Private Practice Income- Masters Vs Doctorate

[Sanman]

This is getting a bit off topic perhaps, but certainly what doesn’t help our field is the ton of unregulated people who have “life experience” and/or “intuition” who do counseling as long as they don’t call it psychotherapy or therapy, and no one does anything about it. Thousands of people out there do counseling/coaching/relationship workshops/etc. with zero education or training. I can’t tell you how many people outside of our field consider themselves experts at counseling because “it’s just so easy to give advice and I’m good at it. My friends say I’m a natural counselor.”

Some also seek life coaches and coaches because there’s still stigma around mental health and it sounds less stigmatizing to go to a coach rather than a therapist in some social circles.

In one of the reality shows I watch, a woman who had no prior training or education held a weekend long relationship workshop because she must be an expert if she’s been in a relationship. It was infuriating to watch her host it.

All of this encroachment from people without education and training trivializes our field and makes it seem like you don’t need any training or expertise to do it. It makes it seem like therapy is easy. I don’t think this helps with our image, and I wish that state boards would do more about this problem because it is so widespread.

While I don't disagree with the sentiment, I have a feeling that this will not change just as juice cleanses, fad diets, and holistic practitioners (read unlicensed) of all sorts will persist. The larger issue is that it is more difficult to regulate for us than with physicians because a prescription pads are a concrete thing and psychotherapy like medical advice is not. The truth is that more professions than we would like to admit are based on good marketing and little actual scientific benefit (chiropractors, stockbrokers, most consultants, the people that came up with Crystal Pepsi, etc.).

As for those that are "natural counselors"...I am a good singer, have been a member of a few choirs, and friends and strangers alike have complimented my karaoke skills. It doesn't mean any of them are willing to spend $125 for a concert ticket to listen to me sing.

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[R. Matey]

In one of the reality shows I watch, a woman who had no prior training or education held a weekend long relationship workshop because she must be an expert if she’s been in a relationship. It was infuriating to watch her host it.

I'll admit to occasionally hate watching life coaches on TikTok. I'm amused when they say things like: "We, in the field, call these Blahdy-blahdy-blah."

 

[Sanman]

I'll admit to occasionally hate watching life coaches on TikTok. I'm amused when they say things like: "We, in the field, call these Blahdy-blahdy-blah."

There was some hot goss among some folks I know because a member of the group who had quit her job as a healthcare professional during the pandemic to become a relationship coach. Only issue was this person has never had a successful relationship.

 

[R. Matey]

There was some hot goss among some folks I know because a member of the group had quit her job as a healthcare professional during the pandemic to become a relationship coach. Only issue was this person has never had a successful relationship.

You didn't say it, but this post made me wonder how many life coaches out there are actually defunct therapists for one reason or another.

 

[foreverbull]

While I don't disagree with the sentiment, I have a feeling that this will not change just as juice cleanses, fad diets, and holistic practitioners (read unlicensed) of all sorts will persist. The larger issue is that it is more difficult to regulate for us than with physicians because a prescription pads are a concrete thing and psychotherapy like medical advice is not. The truth is that more professions than we would like to admit are based on good marketing and little actual scientific benefit (chiropractors, stockbrokers, most consultants, the people that came up with Crystal Pepsi, etc.).

As for those that are "natural counselors"...I am a good singer, have been a member of a few choirs, and friends and strangers alike have complimented my karaoke skills. It doesn't mean any of them are willing to spend $125 for a concert ticket to listen to me sing.

True, it probably won’t change but it’s infuriating to watch laypeople delegitimize the science and theory behind our work by ignoring it and doing whatever they want and calling it something adjacent to therapy or counseling and charging $200-$300/hr in some areas.

I think the general public really does think therapy would be an easy job—I used to set my psych students straight in counseling theories class because they came in told they were good at advice and helping, etc. and that’s why they wanted to become therapists. I tried to explain that it was actually difficult to master and a huge responsibility because of the nuance, theory, science (and ethics) involved.

