Private practice logistics

[Freedoc]

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I am a PGYIV planning to start private practice. I am just beginning to look into some of the logistics of accepting insurance, cash based practice, telepsychiatry etc. I have many questions that one way or another I will find the answer to but I'm hoping that some here may be able to shorten the time to acquisition of these answers. My main goal is that my income, schedule, geography not be dictated by anyone other than myself and that I earn enough to save for retirement and health costs and live a reasonably comfortable life. Among the questions I have are these:


What is entailed (logistically, how much time, effort etc) does it take to get paneled by various insurances?
Can I become paneled by insurance as a resident if licensed?
Has anyone used services such as "drchrono" for EHR and billing? - (for a fee they will bill insurance for you)
I am considering various non-traditional marketing routes to telepsych such as trendy local news papers with band and local event shows in them and even possibly Craigslist
Has anyone actually tried companies like voyager etc who provide a (quite) basic set-up to run private practice telepsych?

 

[ferning]

I am a PGYIV planning to start My main goal is that my income, schedule, geography not be dictated by anyone other than myself and that I earn enough to save for retirement and health costs and live a reasonably comfortable life.

Well your income is invariably dictated by someone else: patient population (if you have one) and insurance (if you choose to accept it) and your geography market for psychiatrists. How many patients needing one are there and that arent being seen by someone, as well as how many that are but are interested in a new one.

Before going further dictate your own geography and research what others charge for an intial visit and follow up if patients pay cash and what insurance providers they take, then look at what private insurance companies are even in your state/area, then look at a more specific location in your area for a practice. See if there is an older psych doc in the area with an established practice (who maybe looking to retire soon or go more part time) and would be interested in renting out his office when hes not there.

An area lr complex with other referring physicians would be good for some pts to start with or at least make those contacts and say you are looking for patients. Get a place thats easily accessible, visible, and within a reasonable driving distance to where potential patients will live. Good parking is key too

Do a basic cost analysis of rent, utilities, taxes, and what minmum you need to make a month to keep the office going and your own basic lifestyle. Then add in what more $ you want to make and desired hours.

Be flexible and make hours that work with working peoples schedule (ones who will have insurance or $ to pay cash) like som 3-9pm days. Throw in a saturday since you are just starting up and need a minimum # of pts just to keep your rent and your offices going

-Get credit card payment processor, depending on your state you may have to register your name and practice location

Some insurance providers I believe reimburse higher or with better turnaround if you take them exclusively. See how many people are insured by them in your area, as well as copay for the patient and deductible.

Dont go making any quick deals with them or you will be low balled for life from them or enter into a contract when many theres another insurance provider that would be better

And underprice yourself for cash payers compared to others, there maybe people who can do $75-90 visit but not $160 that could be yours. With minimal overhead and sheduling yourself at first (then a dedicated satellite secretary when its too many patients) this is almost all take home. $90 an hour for 40 hrs a week is 180k a year. Do your taxes write to make uncle sams cut minimal.

A self employed 401k or IRA can be like a 40-50k above the line deduction.

Get high on google search and facebook your practice as well

Be flexible with patients who are looking for more frequent visits and pay out of pocket and who seem reliable, you can set up reoccuring billing through different payment processors for like $50 a month till they are paid off

 

[TexasPhysician]

I would research telepsych further. I believe it is illegal in some states to do telepsych unless the patient is being seen from an established clinic. Even if it were legal to see a patient in their home, I wouldn't do it for high liability reasons.

I contacted my insurance company about a potential telepsych moonlighting job. They required a letter/contract from the company guaranteeing that all patients I see will be in a clinical setting with appropriate staff to handle all potential problems. Anything other than this would result in no malpractice coverage.

Insurance panels need you more than you need them. Remember that when they cause you problems.

 

[F0nzie]

And underprice yourself for cash payers compared to others, there maybe people who can do $75-90 visit but not $160 that could be yours. With minimal overhead and sheduling yourself at first (then a dedicated satellite secretary when its too many patients) this is almost all take home. $90 an hour for 40 hrs a week is 180k a year.

If you are running a cash private practice, the clinical work is triple. You are taking depressed and extremely anxious people under your wing and responsible for them 24/7) If they initiate contact with you 20x in the span of 3 months and pay you $75 for 1 visit is that worth your time? Not all patients are like this, but a small handful of them will take up a lot of your time. As a general rule, take your hourly rate of $90/hour and divide it by 3-- $30/hour is your true hourly rate just for the clinical, not including the business and marketting. Under cutting the market is definitely not the way to go unless you are running a massive operation and want to be the Walmart of psychiatry. Plus lowering your rates does not make it all that much more desirable for the majority of people who are dead set on going through their insurance company... you will be shooting yourself in the foot IMO.

 

[whopper]

Getting paneled with insurance companies is a big pain in the butt. When I did private practice, they had someone do all the paper work for me except for the stuff where I had to sign the papers myself.

