Private Practice Olio

[WisNeuro]

Just a thread, similar to the Friday thread to discuss some PP issues.

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[WisNeuro]

To start out with, for those with small PP setups, what day to day accounting software are you using? At the moment, I've just been using spreadsheets that I made to track revenue and expenses. My setup is fairly easy as I only see a few clinical cases a week, and my IME work is generally very straightforward (10+ hours/case, but just one big paycheck). Wondering if it makes sense to try something else, or stick with what's currently working.

 

[ela]

I use quickbooks online for self-employed. Automatically connected to bank account so profit / loss, classifying expenses etc is all automated, essentially. Very worth the small fee IMO! But I too have a very small part-time PP.

 

[Therapist4Chnge]

I have quickbooks (I'm still loading stuff into it), but I've kept spreadsheets for everything, as I'm comfortable w my own setup....I think. I'm low volume between IMEs, mostly neuropsychs, and a small clinical caseload. My mid-level is somewhat busier, though as I was reminded yet again today....I need to have a better internal process to get everything billed. This is at least the 2nd time in 6 months I've missed a week of notes (I have them send me their notes at the end of each week).

Great idea for a thread.

 

[WisNeuro]

For those that do use quickbooks, is your main plus of the service the ability to sync to your bank account? Trying to calculate how much time may be saved in that method as opposed to my spreadsheet/workbook methods.

 

[Justanothergrad]

I use an excel sheet similar to you. I haven't found a need to go more advanced. My accountant loves how I have it setup, so that slows my motivation as well.

 

[Sanman]

Great thread idea, just as I am starting to set things up....will be reading with great interest.

 

[WisNeuro]

Hmm, I may stick with spreadsheets for a while. Expenses are pretty easy to track, pretty much rent, testing supplies, some odds and ends. And income is usually coming in easy to track batches.

 

[Therapist4Chnge]

My biggest hurdle has been managing the billing with the ever changing attempts for companies to screw providers. For instance, most new (workers comp) companies first send "virtual credit cards", usually with the EOB separately. Then you have to call the 3rd party company who only has payment information, waste more time, just to opt-out. The 3rd party (but sometimes the WC company) will re-issue the payment in a check, but then trying to match up the "new" check with the EOB (old or new) can be a hassle. Depending on when you call and what checks are out, then they bundle and then getting the EOBs sorted gets more complicated. Thankfully I have a good billing company that sends me a monthly statement by patient, so I can mostly use that, but then there are the electronic payments + EOBs, some of which may be re-issued virtual credit cards, and the amounts don't match up....etc.

Currently I utilize spreadsheets to track appointments for both myself and counselor. This is used for both tracking hours and also notes submitted. I get weekly timesheets that I use as a reference for billing. I have/had a master list of everything, but that was getting overly complicated to track where in the process things were. It's very much still a work in progress.

 

[StellaB]

Spreadsheets FTW over here. Though my practice is 100% cash, so it's unbelievably easy to track, even as a small group (assessment only, part-time for everyone) practice. I used to be an accountant many moons ago, so def do not feel the need for a fancier setup - it's just not difficult or time-consuming at all, so "if it ain't broke, don't fix it" wins the day. I'm sure that's a little different when you're dealing with varying rates of reimbursement.

 

[R. Matey]

I'll also be following with great interest. A small side PP is something I'll be diving in the next few months.

 

[AcronymAllergy]

I have a Quickbooks account, but I have yet to sit down and set it all up. As of right now, it's just spreadsheets.

Somewhat related question: for those going the S corp or similar route (especially if you're a sole proprietor), do you use a payroll service, payroll software, something similar...?

 

[WisNeuro]

I have a Quickbooks account, but I have yet to sit down and set it all up. As of right now, it's just spreadsheets.

Somewhat related question: for those going the S corp or similar route (especially if you're a sole proprietor), do you use a payroll service, payroll software, something similar...?

I'm a disregarded entity this year, but will likely be electing S-corp next year. I have an upcoming meeting with my CPA to discuss it. My office colleague uses a payroll service, though it's someone they know and they also technically employ their spouse for admin work. I'd imagine there's slightly less complexity if it's just you.

 

[R. Matey]

I'm a disregarded entity this year, but will likely be electing S-corp next year. I have an upcoming meeting with my CPA to discuss it. My office colleague uses a payroll service, though it's someone they know and they also technically employ their spouse for admin work. I'd imagine there's slightly less complexity if it's just you.

