Private Practice in Progress

[Sushirolls]

2021 STATS (Year Three):

27 days vacation for the year - fell short of my goal for 6 weeks. Need to fix that.
115 consults
848 follow ups
10.4 clinical hours per week on average (*11.5 with new formula)
2.2 consults per week on average
16.3 follow ups per week on average

GROSS PROFIT	$203,846.32 (*$19,953.33 of the 203K was sublease)	100.00%
Expenses
Accountant	830	0.41%
Advertising & Marketing	772.4	0.38%
Board cert fees	350	0.17%
CME	228	0.11%
Credit Card Processing Fees	1,674.34	0.82%
Insurance	2,985.00	1.46%
Legal / Processional Services	1,317.50	0.65%
Medical Billing Services	793.44	0.39%
Medical Society Membership Dues	560	0.27%
Office Supplies & Software	2,411.07	1.18%
Payroll - Employee SEP-IRA	4,676.44	2.29%
Payroll - Taxes	3,522.09	1.73%
Payroll - Wage Expenses	17,134.36	8.41%
Reimbursable Expenses	384.53	0.19%
Rent & Lease	43,966.62	21.57%
State Tax	3,286.43	1.61%
State Medical License	441	0.22%
Taxes & Licenses	250	0.12%
Utilities	1,577.59	0.77%
Total Expenses	$87,160.81	42.76%
NET INCOME	$116,685.51	57.24%

Wins for the year: more income, lower overhead with medical billing costs, getting paid more per unit of time, see the above ~$463 gross per clinical hour. This rising rate of work can also be reflected in the Blended Payer Mix formula. Also compare this year’s total overhead to last years (post #285). Nice knowing the overhead is fairly dialed in.

But a big win that I feel proud of, is the deposit for retirement this year. Not yet fully calculated out by the accountant, but I estimate a possible deposit of ~$23,400 for 2021. The 401K deposit max for 2021 was $19,500. One of my previous Big Box shop employers had a limited match that would have added 2-3K on top of that. In summary, I have surpassed the retirement capabilities of a typical employed job. I’m really excited about eventually getting to the max with a SEP-IRA (FYI, for 2022 that’s increased to $61K corresponding to an income of $305K).

Goals for next year:

Increase the income, hopefully to propel overhead well below 40%.

Drop medicare.

Wrap up dropping Medicaid contracts hanging out there, so as to allow cash pay.

Consider dropping the insurance that pays same as medicare – but they are big % of panel and if the ~17.4% conversion to cash paying holds true as the other similar insurance I dropped, this will be a more painful transition and need a bigger patient panel buffer.

Have better idea what the future holds if doing simple office with telemedicine focus, or having office, or having office with goals to expand and add more people.

Continue to rejoice I’m not part of a Big Box Shop - PRICELESS.

---

Members don't see this ad.

 

[calvnandhobbs68]

You need to be billing more 90833. Seriously. At least half my patients I add on 90833, it's worth the extra pop for a few more minutes of documentation. Just check with the insurance companies what their requirements are for 90833 documentation and always document what the most restrictive one requires so you know you're overdocumenting if anything.

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.

These guys can suck it. I've said this before but from what I see on facebook groups, the psychiatrists who bill 99212s are people billing for multiple therapy sessions per week trying to avoid an audit...unfortunately insurance then uses that against us as a "norm" to reference. I would never ever bill a 99212 for a psychiatry patient.

 

[Jules A]

Thank you for the update. The insurance woes make me all the more appreciative of my cash only practice despite the slower amp up time. The psychiatrist transitioning to TMS will be a nice perk for your business if he starts sending you his existing patients. It sounds as if your area is overrun with psychiatric services? Unusual and not helpful with growing your practice but relocating and starting over doesn't necessarily make sense either. Your office manager who sounds both competent and invested is a major plus.

I'm glad you are getting out of that expensive lease as well as receiving some financial assistance from your suite mate. Personally I would sublet two offices, one for you and one for your office mgr, in an existing therapist practice which will reduce expenses and also provide inhouse referrals. If you decide to lease I would go modern, attractive but small. I suspect most patients will be opting for telemedicine in upcoming years anyway so having an expensive or large office will likely be overkill particularly if you plan to continue working on a part time basis. Renting an office would be my recommendation with the concerns that commercial real estate in addition to being expensive to acquire and maintain can be difficult to sell or rent out depending on a variety of factors. Happy 2022, thank you for continuing to share your journey. I enjoy learning from your updates and wish you much success.

 

[Sushirolls]

Definitely is saturated with Psych services, at least in the commercial payor arena.
The cash Psychiatrist transitioned into TMS, and quite the boon, but I believe signifies that cash is tough market here, too.
High percentage of Big Box shops, and one finally got their act together and is rapidly expanding. They went from ~2 Psychiatrists when I opened to now possible 6 and with postings for more. So their external referrals have dropped off from the few I would get.
As expected, wide open in the CMHC sphere and SMI populations.
One ARNP who (bought?) took over an older retiring ARNP practice, took ~1.5 years to top off and declare being full. So that should give others more idea as to the saturation in this area.

I'm still in the expensive lease, just renewed it for another year, but having the Sleep Doc sublease helps the cost. All offices in this space are used up with my assistant and the assistant Sleep Doc has. So no room for others now.

 

[friendlygiant]

Incoming medical student very interested in the clinical-side of psych, read this thread from top to bottom. Very informative, really fun read, and really cool to get insight on billing, local politics and how entrepreneurship might work. I'm interested in starting out working for big box/locums and saving some money to transition into solo pp work. Do you guys think there will be room for newly minted psychs who won't be finishing their training for 8 more years? Or is it a bad time to specialize in psych?

 

[Sushirolls]

Too far out to say. Anything is possible 8 years from now.
Health care could drastically worsen or stay about the same.
But Psychiatry and Primary care will likely be the specialists who get to "turn out the lights" and will have the options of independent private practice for far longer than the other specialists.
In summary, if you like Psych, can handle it, and able to match, you have a reasonable chance for a good go of it.

 

[friendlygiant]

Too far out to say. Anything is possible 8 years from now.
Health care could drastically worsen or stay about the same.
But Psychiatry and Primary care will likely be the specialists who get to "turn out the lights" and will have the options of independent private practice for far longer than the other specialists.
In summary, if you like Psych, can handle it, and able to match, you have a reasonable chance for a good go of it.