 

[smalltownpsych]

Speaking of life coaches, one edge we have is that we can bill insurance, meanwhile I don't accept insurance.
Fortunately people with significant mental health diagnoses who need treatment tend to want solid and experienced practitioners. It is getting harder for the consumers to wade through the weeds though. It would be nice if we as psychologists could put a little more emphasis on our skill set and advantages and market it a bit. Even if we can't "prove" in a research design that we are better than the average online-degree counselor down the street, we could still market that and my practice could use all the help it could get with that.

 

[smalltownpsych]

True, it probably won’t change but it’s infuriating to watch laypeople delegitimize the science and theory behind our work by ignoring it and doing whatever they want and calling it something adjacent to therapy or counseling and charging $200-$300/hr in some areas.

I think the general public really does think therapy would be an easy job—I used to set my psych students straight in counseling theories class because they came in told they were good at advice and helping, etc. and that’s why they wanted to become therapists. I tried to explain that it was actually difficult to master and a huge responsibility because of the nuance, theory, science (and ethics) involved.

One reason I like to work with more severe or acute clinical presentations is that the amateurs tend to stay away and the patients quickly recognize that the well-meaning people prior either didn't really help or often made things worse. Many of my clients have had plenty of therapy before.

 

[foreverbull]

You didn't say it, but this post made me wonder how many life coaches out there are actually defunct therapists for one reason or another.

I’ve heard of some therapists interested in adding it to their repertoire because of the appeal of not having that activity regulated by a state board. I think they also want to add it because it looks good to have multiple roles, certifications, and titles in their professional practice—like adding another thing they can do because the more titles, the better.

My personal favorite: a masters level clinician in psychology today advertised their title as John Doe, LMFT, EMDR.

Because you ARE EMDR? Hmmmmmm.

 

[eeor1006]

One reason I like to work with more severe or acute clinical presentations is that the amateurs tend to stay away and the patients quickly recognize that the well-meaning people prior either didn't really help or often made things worse. Many of my clients have had plenty of therapy before.

I, for one, would love to hear your experience transitioning from being an employee to full-time private practice, particularly cash only private practice.
I recently got a scam email from Betterhelp offering 20% off on-line therapy. I have to admit, if I was an uninformed layperson, I would probably be tempted to use their services. The website and supposedly real clients' reviews all seem solid and trustworthy. They even have in place a "rigorous vetting process" to guarantee "highly qualified therapy" whatever that means.
As a early career solo practitioner, I am interested to hear how others distinguish and sell what we offer and get the clients we want to attract through the door.

 

[smalltownpsych]

I, for one, would love to hear your experience transitioning from being an employee to full-time private practice, particularly cash only private practice.
I recently got a scam email from Betterhelp offering 20% off on-line therapy. I have to admit, if I was an uninformed layperson, I would probably be tempted to use their services. The website and supposedly real clients' reviews all seem solid and trustworthy. They even have in place a "rigorous vetting process" to guarantee "highly qualified therapy" whatever that means.
As a early career solo practitioner, I am interested to hear how others distinguish and sell what we offer and get the clients we want to attract through the door.

I work for betterhelp, signed up for it to have a little income while I was getting my practice started. It definitely has its place in our system and does improve access. That being said, it doesn’t pay that well, especially for a psychologist, and I am almost done with it. I am actually using my ability to provide therapy and generate income to fund, get experience running a business, and develop team members so that I can start up my own treatment program.

Because of my connections and experience in private pay residential treatment, I have a referral source that helps. that being said, I have a number of clients that are coming through Psychology Today and a few through my own community connections. Tomorrow is the end of my second month and my practice generated 5k first month and 8.5k second month. I am paying out about 3.5k. We are going to pay me 5k salary so looks like we’re breaking even. That being said, I made more than double that in my prior job even without counting benefits so got a little way to go to make that up.

Getting referrals and identifying target market is key. I am not a natural networker so it’s a good thing that I have solid clinical skills and thus good patient retention and reputation. Our sign just went up two weeks ago and it is visible and my website is not really up, just have a placeholder type that I through up really quickly myself just so we had something. Our infrastructure is all set up and pretty solid. Extremely part-time Psychiatric NP will be committing fully in a couple weeks and I have a couple of counseling interns who will be starting to see people for a reduced fee and/or providing community-based support services. So that is where we stand going into our third month. Goal is to make 10k next month.