If you don't have staff already doing this for you, prepare to be bummed out for a very long, tedious, and frustrating process. It's like doing taxes. It's worth it to pay someone to do it for you.

How long does it take? It all depends on the company. Some take just a few days, some weeks, others months.

I got panelled with several several companies. Some of them were easy, others were a pain in the butt. It all depends on them. I also had some ridiculous questions. E.g. there's another doctor in the same state with my name who's a cardiologist. One company asked me why I, a cardiologist, wanted to practice as a psychiatrist and I told them over and over it was a different guy and they refused to believe me for a few weeks despite that all they had to do was check it up on a computer.

 

[Freedoc]

Thankds for the replies -

firning

Are you now or have you been in pp?

I like that suggestion of flexible hours. I have considered this as well as getting the right combonation of people with both time and sufficient money can be tricky.

As for a credid card payment processor, I was planning on using squared. How does one "register"? Where do I start to do something like that?

"Some insurance providers I believe reimburse higher or with better turnaround if you take them exclusively. See how many people are insured by them in your area, as well as copay for the patient and deductible."
- Interesting, I was unaware of this
"Dont go making any quick deals with them or you will be low balled for life from them or enter into a contract when many theres another insurance provider that would be better"
- What factors affect re-embursment rates? How much leverage to Physicians have in this process?

'And underprice yourself for cash payers compared to others, there maybe people who can do $75-90 visit but not $160 that could be yours. With minimal overhead and sheduling yourself at first (then a dedicated satellite secretary when its too many patients) this is almost all take home. $90 an hour for 40 hrs a week is 180k a year. Do your taxes write to make uncle sams cut minimal."
- I like this "mix" of insurance and cash based philosophy, I don't understand why some seem to imply it has to be all one or the other.
- As for cash payers, I will have to look at pricing further but I agree with the logic. I am not planning on pampering my patients just as I do not in my residency. If one is suicidal after hours that is a shame but that is what EDs are for... sorry tough love and used to dealing with a lot of people playing the suicidal card... yes I know some are the real deal... lets not go there now. Believe me in my 30min to an hour with them that they pay me for I will be doing my best to help them change their lives this is not a matter of compassion, drive, passion for my profession etc.
- To me, this can acually be a potential problem of charging top dollar - patients want hand-holding if paying that much and as Fonzie pointed out - that actually can translate into less $ per hour.

A self employed 401k or IRA can be like a 40-50k above the line deduction.
- sorry, what do you mean by "above the line?" poor resident here still unawares of much of the -what to do when actually have money topics

"Be flexible with patients who are looking for more frequent visits and pay out of pocket and who seem reliable, you can set up reoccuring billing through different payment processors for like $50 a month till they are paid off[/QUOTE]


TexasPhysician
"I would research telepsych further. I believe it is illegal in some states to do telepsych unless the patient is being seen from an established clinic. Even if it were legal to see a patient in their home, I wouldn't do it for high liability reasons."
- where did you get that info? Did you hear that it was illegal from someone?
- my plan woud be to pick 2-3 major cities (other than the one I will live in) for telepsych , concentrate my patients there as to not have them spread out then periodically - like every 3-6 months actually fly to the area and physically see the patients in a rented space.
"I contacted my insurance company about a potential telepsych moonlighting job. They required a letter/contract from the company guaranteeing that all patients I see will be in a clinical setting with appropriate staff to handle all potential problems. Anything other than this would result in no malpractice coverage."
- In this case perhaps it would be best to only accept insurance for my local patients then do cash based for telepsych unless insurance compainies bought into my periodic physical visit plan.
]

F0nzie
"If you are running a cash private practice, the clinical work is triple. You are taking depressed and extremely anxious people under your wing and responsible for them 24/7) If they initiate contact with you 20x in the span of 3 months and pay you $75 for 1 visit is that worth your time? Not all patients are like this, but a small handful of them will take up a lot of your time. As a general rule, take your hourly rate of $90/hour and divide it by 3-- $30/hour is your true hourly rate just for the clinical, not including the business and marketting. Under cutting the market is definitely not the way to go unless you are running a massive operation and want to be the Walmart of psychiatry. Plus lowering your rates does not make it all that much more desirable for the majority of people who are dead set on going through their insurance company... you will be shooting yourself in the foot IMO."
-I guess this is actually my argument against charging top dollar. I feel like patients will expect a high level of service, feel entitled and want hand holding and that may likely translate into watering down the "top dollar" to an actually lower hourly pay


whopper

"Getting paneled with insurance companies is a big pain in the butt. When I did private practice, they had someone do all the paper work for me except for the stuff where I had to sign the papers myself."
- I am cheap, (and poor at this point) is it really THAT bad?