Thank you sir

 

[mistafab]

I was interested to see that your advertising expenses was so low. Are you hoping to keep your actual clinical hours low, or perhaps have you found that patients found through advertising are not good fits for your clinic? I would imagine using aggressive advertising (perhaps at least 3-5k per year) if I was hoping to build a cash practice. Or at least paying a marketing specialist to design/implement a campaign.

 

[clausewitz2]

You need to be billing more 90833. Seriously. At least half my patients I add on 90833, it's worth the extra pop for a few more minutes of documentation. Just check with the insurance companies what their requirements are for 90833 documentation and always document what the most restrictive one requires so you know you're overdocumenting if anything.

Agreed. As much time as you have described.l spending with patients, you are leaving a ton of money on the table.

 

[Sushirolls]

I currently have a private practice in Cannabis State.
I may be needing to move to a nearby state, Real 'Murica.

Plan A, keep a smaller real office with lease in Cannabis State, do telemedicine from afar from Real 'Murica. Every few weeks or so drive back to do in person consults to stay on the right side of the Ryan Haight Act. Consults in person, all follow ups telemedicine.

Plan B is screen out any consults for Plan A that might need Stimulants, i.e. ADHD, and only do telemedicine consults. Open up a physical office in Real 'Murica State.

What I'm wondering, with Plan B, is how to navigate the logistics. I currently have a Federal Tax ID, NPI-II, Business License with a registered LLC, and DEA in Cannabis State. How do I open a branch office in another state?
1) I'm assuming Fed Tax ID stays the same, no change
2) NPI-II doesn't change, but does it need an updated address or can it have multiple listings?
3) I'm assuming I register the same name of the LLC in Real 'Murica State, or is there a way to register one from the original state in multiple states?
4) Probably get another DEA since technically practicing in 2 states...
5) Need a license for Real 'Murica State
6) Reach out to all the insurance companies of this new branch office, and likely get paid lower contract rates for that state, and not the higher rates I get in Cannabis State

 

[TerraceHouse]

I currently have a private practice in Cannabis State.
I may be needing to move to a nearby state, Real 'Murica.

Plan A, keep a smaller real office with lease in Cannabis State, do telemedicine from afar from Real 'Murica. Every few weeks or so drive back to do in person consults to stay on the right side of the Ryan Haight Act. Consults in person, all follow ups telemedicine.

Plan B is screen out any consults for Plan A that might need Stimulants, i.e. ADHD, and only do telemedicine consults. Open up a physical office in Real 'Murica State.

What I'm wondering, with Plan B, is how to navigate the logistics. I currently have a Federal Tax ID, NPI-II, Business License with a registered LLC, and DEA in Cannabis State. How do I open a branch office in another state?
1) I'm assuming Fed Tax ID stays the same, no change
2) NPI-II doesn't change, but does it need an updated address or can it have multiple listings?
3) I'm assuming I register the same name of the LLC in Real 'Murica State, or is there a way to register one from the original state in multiple states?
4) Probably get another DEA since technically practicing in 2 states...
5) Need a license for Real 'Murica State
6) Reach out to all the insurance companies of this new branch office, and likely get paid lower contract rates for that state, and not the higher rates I get in Cannabis State

Hey doc, if one works at an inpatient facility accepting medicaid/medicare patients, can that same psychiatrist have an outpatient cash clinic?

 

[Sushirolls]

Hey doc, if one works at an inpatient facility accepting medicaid/medicare patients, can that same psychiatrist have an outpatient cash clinic?

Cash practice without Medicare opt out

Per the title, if someone wanted to start a modest side practice and accept cash only, but could not opt out of medicare due to their primary job, is it possible to screen out medicare patients? Or what strategies can be used to avoid problems?

forums.studentdoctor.net

 

[calvnandhobbs68]

4) Probably get another DEA since technically practicing in 2 states...

You only need another DEA in another state if prescribing controlled meds in multiple states is my understanding. If you're not gonna do controlled meds in one of the states, you shouldn't need a DEA in that state. People will let their DEA # lapse if they don't want to prescribe controlled meds anymore.

 

[trophyhusband]

@Sushirolls are you allowing patients to book themselves on Luminello? If so how is it working out? I'm currently doing all of the scheduling and I don't mind it but I was wondering if it's worth turning the feature on. We'd heard some issues with double booking and patient being able to schedule over non-appointments that were used to block time so we haven't investigated further yet.

 

[Sushirolls]

I've been leaning into heavy the online scheduling feature since the start. Overall its been working great. The big issue is when family members open a chart on behalf of their loved one. We usually have to archive those charts, call them and emphasize patient needs to open the chart. I haven't had any double booking issues. I made the consults 90 min blocks and follow up 30 min blocks. The designated online scheduling I do in 90 min blocks to accommodate the consults and depending on the day will turn off the follow ups for some blocks.

Two rare issues, patient schedules a consult when should have only picked a 30 min block. Or very rare some glitch happens and luminello allows patient to schedule of the usual :00 or :30 minute intervals, and they book for 10:10AM or something odd. This is like 2-3x per year I've seen it.

It also allows patients to freely change things, and decreases my staff time for schedule changes or cancellations.

One downside is staying on top of people cancelling, not scheduling, and going past my required Q3 month minimum, and needing to stay on top of those folks. We've got a bit of system worked out to stay on top cancels that didn't reschedule themselves though.

 

[trophyhusband]

I've been leaning into heavy the online scheduling feature since the start. Overall its been working great. The big issue is when family members open a chart on behalf of their loved one. We usually have to archive those charts, call them and emphasize patient needs to open the chart. I haven't had any double booking issues. I made the consults 90 min blocks and follow up 30 min blocks. The designated online scheduling I do in 90 min blocks to accommodate the consults and depending on the day will turn off the follow ups for some blocks.

Two rare issues, patient schedules a consult when should have only picked a 30 min block. Or very rare some glitch happens and luminello allows patient to schedule of the usual :00 or :30 minute intervals, and they book for 10:10AM or something odd. This is like 2-3x per year I've seen it.

It also allows patients to freely change things, and decreases my staff time for schedule changes or cancellations.