 

[eeor1006]

I work for betterhelp, signed up for it to have a little income while I was getting my practice started. It definitely has its place in our system and does improve access. That being said, it doesn’t pay that well, especially for a psychologist, and I am almost done with it. I am actually using my ability to provide therapy and generate income to fund, get experience running a business, and develop team meme ears so that I can start up my own treatment program. because of my connections and experience in private pay residential treatment, I have a referral source that helps. that being said, I have a number of clients that are coming through Psychology Today and a few through my own community connections. Tomorrow is the end of my second month and my practice generated 5k first month and 8.5k second month. I am paying out about 3.5k. We are going to pay me 5k salary so looks like we’re breaking even. That being said, I made more than double that in my prior job even without counting benefits so got a little way to go to make that up.

Getting referrals and identifying target market is key. I am not a natural networker so it’s a good thing that I have solid clinical skills and thus good patient retention and reputation. Our sign just went up two weeks ago and it is visible and my website is not really up, just have a placeholder type that i through up really quickly myself just so we had something. Our infrastructure is all set up and pretty solid. Extremely part-time Psychiatric NP will be committing fully in a couple weeks and I have a couple of counseling interns who will be starting to see people for a reduced fee and/or providing community-based support services. So that is where we stand going into our third month. Goal is to make 10k next month.

Thanks for the information. Hope things to well for you and your practice!

 

[medium rare]

The truth is that I was surrounded by a lot of non-psychologist therapists with varying degrees of competence/rigorous thinking processes so it is nice to be back with my people.
I pounded my fist on the table during quite a few "case conferences" aka treatment team meetings. Fortunately, the owner had my back and was an experienced and brilliant psychiatrist. When he sold the business to eguity investors and my new boss was a non-clinician who thought they could make treatment decisions, it was time for me to go.

Your experience is exactly why I will never work for anyone but myself again. I’ve seen what happened to you too many times to count.

 

[FredBerfil]

Back to the OP's question - if you want to do therapy, get a masters (I'd say aim for a quality LCSW degree) and make sure you get some good training / mentorship in business and make sure you have a good professional network. If you can do those things, you'll eat the average psychologist for lunch in terms of private practice income and in all likelihood be a better therapist besides.

 

[R. Matey]

Back to the OP's question - if you want to do therapy, get a masters (I'd say aim for a quality LCSW degree) and make sure you get some good training / mentorship in business and make sure you have a good professional network. If you can do those things, you'll eat the average psychologist for lunch in terms of private practice income and in all likelihood be a better therapist besides.

I think you may be thinking of the exception rather than the rule. It really all hinges on where an LCSW completes their post-master's training, IME.

 

[smalltownpsych]

Update on private practice. 9800 in third month. Just added an intern who has first client tomorrow and have a PSR working with a couple of clients. Have another intern starting next month. Beginning to identify niches and building good referral sources. It is a slow process and it often seems like two steps forward and 1 step back.

 

[BuckeyeLove]

you'll eat the average psychologist for lunch in terms of private practice income and in all likelihood be a better therapist besides.

Ummm.....no.

 

[smalltownpsych]

Intern had great first session today. So much fun, she was anxious as hell and very aware of the seriousness of this job from a life and death stance, from a competency stance, and from a business stance. She was very much relieved that patient was not suicidal, is eager to do the CBT homework, and rescheduled. I told her next week she’ll get the opposite of the YAVIS client so enjoy this one and the opportunity to develop and practice your skills because the unmotivated client with poor hygeine and doesn’t know why their spouse sent them won’t help you learn how to help people. Also I made a few bucks while she was working and learning and I was just catching up on my paperwork.

 

[PsySeeker]

Payers in my area generally reimburse master level clinicians at 75% of the psychologist rate for therapy. Recently two big payers also eliminated the pay differential with psychiatrist by bumping psychologists to the current psychiatrist rate.

 

[allantois]

The ones who are gonna make good money are ultimately going to be business owners supervising other clinicians. Most of these people from my observations are regular therapists. Most psychologists seem to do their own solo practice thing

 

[allantois]

Payers in my area generally reimburse master level clinicians at 75% of the psychologist rate for therapy. Recently two big payers also eliminated the pay differential with psychiatrist by bumping psychologists to the current psychiatrist rate.