Asking because I have no idea: What's advantageous about an S-corp?

 

[WisNeuro]

Asking because I have no idea: What's advantageous about an S-corp?

In general, it's electing to be taxed as an S-corp, unless you're a larger practice, but that's a different thread. In general, once you hit a certain gross revenue, you can take advantage of certain tax rules and deductions if you are taxed as an s-corp vs a sole proprietorship or partnership. In certain circumstances you can also pass through some income as a dividend to owners of the "corporation" and avoid certain self-employment taxes.

 

[PsyDr]

Just file form 8882, then file form 2553. Boom, your LLC is treated as an S corp. Works for Coca Cola. Works for me.

 

[Gepetto]

Hello, I am brand new to PP and in the process of paneling with insurance.

Im trying to figure out the rules around Medicare and I get different answers each time I call them.

As I understand it, I can’t see anyone who has Medicare at all until I either opt out or panel with them.

What I don’t yet know is how claims work with someone who has Medicare supplemental.
So let’s say they have commercial insurance that I am NOT paneled with, but also Medicare supplemental. Since I’m out of network with commercial, do I just bill Medicare ? Do I do a superbill for commercial and then bill Medicare for what’s not covered? Am I allowed to see these folks prior to being paneled with Medicare since their primary coverage is commercial ?

Thanks in advance and sorry for the naïveté- it’s been a struggle getting answers from the source!

 

[Therapist4Chnge]

That's a common but complicated question. I'm not going to attempt to answer it because I've seen a range of answers over the years, and they mostly just make me want to get into the fetal position and ask the bad people to stop. Good luck and I hope you get a satisfactory answer because it sure seems like a convoluted process on the best day.

 

[PsyDr]

Medicare is ALWAYS the primary.

 

[WisNeuro]

Yeah, people commonly call up for appointments and say things like "I have BCBS" or "I have United", and almost always, they have Medicare with those as supplemental. I do see mostly 65+, so it's to be expected. You can verify this, at least after you've signed up for all of the various web portals (e.g., Availity) to make sure you save yourself hassles on the billing end later.

 

[PsyDr]

Or they say they have “Medicare”, but when they get to the office they actually have a UnitedAetnaHumana replacement plan. And then you have to spend an hour exposing that you’re not empaneled on those.

Medicare replacement plans are useless.

@Gepetto you submit the bill to Medicare. They traditionally send the remainder to the secondary insurance as a courtesy, so you don’t have to do more.

 

[Gepetto]

Or they say they have “Medicare”, but when they get to the office they actually have a UnitedAetnaHumana replacement plan. And then you have to spend an hour exposing that you’re not empaneled on those.

Medicare replacement plans are useless.

@Gepetto you submit the bill to Medicare. They traditionally send the remainder to the secondary insurance as a courtesy, so you don’t have to do more.

This feels like a stupid question, but, will I get paid if I bill Medicare, then it goes to secondary insurance who I am out of network with? And/Or if Medicare is secondary but I'm out of network with the primary?

 

[WisNeuro]

This feels like a stupid question, but, will I get paid if I bill Medicare, then it goes to secondary insurance who I am out of network with? And/Or if Medicare is secondary but I'm out of network with the primary?

At least in my experience, when you are credentialed with Medicare, and you bill a pt with MC primary, MC pays that put and forwards the rest to supplemental. I have been paid whether or not I'm on that panel. If you see someone who has a primary carrier that you are not credentialed with, reimbursement just got a lot harder.

 

[Gepetto]

At least in my experience, when you are credentialed with Medicare, and you bill a pt with MC primary, MC pays that put and forwards the rest to supplemental. I have been paid whether or not I'm on that panel. If you see someone who has a primary carrier that you are not credentialed with, reimbursement just got a lot harder.

Thank you for this. One more novice question. If I panel with Medicare... this is in no way helpful to things like "BCBS Medicare" or "UnitedHealth Medicare," etc., right? I'd have to be in-network with BCBS or United in order to take those Medicare patients as they are totally separate plans from Medicare?
And could those folks do private pay if I'm not paneled with BCBS/United? Or is that against the rules without an opt-out, same as national Medicare?