One downside is staying on top of people cancelling, not scheduling, and going past my required Q3 month minimum, and needing to stay on top of those folks. We've got a bit of system worked out to stay on top cancels that didn't reschedule themselves though.

Yeah, it might be difficult for us to set up since the consults are 60 min for adults and 90 min for C&A. We try to keep the late and early appointments open for kiddos as long as possible and I could see the adult patients taking those appointments up right away.

We've largely been able to cut down on family members creating charts by adding an additional "question" to the Luminello standard pre-screen that makes it clear that if the patient is over 18 they need to fill out their own request. We got a ton of those due to being in a college town and once we put that in we haven't gotten one since.

I don't see a way to stop people from scheduling before their paperwork and everything is complete which we require before scheduling. They have to turn in all forms/questionnaires/add credit card/etc. before they can be scheduled. Might just need to look into it more.

 

[Sushirolls]

The key, is we have the default setting to online schedule turned off for new charts. This doesn't get turned on manually, until ALL paperwork completed. Once the paperwork completed, we send a Luminello message saying its open, go ahead and schedule, or call if you have struggles.

You can create different calendars/schedule labs. That will also show for the patients. Hopefully you have a fake patient account to visual check, so create a label that clearly says Adult New Consult, Child/Teen New Consult, Follow up Adult, Follow up Child/Teen, etc.

Early stages I thought I'd have a lot more OUD, and even had OUD specific slots, but my volume has never got more than like 6, so I stopped that.

*My assistant lately wanted to spear head, a secondary pathway for intakes. So if she catches people on the phone, gives a very long verbal intro, and schedules a held slot. She keeps tabs, and calls to remind, and if doesn't have paperwork done 24-48 hours ahead of time she'll release that slot. So far seems to work 70-80% of the time and satisfies the crowd that 'wants an appointment at time of calling.' Once/if I ever get more full, I'll likely stop doing this as those consult slots will have a greater value.

 

[randomdoc1]

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.

Love it. Reviews hit so close to home. It's a realistic threat to your traffic (and your own business which we put so much work into) and is upsetting when it is so one-sided and we are limited when it comes to privacy laws. There are also legit ways to encourage good reviews from the satisfied patients too. This is what we do. What I loved is some of the good reviews called out the bad ones and one said something like "I personally have not had similar experiences with Dr. ____" or another one vaguely referenced a negative review and said "we need to be ready to be honest with ourselves and truly get out of treatment what we put in." How validating! I have a google my business account and linked it to my phone in an app. So an alert comes right away soon as someone leaves a review. It's often after some negative experience within the past 24h and if it's not obvious who it was, usually we're able to figure it out by asking around in the office. Then I call the patient as the owner of the office and usually they are more meek during the interaction and I offer to do what we can to resolve the matter. Admittedly, I get a sick pleasure out of scaring the pants off them because they likely did not expect a call so soon and to be found so quick. And everyone I've contacted has admitted the review was unfair and we had a constructive discussion about it. Interesting indeed.

 

[trophyhusband]

*My assistant lately wanted to spear head, a secondary pathway for intakes. So if she catches people on the phone, gives a very long verbal intro, and schedules a held slot. She keeps tabs, and calls to remind, and if doesn't have paperwork done 24-48 hours ahead of time she'll release that slot. So far seems to work 70-80% of the time and satisfies the crowd that 'wants an appointment at time of calling.' Once/if I ever get more full, I'll likely stop doing this as those consult slots will have a greater value.

How have the ones that have shown up worked out for you? I work fulltime in addition to being the assistant so I wouldn't have time for this currently. But we have a kiddo approaching kindergarten so we're not sure how that's going to work with her practice and my job.

It seems like every patient we've tried to make any sort of accommodations for has been inappropriate for the practice. It could just be our market or a non-insurance practice thing but it has really curtailed the want to go above and beyond before the patients are actually a part of the practice.

 

[trophyhusband]

Love it. Reviews hit so close to home. It's a realistic threat to your traffic (and your own business which we put so much work into) and is upsetting when it is so one-sided and we are limited when it comes to privacy laws. There are also legit ways to encourage good reviews from the satisfied patients too. This is what we do. What I loved is some of the good reviews called out the bad ones and one said something like "I personally have not had similar experiences with Dr. ____" or another one vaguely referenced a negative review and said "we need to be ready to be honest with ourselves and truly get out of treatment what we put in." How validating! I have a google my business account and linked it to my phone in an app. So an alert comes right away soon as someone leaves a review. It's often after some negative experience within the past 24h and if it's not obvious who it was, usually we're able to figure it out by asking around in the office. Then I call the patient as the owner of the office and usually they are more meek during the interaction and I offer to do what we can to resolve the matter. Admittedly, I get a sick pleasure out of scaring the pants off them because they likely did not expect a call so soon and to be found so quick. And everyone I've contacted has admitted the review was unfair and we had a constructive discussion about it. Interesting indeed.

How do you encourage reviews? My wife is hesitant to do it currently. And yeah, I get the Google Business notifications to my phone as well. The two bad reviews were of course put in during the middle of the night. The one that I got removed and another one that basically said that she was more than happy to treat my anxiety and depression but wouldn't refill my sleep meds inappropriately. She was fine with that one because it showed she doesn't mess around with certain medications.

 

[randomdoc1]

It seems like every patient we've tried to make any sort of accommodations for has been inappropriate for the practice. It could just be our market or a non-insurance practice thing but it has really curtailed the want to go above and beyond before the patients are actually a part of the practice.