Psychiatrist rate for what? Psychiatric billing codes are different from therapists codes

 

[WisNeuro]

The ones who are gonna make good money are ultimately going to be business owners supervising other clinicians. Most of these people from my observations are regular therapists. Most psychologists seem to do their own solo practice thing

Well, employing others, or legal work.

 

[allantois]

Well, employing others, or legal work.

LMHC, LCSW, and LMFT have to get something like 2 years of supervised clinical work so there’s supervisor practice owners supervising half a dozen interns and making bank off of them. I don’t think psychologists can supervise these clinicians but I’m not sure?

 

[WisNeuro]

LMHC, LCSW, and LMFT have to get something like 2 years of supervised clinical work so there’s supervisor practice owners supervising half a dozen interns and making bank off of them. I don’t think psychologists can supervise these clinicians but I’m not sure?

I'm a little siloed as midlevels can't bill my codes anyway, so I actually don't know the rules on that specifically, but I doubt psychologists can. It's challenging enough supervising our own interns giving the billing limitations there. By and large, supervision of interns is a net loss in money/time. Also, even if we could supervise midlevels, not sure I'd want that sort of liability on my license.

 

[R. Matey]

LMHC, LCSW, and LMFT have to get something like 2 years of supervised clinical work so there’s supervisor practice owners supervising half a dozen interns and making bank off of them. I don’t think psychologists can supervise these clinicians but I’m not sure?

We can supervise LMHC/LPCs in most places. Social work is a bit more of a closed loop. Liability would definitely be a concern in a PP setting, but this arrangement might be more common in a community agency or post-master's licensing fellowship like in a UCC.

 

[smalltownpsych]

I am not sure how you make bank off interns as most insurances won’t reimburse for non-licensed individuals. Perhaps, if the medicaid rules in your state allows for it, then it could be a thing. I am supervising a couple but I don’t foresee making bank off them. It actually just fits with my model of being able to offer additional services and support to individuals coming out of private pay residential settings.

 

[WisNeuro]

I am not sure how you make bank off interns as most insurances won’t reimburse for non-licensed individuals. Perhaps, if the medicaid rules in your state allows for it, then it could be a thing. I am supervising a couple but I don’t foresee making bank off them. It actually just fits with my model of being able to offer additional services and support to individuals coming out of private pay residential settings.

Yeah, interns aren't great for a lot of neuropsych practices. We can't bill Medicare and some insurances for any of the work they do as part of their training, so it's a huge loss in terms of time spent.

 

[smalltownpsych]

Yeah, interns aren't great for a lot of neuropsych practices. We can't bill Medicare and some insurances for any of the work they do as part of their training, so it's a huge loss in terms of time spent.

I bill 175 for an hour of therapy so it will be a while before I can make up for the hours I dedicate to interns. Maybe even never. Another reason I do it is because grinding out sessions 40 hours a week is not what I want to do and teaching/training others is something I enjoy so it helps keep me emotionally stable and balanced. One reason I enjoy being a psychologist is I get to do many different things each week.

 

[WisNeuro]

I bill 175 for an hour of therapy so it will be a while before I can make up for the hours I dedicate to interns. Maybe even never. Another reason I do it is because grinding out sessions 40 hours a week is not what I want to do and teaching/training others is something I enjoy so it helps keep me emotionally stable and balanced. One reason I enjoy being a psychologist is I get to do many different things each week.

I used to enjoy teaching/training. Then I got into legal/IME work and found out I enjoyed greatly increasing my hourly billing even more But, half-joking aside, I still get some of that with peer consultation, as well as working with grad students/psychometrists on a few of the projects I work on. My clinical portion of work is just solo, though.

 

[Sanman]

We can supervise LMHC/LPCs in most places. Social work is a bit more of a closed loop. Liability would definitely be a concern in a PP setting, but this arrangement might be more common in a community agency or post-master's licensing fellowship like in a UCC.

Not sure it would be worth the trouble compared to just hiring newly licensed grads that need a job.

 

[R. Matey]

Not sure it would be worth the trouble compared to just hiring newly licensed grads that need a job.

It is when you can pay them ~20k-30k less. These are also types of jobs that psychologists avoid due to lower pay.