 

[WisNeuro]

Thank you for this. One more novice question. If I panel with Medicare... this is in no way helpful to things like "BCBS Medicare" or "UnitedHealth Medicare," etc., right? I'd have to be in-network with BCBS or United in order to take those Medicare patients as they are totally separate plans from Medicare?
And could those folks do private pay if I'm not paneled with BCBS/United? Or is that against the rules without an opt-out, same as national Medicare?

Are you taking about Medicare Advantage plans? If so, my understanding is that yes, you need to be in that network. And, as long as they are not MC, and you are not paneled with that particular private insurer, you can do private pay.

 

[LadyHalcyon]

For those that do use quickbooks, is your main plus of the service the ability to sync to your bank account? Trying to calculate how much time may be saved in that method as opposed to my spreadsheet/workbook methods.

I really like the quickbooks self - employed version. Plus, it syncs easily with everything.

 

[R. Matey]

Here's a question: LLC or solo proprietorship for small cash practices? I've seen mixed responses.

 

[WisNeuro]

Here's a question: LLC or solo proprietorship for small cash practices? I've seen mixed responses.

Might as well go LLC as you can elect to be taxed as a sole proprietor, or if it eventually makes sense, s-corp.

 

[Therapist4Chnge]

Might as well go LLC as you can elect to be taxed as a sole proprietor, or if it eventually makes sense, s-corp.

This is the route I went. I'm just going through everything for the first time this year, so I can't say I know what is easier...but this route seemed to make sense.

 

[Therapist4Chnge]

Any good info/websites/books about the best investment options (akin to 401k / retirement) for a small biz owner? I still need to rollover prior investment accounts, but I'm open to opening a new one and leave my prior retirement investments alone.

 

[WisNeuro]

Any good info/websites/books about the best investment options (akin to 401k / retirement) for a small biz owner? I still need to rollover prior investment accounts, but I'm open to opening a new one and leave my prior retirement investments alone.

Kind of depends on your income level and other income sources. I'm probably going the SEP IRA route after electing S-corp. It allows for a pretty good amount to be shielded from taxes to bring down your taxable income. I think it's the lesser of 61k or 25 of your compensation.

 

[WisNeuro]

We're a little old school in our office, still using a physical fax machine. Anyone using e-fax? Specifically something where the referring provider's office still faxes as normal (because they are also old school) and we get a pdf or something on our side?

 

[PsyDr]

We're a little old school in our office, still using a physical fax machine. Anyone using e-fax? Specifically something where the referring provider's office still faxes as normal (because they are also old school) and we get a pdf or something on our side?

you HAVE to use a fax. There is a weird part in the actual text of HIPAA or HiTEC that makes faxing a confidential form of communication. But if you email, the standards are very high for security.

Fun fact: fax machines were invented 11 years before the telephone.

 

[WisNeuro]

you HAVE to use a fax. There is a weird part in the actual text of HIPAA or HiTEC that makes faxing a confidential form of communication. But if you email, the standards are very high for security.

Fun fact: fax machines were invented 11 years before the telephone.

I was under the impression that if you were using an email with a BAA in place this would be copacetic with eFax?

 

[PsyDr]

I was under the impression that if you were using an email with a BAA in place this would be copacetic with eFax?

In that scenario, the responsibility is on the efax company.

There is an exemption if you are in a federally identified “rural” area. Then, pretty much anything goes for security.

 

[WisNeuro]

In that scenario, the responsibility is on the efax company.

There is an exemption if you are in a federally identified “rural” area. Then, pretty much anything goes for security.

Yeah, I was looking to find an eFax service that would also sign a BAA to have it on both ends of transmission there.

 

[Westbound2019]

We're a little old school in our office, still using a physical fax machine. Anyone using e-fax? Specifically something where the referring provider's office still faxes as normal (because they are also old school) and we get a pdf or something on our side?

I’ve used Faxage - they’re HIPAA compliant and offer a BAA.
It works great for the most part - I send and receive fax online and have a fax number so no one would know it’s anything different. The one issue is I had a couple low quality or blank faxes get sent when I tried scanning via iPhone and then faxing . If I print and scan or download a pdf, no quality issues. Love being able to download the fax and save directly to the patients EHR.

 

[Sanman]

We're a little old school in our office, still using a physical fax machine. Anyone using e-fax? Specifically something where the referring provider's office still faxes as normal (because they are also old school) and we get a pdf or something on our side?

I used efax a great deal in the past at the nursing home gigs for printing PDF notes for the paper chart. The system is decent, but there can be delays and you do need to double check failures if sending. Receiving seemed to go more smoothly. Keep in mind I was using printer/fax/copy machines shared with many inpatient staff that probably messed up reliably sending transmissions.