I'm super careful with accommodations. Every patient interaction bears some sort of clinical relevance but I too have found those asking for a little more, tend to be more complex (often correlating highly with some axis II). And healthy boundaries are not only necessary, but therapeutic. That's another reason I like going through insurance because the self pay ones can act more like "customers" and it can open more of a gate for boundary challenging. For example, in economic hardship, someone may ask to haggle you down whereas with insurance, it's in the contract for you to go with their rate. If the rate is high, it opens the channel for a therapeutic discussion of how to handle real life circumstances be it shorter appointments, brief phone calls/email, etc. Another example, patients asking for appointments the day of, rarely have I found it to be clinically necessary. And if it is that necessary, it should not be an expectation of the patient (nor should it be an expectation for a patient for us to always be available late afternoons/evenings, they need to understand us as humans and be respectful as demonstration of a healthy relationship). The office is not an ER or urgent care center. It seems to be helpful when the desk hears the patient out and gives the patient a time frame for when to hear back from the provider without a promise of a same day appointment because it opens up a chance for them to practice their own coping skills and self soothing. Of course, we make sure not to be negligent and patients still get addressed appropriately, but that dynamic can be a slippery slope. I had to train one of my front desk staff about certain phone calls because she started acting as a semi-therapist to this patient who called about every physical symptom and 1 call a week turned to 2, then 3 then multiple times a day. I said best thing to do is let a little more time lapse each time before calling this patient back, and it was therapeutic in this situation.

How do you encourage reviews? My wife is hesitant to do it currently. And yeah, I get the Google Business notifications to my phone as well. The two bad reviews were of course put in during the middle of the night. The one that I got removed and another one that basically said that she was more than happy to treat my anxiety and depression but wouldn't refill my sleep meds inappropriately. She was fine with that one because it showed she doesn't mess around with certain medications.

There are good services for this. One that is well regarded is Gather Up. The Google terms does forbid something called "review gating" though. Meaning only asking reviews of people you know will give good ones. But at the same time, why would I ask a review of someone who's scathing and likely for unfounded reasons? I'm not sure if google can prove it unless it's on some sort of mass scale. Anyways, we use a tool that has a customizable message and likely the vast majority of the patients are satisfied. Why would they keep coming back then lol? I also found with google reviews, it's also good to be proactive about being preventative. We can control our interactions with the patient and usually it is not from providers that sparks the negative review. Or if I sense it could happen, I try to sound very empathic and help the patient feel listened to, even if they don't get what they ask and offer them potential solutions including referrals elsewhere. For the front desk, I've trained them on phone etiquette bearing in mind this is a specialized population and that's really minimized the incidence of negative reviews. The ones who were addressed, almost all took their reviews down.

HR wise, hiring for front desk staffing is a PAIN. But a good population I found was pre-professional students (and ask for 3 references and call them). Pre-vet, pre-PA, pre-med, pre-dental, etc. They have better inherent qualities, often tech savvy, good learners and decent attitude, don't ask for exorbitant pay, and generally want to impress you. Be firm with attendance. They can't show up at least 95% of the time? Something needs to change. Attendance issues tends to become a pattern so address it early on and make it clear at hiring. I've also tried to streamline the work flow so it's very trainable to be ready for turnover. For intakes, there's a sheet with a script. Just read it, fill out the answers. Provider may or may not need to review it. Bam, there ya go. lol. We generate aging reports too on accounts receivable and we've taught students how to call to collect and update the sheet. But collecting at time of service is king.

 

[Sushirolls]

How have the ones that have shown up worked out for you? I work fulltime in addition to being the assistant so I wouldn't have time for this currently. But we have a kiddo approaching kindergarten so we're not sure how that's going to work with her practice and my job.

It seems like every patient we've tried to make any sort of accommodations for has been inappropriate for the practice. It could just be our market or a non-insurance practice thing but it has really curtailed the want to go above and beyond before the patients are actually a part of the practice.

The patients so far the talks with on phone to do this new 'held' consult slot versus those who just 100% do the online themselves, appear to be the same. Possibly the assistants method may be better for getting more people on the books. But both pathways the patient ultimately has to fill out all the questionnaires online, and E-sign all the office policies.

 

[randomdoc1]

*My assistant lately wanted to spear head, a secondary pathway for intakes. So if she catches people on the phone, gives a very long verbal intro, and schedules a held slot. She keeps tabs, and calls to remind, and if doesn't have paperwork done 24-48 hours ahead of time she'll release that slot. So far seems to work 70-80% of the time and satisfies the crowd that 'wants an appointment at time of calling.' Once/if I ever get more full, I'll likely stop doing this as those consult slots will have a greater value.

Sounds like you have an assistant with the right attitude! Congrats. I think it all has it's pros and cons. I have found patients you have to keep prodding and reminding, it tends to clinically correlate with a more challenging case. Those who show initiative and get it done on their own (we have something very much like a docusign) tend to be higher functioning, with higher defenses, better med compliance, pay their bills more consistently and the sooner they get the papers in, the clinically better they seem to be (and saves you cost because the employee can spend time getting more work done for you). Which I think is pretty funny. Usually if 48+ hours has passed and the patient has not gotten it in, there's elevated risk of them not keeping the appointment/some ambivalence about becoming a patient. I also find those who "want an appointment at time of calling", indicates to me something more actively going on and potentially to be on the lookout for. Especially if they start challenging the person and demanding why they can't "just schedule." Now, all these patient profiles are manageable. But when someone has the luxury of choosing amongst different inquiries, I like the higher functioning ones. Someone who insists they "can't wait" or is a little pushier on the phone compared to someone who understands the assistant needs to check with provider availability, the latter shows they have more stability or at least stronger defenses and can go with the flow better. And for a little humor, any patients who sound like they need to get in super urgently and sound agitated on the phone, high chance of them running out of a benzo or stim soon. PDMP checking shows it to be right about 70+% of the time. How I wish it was just a joke and not true lol. If not doing this already, it can be helpful to network with some good therapists. I've found they tend to be a great source of referrals with the right patient profiles and since they already engage in therapy, it's a good start. Plus, since the therapist personally recommended you, the follow through is much higher. Therapists often are starving to find places to refer patients to.
Every patient interaction carries some clinical relevance. lol

 

[Sushirolls]

We ask from the start, or have on Luminello pre-questionnaire if taking benzos. We preempt and let people know will likely be tapered of or won't prescribe. This eliminates the benzo issues. I have 2-3 that are getting from a PCP. I prescribed ativan #2 tabs in the past 4 years, for a patient who proved with documentation they were going on plane flight. Might have done 2-3 or tapers for patients who were motivated, too.

My assistant is amazing, so lucky to have, but conversely had already worked with me and knew I was a doc worth working for. Definitely a two way respect street.