 

[WisNeuro]

It is when you can pay them ~20k-30k less. These are also types of jobs that psychologists avoid due to lower pay.

Plenty of people want the flexibility of PP. Plus, pretty easy to beat the 50/50 splits everyone else is offering while still making profit.

 

[allantois]

They bill patients $100 for therapy with interns and pay therapists a small portion of that and profit..

 

[R. Matey]

Plenty of people want the flexibility of PP. Plus, pretty easy to beat the 50/50 splits everyone else is offering while still making profit.

No doubt, I'm only saying these types of jobs exist at the master's level. Much more common in community mental health or a UCC, where there are fewer and fewer psychologists. Psychiatrists probably see it more than you or I would. I wouldn't know anything about it if I hadn't already been a midlevel first.

Edit: We give the advice on here a lot that people who want therapy careers should just pursue master's degrees, but those post-master's licensing hours are often harrowing experiences, especially for LPCs who don't have the same opportunities that social workers do. Many people are stuck with so few options that they basically have to take a horrible split in order to get their licensing hours done where psychologists and/or business people are 100% profiteering off their Medicaid billing. It's probably less worse in a UCC where the gains are overall reduction in demand of services for a fraction of the cost of what it would be to hire staff (think in terms of ~35-40k for a willing unlicensed mid-level vs. 58-60k for a desperate psychologist).

 

[Sanman]

It is when you can pay them ~20k-30k less. These are also types of jobs that psychologists avoid due to lower pay.

Yes but I was referring to newly licensed midlevels as well. Why supervise the hours if it is not necessary?

 

[R. Matey]

Yes but I was referring to newly licensed midlevels as well. Why supervise the hours if it is not necessary?

Ah, so we're just misunderstanding each other. I meant that psychologists can supervise LPCs/LMHCs to licensure.

 

[taylortaylor164]

Ah, so we're just misunderstanding each other. I meant that psychologists can supervise LPCs/LMHCs to licensure.

Psychologists can definitely supervise LPCs and LMHCs in my state. In the private practice I was in previously, the PhD was the CEO and had an all LPC staff pretty much they supervised and they acted as the psychology associates. Does insurance bill psychology associates at different rates than if a licensed psychologist gave the session?

 

[R. Matey]

Does insurance bill psychology associates at different rates than if a licensed psychologist gave the session?

Interesting, I think that's the same in every state I've worked as well back when I was a practicing LPC. I imagine that is very insurance and state dependent. In my current state, I think insurance companies bill psych associates at the same rate.

 

[WisNeuro]

Interesting, I think that's the same in every state I've worked as well back when I was a practicing LPC. I imagine that is very insurance and state dependent. In my current state, I think insurance companies bill psych associates at the same rate.

Masters level are billed at different rates for several insurers here. Also, non SW masters can't bill certain payers for certain codes.

 

[R. Matey]

Masters level are billed at different rates for several insurers here. Also, non SW masters can't bill certain payers for certain codes.

I know that I couldn't touch Medicare as an LPC back in the day (what a blessing that was), but didn't know there were certain CPT codes that SWs can bill, LPCs couldn't.

 

[Sanman]

I know that I couldn't touch Medicare as an LPC back in the day (what a blessing that was), but didn't know there were certain CPT codes that SWs can bill, LPCs couldn't.

Not sure why being unable to touch medicare is a blessing, but okay. I think LPCs can bill the same codes generally, but certain insurers will not reimburse LPCs for some of those codes (only SWs).

 

[R. Matey]

Not sure why being unable to touch medicare is a blessing, but okay. I think LPCs can bill the same codes generally, but certain insurers will not reimburse LPCs for some of those codes (only SWs).

I just channeled Michelle Obama so I didn't reply with equivalent snark, but what I meant was no Medicare usually meant lower caseloads and less paperwork, IME. I am, though, genuinely curious of an example of such a code.

 

[WisNeuro]

I know that I couldn't touch Medicare as an LPC back in the day (what a blessing that was), but didn't know there were certain CPT codes that SWs can bill, LPCs couldn't.

