies starting to cut back their rates. Cash only may be the ultimate destiny.

With my slow note completion, lower volume, and young kids (i.e. they get sick), I have been trying to pepper in an off day every week to actually be off, or have note catch up time, or tend to sick kids. I plan to continue this thru 2022 until schedule starts to show signs of needing to get people in sooner. Currently my schedule looks more like ~3.5 clinical days per week on the schedule. Helped to consolidate the patients and make my days “meatier.”

OBJECTIVE:

Total Patients:	115
Insurance Payor Mix:	26 = to Medicare rates	3 Medicare	86 > Medicare (74.8%)
Follow Ups:	185	14.2 (weekly mean)	range of 11-24 per week
Consults:	24	1.8 (weekly mean)	range of 0-5 per week
Weekly Clinical Hours:	9.0 (quarterly mean)
Weekly Clinical Hours:	9.9 (quarterly mean)	ßupdated formula
Blended Payer Mix:	$162.12 per follow up	ßSecret sauce formula
Overhead Percentage:	43.86%
Days Off:	11

DATA*** SEE NEXT POST***

[Q4 Gross of $54,640.98 – Sublease income $5103.33] / new clinical hours formula 9.9 / 10.8 weeks worked = *** $463.32 gross per clinical hour worked ***

Real worked hours is ~40 per week [replace the 9.9 above], so $114.67 gross per hour worked

[Q4 Net income of $30677.55] / 40 hours worked / 10.8 weeks worked = $71.01 true hourly net rate for Q4 (i.e. overhead subtracted)

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.
• Okay with current pace, anything more I get behind on notes.
• I barely billed any 90833. Like abysmally low. Definitely need to get that up. Had been turning away cash offers from Medicaid patients, but Q1 of 2022 should officially have no residual Medicaid contracts out there and be able to truly do cash pay. Getting closer to wanting to drop Medicare. Will wait on the insurance that’s now “medicare rate” until closer to 20 clinical hours per week. Sleep Doc is subleasing and helping with overhead costs now; changing from $X dollars to now 50/50 for lease bills.
• Still up in air if pursuing office purchase, or downsizing to be minimalist executive suite, heavily operating as telemedicine. Will have 2022 to reflect on this.

Very low risk of conversion to retirement at this time. Will continue to treat with high dose of bills for suppression, and monitor with these quarterly assessments. Pay for this quarter will be ~$30.6K, and 20% of that will be put aside for SEP-IRA contribution, and then 20% of that 0.8 put aside for taxes, leaving ~$19.6K to pay personal bills.

 

[Sushirolls]

GROSS PROFIT	16809.84	13812.07	24019.07	54640.98
EXPENSES
Accountant	0	0	130	130
Advertising/marketing	88.95	88.95	88.95	266.85
CME	0	0	228	228
Credit Card Processing Fees	128.6	154.12	124.47	407.19
Insurance	0	440	0	44
Medical Billing Services	65	65	65	195
Med Society Member Dues	560	0	0	560
Office supplies / Software	123.59	92.21	43.46	259.26
Payroll - Employee SEP-IRA			4676.44	4676.44
Payroll - Taxes			888.81	888.81
Payroll - Wage Expenses	1461.93	1466.74	1240.71	4169.38
Rent/Lease	3526.69	3526.69	3606.66	10660.04
State Tax	0	0	819.61	819.61
Utilities	96.1	82.2	84.55	262.85
Total Expenses	6050.86	5915.91	11996.66	23963.43
NET INCOME	10758.98	7896.16	12022.41	30,677.55

Tried to get this in post above, but SDN was giving me glitch trouble.

 

[trophyhusband]

• I barely billed any 90833. Like abysmally low. Definitely need to get that up. Had been turning away cash offers from Medicaid patients, but Q1 of 2022 should officially have no residual Medicaid contracts out there and be able to truly do cash pay. Getting closer to wanting to drop Medicare. Will wait on the insurance that’s now “medicare rate” until closer to 20 clinical hours per week. Sleep Doc is subleasing and helping with overhead costs now; changing from $X dollars to now 50/50 for lease bills.

You've probably already done this but if you haven't check to make sure your state allows cash payments from Medicaid patients. Ours does but it's illegal in some states.