 

[finalpsychyear]

We ask from the start, or have on Luminello pre-questionnaire if taking benzos. We preempt and let people know will likely be tapered of or won't prescribe. This eliminates the benzo issues. I have 2-3 that are getting from a PCP. I prescribed ativan #2 tabs in the past 4 years, for a patient who proved with documentation they were going on plane flight. Might have done 2-3 or tapers for patients who were motivated, too.

My assistant is amazing, so lucky to have, but conversely had already worked with me and knew I was a doc worth working for. Definitely a two way respect street.

Your going to be nearing 20 hours clinical over the next 12-18 months from the current 10-11 hrs. I wonder if even 1-2 day of the week with contract tele or something just to help cover overhead while things are ramping up which you could even do from home has been explored. That income you would make would cover your entire overhead and come close to maximizing your sep ira which is fully tax deductible. Very quickly your 2021 gross income would be your net income if you did this. Good luck.

 

[Sushirolls]

You are absolutely right, a side gig would certainly shore up finances.

I just don't want the headache of a side gig and it impacting existing insurance contracts with NPI listings and address, etc. Low risk issue, but notable headache if happens. Secondly, with how I juggle personal life, I'm frequently behind on notes with what I'm currently doing. I just wouldn't have the logistical time to pile another gig in. Thirdly, I really, really, don't want to go back to any employed jobs. I've give 110% in the past, and honestly just don't have the motivation to enter that sphere again.

Currently, I'm in a moment of uncertainty and may be needing to move. Possibly would go to middle of nowhere Deep Red state, county with no existing Psychiatrists. Insurance payers are less than current location, but the anticipated wave of referrals will be notable. So preparing to physically move, and move a practice, I'm going to be in more of 'survival mode' for this year possibly. This move could possibly open up the opportunity to get legit acreage and allow me to start slowly building up my medicine exit plan - Ranching/Farming.

 

[Alemo]

I (like Senator Palpatine) have followed this thread/your career with great interest.

I’m always sorry to hear of the administrative and insurance headaches. As others have said, the cash only private practice sounds more and more appealing. The more “passive” the income, the better. Spend more time doing Psychiatry and less time running a Small Business.

I wonder how much documentation could be avoided by forgoing insurance companies. The other headache I could foresee would be collecting with some patients, but it’s probably less than what you’ve dealt with re: insurance panels.

The ranching exit strategy makes me think of this story:

An American investment banker was at the pier of a small coastal Mexican village when a small boat with just one fisherman docked. Inside the small boat were several large yellowfin tuna. The American complimented the Mexican on the quality of his fish and asked how long it took to catch them.

The Mexican replied, “only a little while. The American then asked why didn’t he stay out longer and catch more fish? The Mexican said he had enough to support his family’s immediate needs. The American then asked, “but what do you do with the rest of your time?”

The Mexican fisherman said, “I sleep late, fish a little, play with my children, take siestas with my wife, Maria, stroll into the village each evening where I sip wine, and play guitar with my amigos. I have a full and busy life.” The American scoffed, “I am a Harvard MBA and could help you. You should spend more time fishing and with the proceeds, buy a bigger boat. With the proceeds from the bigger boat, you could buy several boats, eventually you would have a fleet of fishing boats. Instead of selling your catch to a middleman you would sell directly to the processor, eventually opening your own cannery. You would control the product, processing, and distribution. You would need to leave this small coastal fishing village and move to Mexico City, then LA and eventually New York City, where you will run your expanding enterprise.”

The Mexican fisherman asked, “But, how long will this all take?”

To which the American replied, “15 – 20 years.”

“But what then?” Asked the Mexican.

The American laughed and said, “That’s the best part. When the time is right you would announce an IPO and sell your company stock to the public and become very rich, you would make millions!”

“Millions – then what?”

The American said, “Then you would retire. Move to a small coastal fishing village where you would sleep late, fish a little, play with your kids, take siestas with your wife, stroll to the village in the evenings where you could sip wine and play your guitar with your amigos.”

The dream for me is not abandoning Psychiatry entirely, but perhaps doing less of it with more quality/interesting patients as I expand time with family/fishing/gardening/creative writing.

 

[Stagg737]

I wonder how much documentation could be avoided by forgoing insurance companies. The other headache I could foresee would be collecting with some patients, but it’s probably less than what you’ve dealt with re: insurance panels.

If you're cash only then as much as you feel comfortable with in proportion to liability. I did a rotation in med school where the attending was outpatient cash only and used paper charts. Notes were typically no more than 5-6 sentences. Seemed like a great set up in terms of minimizing actual work and maximizing liability risk, but in that state was certainly legal.

 

[Alemo]

Eh the three-faced demon of documentation (clinical communication, legal, and payer) is not a three-legged stool (it’s a demon). You can get rid of the payer bull**** (“I promise that I spent 5 minutes talking about blah blah blah”) and keep the legal and clinical components. In my mind these are really the same (clinical communication of evaluation/services rendered should mirror the legal standard of care).

In your example, 5 sentences about any patient is just plain insufficient (and also consequently liable).

The goal is to work (smarter), not to avoid work.

 

[AD04]

Currently, I'm in a moment of uncertainty and may be needing to move. Possibly would go to middle of nowhere Deep Red state, county with no existing Psychiatrists. Insurance payers are less than current location, but the anticipated wave of referrals will be notable. So preparing to physically move, and move a practice, I'm going to be in more of 'survival mode' for this year possibly. This move could possibly open up the opportunity to get legit acreage and allow me to start slowly building up my medicine exit plan - Ranching/Farming.

I encourage you to do this as you'll fill a huge need. And at the same time, you have potential to make good money. (For reference, I do something similar to what you described and make way more than the highest number in that open salary thread and have option of not supervising mid-levels. I do spent a lot of time at work and don't take too much time off as patients need me which is a downside for some people.) You can own a ranch / farm soon enough.

I know you got burned with institutions in the past but I would urge you to reconsider. If you find a good institution, you can do a lot more than if you did things solo. Others can focus on staff and office expense and what not. You focus just on practicing medicine. Not doing things solo is important especially if you want to do ECT and I personally am very very glad I do it as it helps my patients immensely. Of course, you'll need a good personality so the staff like you and want to help you but based on what I've witness so far, I think you have the right personality to work with others.