 

[billypilgrim37]

-I guess this is actually my argument against charging top dollar. I feel like patients will expect a high level of service, feel entitled and want hand holding

This describes medicaid patients as well, folks without insurance, folks with insurance, rich folks, etc. This describes everybody. Whether they see you for free or pay you 400 dollars an hour, patients expect such "high level of service" and "feel entitled" across the full range of SES. "You have to give me klonopin, I pay you 400 dollars an hour" is just as internally logical as "You have to give me klonopin, the government pays you to take care of me!"

 

[TexasPhysician]

I think you misread my post. My malpractice insurance provider refuses to insure me for telepsych unless all patients are seen in a staffed clinic. I am with the largest medical malpractice insurance provider.

I considered working in telepsych and spoke to the CEO of a large telepsych company. He expressed many regulations and frustrations. He has been lobbying for more lax laws regarding psych as less physical exams are needed in our field. You need to look into state/federal laws and talk to your malpractice provider before going this route. I'd be worried about more potential lawsuits as well especially if you are practicing in large cities with local alternatives. Standard of care is different in every setting in my opinion.

 

[Freedoc]

This describes medicaid patients as well, folks without insurance, folks with insurance, rich folks, etc. This describes everybody. Whether they see you for free or pay you 400 dollars an hour, patients expect such "high level of service" and "feel entitled" across the full range of SES. "You have to give me klonopin, I pay you 400 dollars an hour" is just as internally logical as "You have to give me klonopin, the government pays you to take care of me!"

Good points

 

[Freedoc]

I think you misread my post. My malpractice insurance provider refuses to insure me for telepsych unless all patients are seen in a staffed clinic. I am with the largest medical malpractice insurance provider.

I considered working in telepsych and spoke to the CEO of a large telepsych company. He expressed many regulations and frustrations. He has been lobbying for more lax laws regarding psych as less physical exams are needed in our field. You need to look into state/federal laws and talk to your malpractice provider before going this route. I'd be worried about more potential lawsuits as well especially if you are practicing in large cities with local alternatives. Standard of care is different in every setting in my opinion.

OK, good info thanks.

I do see how it could leave open to suits if it were argued you were not providing the standard of care. I wonder though if the telepsychiatry were primarily ( or only) psychotherapy if this would be an issue and whether malpractice ins may be more amenable to this.

 

[happygilmore]

If you are running a cash private practice, the clinical work is triple. You are taking depressed and extremely anxious people under your wing and responsible for them 24/7) If they initiate contact with you 20x in the span of 3 months and pay you $75 for 1 visit is that worth your time? Not all patients are like this, but a small handful of them will take up a lot of your time. As a general rule, take your hourly rate of $90/hour and divide it by 3-- $30/hour is your true hourly rate just for the clinical, not including the business and marketting. Under cutting the market is definitely not the way to go unless you are running a massive operation and want to be the Walmart of psychiatry. Plus lowering your rates does not make it all that much more desirable for the majority of people who are dead set on going through their insurance company... you will be shooting yourself in the foot IMO.

There's no reason that cash private practice should take 3 times longer than one that accepts insurance. Sounds like you just need to learn the boundaries that other PP psych docs use.

20x contacts in 1 month with only 1 appt? Tell them to have visits once per week if they need attention. If someone wanted to call you 100x a month would you let them? You probably could learn a lot from lawyers. They are always billing.

If expectations are set from day 1 then you can dictate that pretty well. If you tell then tons of personal attention and allow that then your rates should reflect that. .. Yet to set high rates because of a few high maintenance patients would probably not be justifiable.

 

[F0nzie]

There's no reason that cash private practice should take 3 times longer than one that accepts insurance. Sounds like you just need to learn the boundaries that other PP psych docs use.

20x contacts in 1 month with only 1 appt? Tell them to have visits once per week if they need attention. If someone wanted to call you 100x a month would you let them? You probably could learn a lot from lawyers. They are always billing.

If expectations are set from day 1 then you can dictate that pretty well. If you tell then tons of personal attention and allow that then your rates should reflect that. .. Yet to set high rates because of a few high maintenance patients would probably not be justifiable.

I guess I should have clarified. Patients call in with side effects, attempt suicide, get hospitalized, need a doc-to-doc, doc-therapist, need FMLA paperwork, run out of money, no-show (despite text and email reminders), etc. These are all issues that need to be addressed regardless if you are insurance or private pay. I do charge an hourly rate for phone calls >10 minutes as well as extended documentation, and missed appointments (but they also miss for legitimate reasons). It's a tough balance between boundary setting, professionalism, and mitigating liability. If I was paneled on insurance companies I could be the most unavailable psychiatrist and people will still be banging on my door asking for an intake. In a cash practice, that type of behavior will be relayed to referral sources and your income will run dry very quickly.

 

[Freedoc]

Thank you all for your responses and especially thank you to Fonzie for being so sharing of your current experience with the community on this site.

I am wondering... is it possible to be paneled by say .. one or two insurance companies and be in network - for these patients while also running a cash practice for the remainder of clients? Thought on this?