 

[WisNeuro]

I used efax a great deal in the past at the nursing home gigs for printing PDF notes for the paper chart. The system is decent, but there can be delays and you do need to double check failures if sending. Receiving seemed to go more smoothly. Keep in mind I was using printer/fax/copy machines shared with many inpatient staff that probably messed up reliably sending transmissions.

Gracias, after checking with some others, we decided to try out Faxage. Has what we need for a good price, and it was easy to get a signed BAA.

 

[R. Matey]

How many of you private practitioners out there are just doing telehealth AND what's a ridiculous figure to pay to rent an office?

 

[Sanman]

How many of you private practitioners out there are just doing telehealth AND what's a ridiculous figure to pay to rent an office?

Are you talking rent only for a telehealth situation or an office that could be used for in-person services as well?

 

[R. Matey]

Are you talking rent only for a telehealth situation or an office that could be used for in-person services as well?

The second one

 

[calimich]

I'm about 75% telehealth still, sublet office 2days/week @ $400/month, major metro area, steps from subway, blocks from ocean.

 

[Therapist4Chnge]

I live in a high-cost city and current I'm subletting space for when I need it. It's not really market rate as it is through a connection, but it's likely not a long-term solution. I'm seeing how long I can go w/o having dedicated space since the vast majority of my non-testing appts are virtual and the majority of my in-person stuff can be done at lawyer offices.

 

[Westbound2019]

Anyone have HIPAA compliant recs for phone service provider & telehealth platform that they like for a single-provider practice? I think I’m overpaying for bells and whistles that I don’t use, and am looking to switch providers.

 

[foreverbull]

How many of you private practitioners out there are just doing telehealth AND what's a ridiculous figure to pay to rent an office?

Me. Offices in a wealthier city near me go for $1200-$1600/month for full use, but some come with extra amenities. Some folks in those cities will charge $150+/day for subletting one day a week, but depends. I paid $450/month in a smaller town that isn’t as wealthy, but it came with no lobby/waiting room, no Internet, and no elevator to the 2nd floor. I no longer have an office but may sublet in the future—no rush; my clients don’t mind.

Anyone have HIPAA compliant recs for phone service provider & telehealth platform that they like for a single-provider practice? I think I’m overpaying for bells and whistles that I don’t use, and am looking to switch providers.

Psychologytoday subscriptions include free use of their “Sessions” video platform (that’s what I use since I was already subscribed). Another option is Doxyme (free and HIPAA compliant) or you can subscribe and pay for added features.

Phone: Ting works well for business cell phone plans without needing bells and whistles like data use, but they offer those plans too for reasonable rates. I pay like $15/month for my business phone and use it only for calls. When I upgrade my personal phone, my old phone gets used as my business phone—no extra money out of pocket.

 

[Westbound2019]

I love that there’s now a place for me to ask these nonsense questions:

Anyone notice a wardrobe shift after entering PP? Do you dress more or less formally / business casual than when you were working in other settings? Anyone go casual once they became their own boss ? (I mean blue jeans, not sweatpants. Unless on Zoom. All bets off then for pant wear.)

 

[Sanman]

I love that there’s now a place for me to ask these nonsense questions:

Anyone notice a wardrobe shift after entering PP? Do you dress more or less formally / business casual than when you were working in other settings? Anyone go casual once they became their own boss ? (I mean blue jeans, not sweatpants. Unless on Zoom. All bets off then for pant wear.)

Lol, I stick to business casual for in person work. Usually khakis/slacks, a dress shirt, and sometimes a sweater or blazer. I picked up some lounge pants that look like slacks a comfortable knit blazer for telehealth days. If I did not wear pants on a telehealth call, I would likely need to stand up for some reason, just my luck.

 

[Sanman]

How many of you private practitioners out there are just doing telehealth AND what's a ridiculous figure to pay to rent an office?

I have been contemplating purchasing a multi-office business suite and renting the space out to colleagues and using myself. Might make for some decent passive income if the price is right. There a few office suites already setup for sale not too far from me.

 

[WisNeuro]

I have been contemplating purchasing a multi-office business suite and renting the space out to colleagues and using myself. Might make for some decent passive income if the price is right. There a few office suites already setup for sale not too far from me.

Get yoself incorporated.