 

[painballer27]

(For reference, I do something similar to what you described and make way more than the highest number in that open salary thread and have option of not supervising mid-levels. I do spent a lot of time at work and don't take too much time off as patients need me which is a downside for some people.)

So you make more than 635k?

 

[Merovinge]

So you make more than 635k?

The rural PP psychiatrist in the last town I lived in cleared well about 635k. He was working the equivalent of 3 FTEs at least so it's not terribly surprising, but you can get away with a lot more when you are the only game in town.

 

[MedMan80]

I'm in a rural hospital NY. They started me at 280 base, plus some sign on/retention money to keep me here. I'm hearing west coast is netting 350K to start 40/h a week. I question the reason to work >40h at thee expense of family...

 

[Sushirolls]

Just got updates from one of my best paying insurance, and also largest % of my panel, that they are slashing rates. This company uses a strict RVU conversion, with Total RVUs. Going to lose ~11%

Looks like this weird pocket of high payer rates is going to end. I anticipate in months to years this transition will follow the path of entropy on par with the rest of the country.

Meanwhile, it is official I will be moving to deep Red state, middle of nowhere. Trying to weigh the pros/cons of becoming employed to be the only Psychiatrist for a whole county with the critical care access hospital, versus relocation of this practice to an office there.

 

[geripsyched]

EDIT: Agree very strongly about the geri population not being a great fit for luminello/tele so far. Older folks involved in tech seem to do fine with it (a lot of bipolar programmers in their 60s, for some reason) but anyone else struggles mightily. Most of them I just see on doxy.me because the URL never changes, but even this is confusing. I am still trying to socialize them to send a secure message to me instead of call, but this is a slow process. Thank God for doximity's straight-to-voicemail feature.

I'm currently in academics but plan to start a part-time (2 full days/week) geriatric psychiatry private practice (may transition to full-time over 1-3 years if it goes well and I enjoy it). My initial/evolving plan is to only take traditional Medicare or accept cash. There are few private practice psychiatrists in my area (there are some outpatient NPs, but not much; I don't know if any of the psychiatrists are even taking patients), so the demand should be very strong. I am planning to open this clinic on July 1st, 2023 and strongly considering Luminello. However, I want to primarily serve people 60+ with anxiety, depression, and memory impairment... If Luminello is not a good option for older adults, any suggestions on what may work better? E.g., should I plan on 90 minute intakes with 30 minutes going through all of the clinic documents? Is there another EHR that is better for older adults or are all EHR's bad for older adults due to technological issues? I'm trying to keep overhead low and don't want to take any employees due to all of the complexity that adds. It looks like there are virtual assistants for medical/mental health practices that may be available... Thanks for any advice!

p.s. I've really appreciated all of the details on this thread. Another good resource for physicians building a practice is: https://www.thepracticebuildingmd.com/

 

[allantois]

I'm currently in academics but plan to start a part-time (2 full days/week) geriatric psychiatry private practice (may transition to full-time over 1-3 years if it goes well and I enjoy it). My initial/evolving plan is to only take traditional Medicare or accept cash. There are few private practice psychiatrists in my area (there are some outpatient NPs, but not much; I don't know if any of the psychiatrists are even taking patients), so the demand should be very strong. I am planning to open this clinic on July 1st, 2023 and strongly considering Luminello. However, I want to primarily serve people 60+ with anxiety, depression, and memory impairment... If Luminello is not a good option for older adults, any suggestions on what may work better? E.g., should I plan on 90 minute intakes with 30 minutes going through all of the clinic documents? Is there another EHR that is better for older adults or are all EHR's bad for older adults due to technological issues? I'm trying to keep overhead low and don't want to take any employees due to all of the complexity that adds. It looks like there are virtual assistants for medical/mental health practices that may be available... Thanks for any advice!

p.s. I've really appreciated all of the details on this thread. Another good resource for physicians building a practice is: The Practice Building MD-Dr. Sandra Weitz

Medicare sounds like a nightmare to deal with.. you can't charge patients no show fee and then you are going to book them for 90 min intakes.. The elderly are not good with any EMR, unless someone can help them out with it

 

[WisNeuro]

Medicare sounds like a nightmare to deal with.. you can't charge patients no show fee and then you are going to book them for 90 min intakes.. The elderly are not good with any EMR, unless someone can help them out with it

May depend on the service offered, and waitlists for the services. I've only had one late cancellation and zero no shows from Medicare patients in 2 years. And, the late cancellation was due to being hospitalized the night before my eval. I also have a fairly streamlined system for sending out reminders and info about getting to my office which may help. Minimal time spent.

 

[geripsyched]

Good point about the risks of having people no-show a 90-minute appointment - that would be a big financial hit if it were to happen frequently. Although we can't charge Medicare for no-shows, per CMS, providers can still charge patients for no-shows ("The Centers for Medicare & Medicaid Services (CMS) policy is to allow physicians and suppliers to charge Medicare beneficiaries for missed appointments"). Based on this thread, my plan would be to have a credit card on file for every patient before they are seen that automatically gets charged for services/no-shows. I'll have to think more about this but, even if the pre-screening process is simplified for older adults, requiring a credit card may still make sense. My practice will also be located in a well-to-do suburb, so this shouldn't be a major barrier.

Glad to hear the positive experience with the reliability of Medicare patients. I've also found that older adults tend to be more reliable in showing to appointments. However, I've only worked at clinics that had a ton of overhead (lots of front desk and nursing support - most of the time they are sitting around talking or playing on their phones...) and haven't seen how well older adults would interact with a clinic workflow that is based more on online processes rather than layers of people. I hope that the baby boomer generation would be able to schedule an appointment online without needing to talk with someone and be comfortable using a secure message system for questions/concerns... Sounds like a good reason to start scheduling patients 4-8 weeks prior to a soft opening.

Has anyone used virtual office assistants? It looks like Luminello works with a virtual assistant company (Medical Virtual Office Services). If I remember correctly, the cost is ~$44/hour with no minimum hours per month. It seems like many of these companies bill in 15-minute increments, which means that every phone call would be at least $11... Seems steep, especially given the number of spam calls that I've been getting each day. That said, the ease of paying a contractor still seems more appealing than having an employee, particularly when starting out part-time.