Medicare is a slight hassle to get initially credentialed with, but they are by far the easiest to deal with when it comes to billing and having to interact with. I'll see a Medicare with supplemental over a third party insurer any day for my clinical cases. Between prior auth bs and other needless documentation, other insurers add soooooo much unbillable time to what I need to do. At some point in the future when I decide that clinical work will be at or less than 25% of my time, with IME/legal stuff being the other part, I will drop all payers besides Medicare.

 

[R. Matey]

Medicare is a slight hassle to get initially credentialed with, but they are by far the easiest to deal with when it comes to billing and having to interact with. I'll see a Medicare with supplemental over a third party insurer any day for my clinical cases. Between prior auth bs and other needless documentation, other insurers add soooooo much unbillable time to what I need to do. At some point in the future when I decide that clinical work will be at or less than 25% of my time, with IME/legal stuff being the other part, I will drop all payers besides Medicare.

Interesting, I know few providers in PP that won't touch Medicare because of issues with lower reimbursement. That's probably plan dependent and these are psychotherapy practices, unless that's what you mean by clinical cases.

 

[WisNeuro]

Interesting, I know few providers in PP that won't touch Medicare because of issues with lower reimbursement. That's probably plan dependent and these are psychotherapy practices, unless that's what you mean by clinical cases.

They're not very different than some third party payers. There are a few payers with substantially lower rates than Medicare that I do not panel with. As a quick point of reference, for a fairly standard dementia eval medicare plus supplmental (which is most medicare patients in my practice), I get between $750-900. These are pretty straightforward cases. Timewise, I'm probably 60% IME/legal and 40% clinical on about a .75 FTE at the moment.

 

[R. Matey]

They're not very different than some third party payers. There are a few payers with substantially lower rates than Medicare that I do not panel with. As a quick point of reference, for a fairly standard dementia eval medicare plus supplmental (which is most medicare patients in my practice), I get between $750-900. These are pretty straightforward cases. Timewise, I'm probably 60% IME/legal and 40% clinical on about a .75 FTE at the moment.

Great example, thanks. I could see how it would be different in PP than in an agency setting where you're getting like 25% of what you're billing.

Edit: insurance was also one of the many reasons I quit counseling, since reimbursements are lower than psychology and, in my state at the time, getting paneled privately was essentially a lottery.

 

[Sanman]

Great example, thanks. I could see how it would be different in PP than in an agency setting where you're getting like 25% of what you're billing.

Edit: insurance was also one of the many reasons I quit counseling, since reimbursements are lower than psychology and, in my state at the time, getting paneled privately was essentially a lottery.

It really depends on your setup whether medicare vs private insurance has the edge. An example from the flipside is that Optum/UHC paid better for outpatient psychotherapy, but was doing so much gatekeeping we stopped accepting their patients. Tons of utilization reviews, requiring us to do basically free MMSEs on anyone with a cognitive disorder dx every 3 mos, installing their own NPs for gatekeeping, etc.

 

[WisNeuro]

It really depends on your setup whether medicare vs private insurance has the edge. An example from the flipside is that Optum/UHC paid better for outpatient psychotherapy, but was doing so much gatekeeping we stopped accepting their patients. Tons of utilization reviews, requiring us to do basically free MMSEs on anyone with a cognitive disorder dx every 3 mos, installing their own NPs for gatekeeping, etc.

You definitely have to factor in the BS when it comes to reimbursement. Here, BCBS pays a little more than Medicare, but the prior auth process and clunky billing adds time on the backend.

 

[PsySeeker]

Psychiatrist rate for what? Psychiatric billing codes are different from therapists codes

Uh, for psychotherapy codes? They aren't different CPT codes.

 

[allantois]

Uh, for psychotherapy codes? They aren't different CPT codes.

Psychotherapy add on codes with medical codes are different and reimburse differently from stand alone psychotherapy codes

 

[PsySeeker]

Psychotherapy add on codes with medical codes are different and reimburse differently from stand alone psychotherapy codes

They can and do use both and many payer scales for these codes include an MD column that is separate and higher than the PHD column, which is separate and higher than the masters column, and some even have an NP column as well.

United maintains this hierarchy.

Until recently my local BCBS and Aetna were set up this way, but the PHD column is no more and its now PHD/MD at the formally higher MD level.