 

[randomdoc1]

Just got updates from one of my best paying insurance, and also largest % of my panel, that they are slashing rates. This company uses a strict RVU conversion, with Total RVUs. Going to lose ~11%

Looks like this weird pocket of high payer rates is going to end. I anticipate in months to years this transition will follow the path of entropy on par with the rest of the country.

Meanwhile, it is official I will be moving to deep Red state, middle of nowhere. Trying to weigh the pros/cons of becoming employed to be the only Psychiatrist for a whole county with the critical care access hospital, versus relocation of this practice to an office there.

I'm sort of sounding like an annoying optimist here. Also out of curiosity, and you don't have to respond publicly, but is this insurance you are talking about Optum?! Because they can be notorious. There's a big hospital system that is dropping them, yes, dropping United because of the rate slash proposal. Nevermind they profit 14 billion dollars per year minimum and their profit year over year keeps growing. However, our office has not experienced dropping rates. Finances and economics are a true riddle though. It's like dealing with a troll lol. I've just kept paneling on more and more insurances. Kept negotiating higher and higher rates as often as I could. My best luck so far, is asking for e.g. 150% of the CMS rate (it so far has kept up with inflation and I did not have to keep renegotiating because the rate adjusted/increased each year on its own). Each year this clinic has been open, it has grown and helped keep up with inflation. You can also ask for fee schedules based on RVUs with your customized conversion factor. The pay increases we got per unit of work over the past 3 years here has actually exceeded the inflation which is awesome. Then your highest payers, which can vary each year, we promoted our visibility to people who carry that insurance. Your panel fills up more with the higher payers of that unit in time. In a way, you are pitting the insurances against each other. What insurances have always responded to with us, due to the need for mental health services, especially psychiatrists, is when they experience a dwindling network size, which affects their members, affecting their customer satisfaction, potentially affecting their profits. So if we have a stronger working relationship with one insurance then it's in the others' best interest to compete for what we offer. I hope that makes sense? Some of our psychologists are fed up with 1-2 insurances, and they will be individually leaving that network as their patient census has become much more established. Those are valuable bargaining chips. That's the beauty if the free market. You give a sh_tty product, you get a sh_tty outcome. It's like employing people, you give bad pay, you're not going to attract good work. We stick it to insurance that way. It's a huge pain keeping up with this, but we deserve our independence and to be paid what we are worth. Everyone here knows that I fight for this with a passion.

Medicare sounds like a nightmare to deal with.. you can't charge patients no show fee and then you are going to book them for 90 min intakes.. The elderly are not good with any EMR, unless someone can help them out with it

Our office takes Medicare and Medicaid due to the good pay rate in this geographic area and the minimal billing needs. Medicaid here just pays in full and so does straight Medicare, we've never had a supplement insurance deny the 20% remaining. We have a template and some standardized generic trainings, generally they don't need to be renewed more than once a year. As for no shows, yes, that is a tough one. We've set some strict clinic policies about grounds for discharge. But also found that in depth discussion about the missed appointments not just from a financial standpoint but exploring that psychotherapeutically, most patients get the message and they either a) keep up their appointments or b) discontinue. Yes, it's a little trickier, but it can be done : ).

 

[Cath Up]

So you make more than 635k?

Oh god I thought you were gonna stop asking about money finally ?!????

 

[painballer27]

Oh god I thought you were gonna stop asking about money finally ?!????

I have. I wrote that before I resolved to stop.

 

[PikminOC]

I have. I wrote that before I resolved to stop.

Yes but inquiring minds want to know...

 

[throw-away-go-away]

You are absolutely right, a side gig would certainly shore up finances.

I just don't want the headache of a side gig and it impacting existing insurance contracts with NPI listings and address, etc. Low risk issue, but notable headache if happens. Secondly, with how I juggle personal life, I'm frequently behind on notes with what I'm currently doing. I just wouldn't have the logistical time to pile another gig in. Thirdly, I really, really, don't want to go back to any employed jobs. I've give 110% in the past, and honestly just don't have the motivation to enter that sphere again.

Currently, I'm in a moment of uncertainty and may be needing to move. Possibly would go to middle of nowhere Deep Red state, county with no existing Psychiatrists. Insurance payers are less than current location, but the anticipated wave of referrals will be notable. So preparing to physically move, and move a practice, I'm going to be in more of 'survival mode' for this year possibly. This move could possibly open up the opportunity to get legit acreage and allow me to start slowly building up my medicine exit plan - Ranching/Farming.

So does that mean: South/North Dakota, Wyoming, Montana, Idaho?

 

[trophyhusband]

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

 

[randomdoc1]

Cool beans @trophyhusband . Really cool that we are all sharing this data. More need to see this is totally doable. And we need to cut out middle men. lol, my husband ran the profit loss report too! My two cents also, don't be afraid either to take some financial risk. I'm a little more care free with my spending, which my husband hates. So I bought some expensive a55 software, not too long after starting spending $2500 a month on SEO, etc. What you are buying is efficiency which = time = money. Obviously don't be spending more than what you are getting back. Don't be afraid to take insurance either. Yes, in the start as a solo practitioner, they will offer you sh_t. That first year is heavy duty work. My profit that first year of opening was over 400k (solo practitioner but also offered TMS-->another 5k a month expense). I did though, take a partial practice from my previous place of employment. But there was still a lot of building to do.

 

[trophyhusband]

Cool beans @trophyhusband . Really cool that we are all sharing this data. More need to see this is totally doable. And we need to cut out middle men. lol, my husband ran the profit loss report too! My two cents also, don't be afraid either to take some financial risk. I'm a little more care free with my spending, which my husband hates. So I bought some expensive a55 software, not too long after starting spending $2500 a month on SEO, etc. What you are buying is efficiency which = time = money. Obviously don't be spending more than what you are getting back. Don't be afraid to take insurance either. Yes, in the start as a solo practitioner, they will offer you sh_t. That first year is heavy duty work. My profit that first year of opening was over 400k (solo practitioner but also offered TMS-->another 5k a month expense). I did though, take a partial practice from my previous place of employment. But there was still a lot of building to do.

Yeah, if we needed income more quickly she probably would have accepted insurance but despite my handle I actually make enough for her to take it slow.

Probably the biggest hurdle is that she has no interest in employing anyone (well outside of me I guess) so she has to handle a lot of messages/PAs/whatnot that other people could probably take care of for her. The amount of messages she gets from her 250-ish patients takes a lot of time and effort on her part. If her panel was larger due to taking insurance she'd be downing.

We're going to try the single payer thing here for a bit and see how that goes. She'll be an independent contractor, more or less, and the hospital provides the nurses/staff. She just has to send in her charges to the government and the check shows up 10 days later. She should make just about what we were hoping she'd make here (maybe more) when converted to US dollars and we don't have to worry about health insurance for ourselves... which is part of the reason I am still working. She can also just see CAP patients and make more per patient than seeing adult patients due to various complexity codes/time differential billing techniques. Everyone there seemed very happy with the set up when she visited and were horrified when she told them how the US system works (outside of residency since a lot of them did residency/fellowship in the US). So we'll see, it sounds awesome but she won't know until she tries it.

 

[randomdoc1]

Yeah, if we needed income more quickly she probably would have accepted insurance but despite my handle I actually make enough for her to take it slow.

Probably the biggest hurdle is that she has no interest in employing anyone (well outside of me I guess) so she has to handle a lot of messages/PAs/whatnot that other people could probably take care of for her. The amount of messages she gets from her 250-ish patients takes a lot of time and effort on her part. If her panel was larger due to taking insurance she'd be downing.

We're going to try the single payer thing here for a bit and see how that goes. She'll be an independent contractor, more or less, and the hospital provides the nurses/staff. She just has to send in her charges to the government and the check shows up 10 days later. She should make just about what we were hoping she'd make here (maybe more) when converted to US dollars and we don't have to worry about health insurance for ourselves... which is part of the reason I am still working. She can also just see CAP patients and make more per patient than seeing adult patients due to various complexity codes/time differential billing techniques. Everyone there seemed very happy with the set up when she visited and were horrified when she told them how the US system works (outside of residency since a lot of them did residency/fellowship in the US). So we'll see, it sounds awesome but she won't know until she tries it.

Yea, feel free to shoot me a PM if the thought arises! Think I may have some ideas. There's definitely ways to streamline this. PAs can be done in covermymeds (takes me 2 min) and for the insurances that do not use it, I integrated fax with the EMR. There's also ways to rx meds in a way that does not require PA, depends of course on which med you are prescribing (e.g. different formulations, although patented drugs need a PA regardless). I had about 1200 patients and the key was healthy boundary setting, some patient selection (I screen and gather some clinicals before they come for their first appointment to determine if this is something I can accommodate or not). With insurance you can bill for messages although they vary widely on if they reimburse. But patients see the EOB and take thought about if the message is really necessary or it can wait for an appointment. Along the note of messages, if it sounds more engaged, I start telling the patient we need to talk in session because we deserve to be paid for our time.

She will HAVE to get comfortable with hiring someone. Or her income potential is very limited. That is a learning process too. Finding right fit, making work easy to train as there will be turnover, competitively paying (even students are getting paid competitively these days and those who will accept low pay end up being expensive because they are more likely more work than help). But I've learned you have to really really dumb down the work. Make the work organized so tasks are set in categories, super trainable. Reminds me of pharmacies who hire anyone, they do have it down, because they set it up with lots of checks, balances, and a training system. Could they improve? Yes, but they've found a way to get employees in and be productive enough. Also, use software to track things (who opened what chart, what notes are entered) and keep checks and balances with finances is a must so things don't slip through the cracks.

 

[calvnandhobbs68]

Yeah, if we needed income more quickly she probably would have accepted insurance but despite my handle I actually make enough for her to take it slow.

Probably the biggest hurdle is that she has no interest in employing anyone (well outside of me I guess) so she has to handle a lot of messages/PAs/whatnot that other people could probably take care of for her. The amount of messages she gets from her 250-ish patients takes a lot of time and effort on her part. If her panel was larger due to taking insurance she'd be downing.

We're going to try the single payer thing here for a bit and see how that goes. She'll be an independent contractor, more or less, and the hospital provides the nurses/staff. She just has to send in her charges to the government and the check shows up 10 days later. She should make just about what we were hoping she'd make here (maybe more) when converted to US dollars and we don't have to worry about health insurance for ourselves... which is part of the reason I am still working. She can also just see CAP patients and make more per patient than seeing adult patients due to various complexity codes/time differential billing techniques. Everyone there seemed very happy with the set up when she visited and were horrified when she told them how the US system works (outside of residency since a lot of them did residency/fellowship in the US). So we'll see, it sounds awesome but she won't know until she tries it.

She got licensed in another country? That's interesting and super uncommon...is she originally from that country/a citizen there?

 

[trophyhusband]

Yea, feel free to shoot me a PM if the thought arises! Think I may have some ideas. There's definitely ways to streamline this. PAs can be done in covermymeds (takes me 2 min) and for the insurances that do not use it, I integrated fax with the EMR. There's also ways to rx meds in a way that does not require PA, depends of course on which med you are prescribing (e.g. different formulations, although patented drugs need a PA regardless). I had about 1200 patients and the key was healthy boundary setting, some patient selection (I screen and gather some clinicals before they come for their first appointment to determine if this is something I can accommodate or not). With insurance you can bill for messages although they vary widely on if they reimburse. But patients see the EOB and take thought about if the message is really necessary or it can wait for an appointment. Along the note of messages, if it sounds more engaged, I start telling the patient we need to talk in session because we deserve to be paid for our time.

She's the only doctor in town who is willing to treat Adult ADHD... in a college town (even the university's student health Psychiatrists don't want to deal with it). So she's got quite a few of them. PAs galore and the way the DEA deals with controlled Rx's leads to lots of messages (for the 40th time please don't call the pharmacy and say you want a refill just say please fill this medication!). If she took insurance she'd have more variety and it would maybe cut down on some of those annoyances... but it is what it is.

 

[trophyhusband]

She got licensed in another country? That's interesting and super uncommon...is she originally from that country/a citizen there?

No, we we're both originally from the US. Just have to jump through hoops to get your credentials certified as equivalent and then get the health system to sponsor you. The licensing board has a someone come and check on your work for a few weeks and if they don't find any issues you're fully licensed. You might be tied to the health system until your a permanent resident or citizen we haven't really looked into that part yet.