Private Practice Olio

[PsyDr]

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Another question - for those of you who started your own practice vs. joining one - do you think it was a good call to start your own business? I'm leaning in that direction, but I am a risk-averse VA employee.

One of the best decisions of my life. Also one of the hardest things I've ever done.

If you're considering it, you should spend 40+hrs in learning the business side of the field. How many patient hours you produce on a high week and a low week, how much CMS pays for that, where you would get patients, how much money you should have in savings/which practices got wiped out in the pandemic because they didn't have sufficient cash reserves, office rent costs, health insurance quotes, etc. You might get all of those numbers and say, "I'm honestly not going to work that hard for years". You might say, "I can do that in my sleep, and I've been getting robbed". Just be honest with yourself. The primary way I see psychologists fail, is to start their practice based upon a fantasy where they see 2 patients from 9-11, have an extended lunch, see another 2 patients, and get home by 3:30pm.

 

[Sanman]

One of the best decisions of my life. Also one of the hardest things I've ever done.

If you're considering it, you should spend 40+hrs in learning the business side of the field. How many patient hours you produce on a high week and a low week, how much CMS pays for that, where you would get patients, how much money you should have in savings/which practices got wiped out in the pandemic because they didn't have sufficient cash reserves, office rent costs, health insurance quotes, etc. You might get all of those numbers and say, "I'm honestly not going to work that hard for years". You might say, "I can do that in my sleep, and I've been getting robbed". Just be honest with yourself. The primary way I see psychologists fail, is to start their practice based upon a fantasy where they see 2 patients from 9-11, have an extended lunch, see another 2 patients, and get home by 3:30pm.

Wait, I have to see another two in the afternoon also? When will I self-reflect and process my morning sessions?

 

[WisNeuro]

Wait, I have to see another two in the afternoon also? When will I self-reflect and process my morning sessions?

"What do you mean you're not going to pay me $200k/year, with benefits, for my proposed schedule of seeing 15-20 patients a week!?! It's not fair! You're just a late stage capitalist, and classist, and ableist, racist, and you probably drown kittens!"

 

[PsynofTimes]

Can I ask, what is reasonable do you think? I had a schedule in mind and some practice owners have been suggesting that it's too high. I'm used to a high patient load coming from VA, but I'm not private sector savvy and don't want to mess up.

 

[WisNeuro]

Depends on what you're doing, and how you're billing. My schedule would look a lot different depending on if I were doing therapy vs. assessment, and even what kinds of assessments I am normally doing.

 

[AcronymAllergy]

Can I ask, what is reasonable do you think? I had a schedule in mind and some practice owners have been suggesting that it's too high. I'm used to a high patient load coming from VA, but I'm not private sector savvy and don't want to mess up.

I'd say it depends almost entirely on what your earnings expectations are.

From an employer's perspective, I don't think it's unreasonable to expect a psychologist providing therapy to see ~6 patients/day in a traditional outpatient setting. For simplicity's sake, if those are all Medicare patients and you're billing 90834 for all of them (a little over $100 per, depending on where you are), you're working 48 weeks/year, and you factor in 10% no-show, that's a gross of around $135k. If those are all 90837, which is about $150 per, that's $195k/year. If you're private pay and charging $200/session, that's $260k. Etc.

 

[Sanman]

I'd say it depends almost entirely on what your earnings expectations are.

From an employer's perspective, I don't think it's unreasonable to expect a psychologist providing therapy to see ~6 patients/day in a traditional outpatient setting. For simplicity's sake, if those are all Medicare patients and you're billing 90834 for all of them (a little over $100 per, depending on where you are), you're working 48 weeks/year, and you factor in 10% no-show, that's a gross of around $135k. If those are all 90837, which is about $150 per, that's $195k/year. If you're private pay and charging $200/session, that's $260k. Etc.

6 Is a fair number of patients per day. I find that norms on work hours and salaries are regional. 9-10 sessions/day was not considered unreasonable in the NYC area. However, the cost of living is high there.

 

[thebalmofhurtminds]

Most of the people that I know in private practice see 5/day, but they were also selective about being mostly private pay and only insurance that reimburses well. So they still make more than the average salary and have a shorter work day. Of course, many are women having young children currently, so their main priority may not be making as much money as possible at the moment.

 

[PsynofTimes]

So this is similar to the feedback I'm getting from the private practices I've consulted with as I consider my options... six patients a day seems really low to me and six 90834s seems crazy low. So say I did six 90837s M, W, Fri and two ADHD or other psychological assessments on Tues/Thurs - does that seem realistic? I know there's a lot of variables in this. But I see three 90837s in the evenings after working at the VA all day some nights a week now, and I don't feel overwhelmed by that. I do feel overwhelmed at the VA, but it's not the patient care that's doing it.

 

[Sanman]

So this is similar to the feedback I'm getting from the private practices I've consulted with as I consider my options... six patients a day seems really low to me and six 90834s seems crazy low. So say I did six 90837s M, W, Fri and two ADHD or other psychological assessments on Tues/Thurs - does that seem realistic? I know there's a lot of variables in this. But I see three 90837s in the evenings after working at the VA all day some nights a week now, and I don't feel overwhelmed by that. I do feel overwhelmed at the VA, but it's not the patient care that's doing it.

90834 vs 90837 is not really much more work. More about billing norms and audit concerns.

The other thing to think about is when those clients are showing up. What happens if you can't get 7 straight hours and 7 clients means 10 or 12 hours in office?

 

[AcronymAllergy]

So this is similar to the feedback I'm getting from the private practices I've consulted with as I consider my options... six patients a day seems really low to me and six 90834s seems crazy low. So say I did six 90837s M, W, Fri and two ADHD or other psychological assessments on Tues/Thurs - does that seem realistic? I know there's a lot of variables in this. But I see three 90837s in the evenings after working at the VA all day some nights a week now, and I don't feel overwhelmed by that. I do feel overwhelmed at the VA, but it's not the patient care that's doing it.

In a perfect world (e.g., considering the factors Sanman mentioned about scheduling), and depending on your work ethic, that seems realistic. It just might mean your M/W/F workday is a bit longer than 8 hours, depending on how long of a lunch break you take and how long it takes you to chart. If you can knock out a note in 5-10 mins and take a 30-minute lunch, it's probably fine.

Although do you mean 2 ADHD/psych assessments on Tu and another 2 on Th, or 1 each day for 2 total per week? Either is probably feasible, but if you're doing 1/day, you could probably write the report that same day and stay caught up. If you're doing 2/day, you might need a separate day set aside to help you finish writing.

 

[PsyDr]

So this is similar to the feedback I'm getting from the private practices I've consulted with as I consider my options... six patients a day seems really low to me and six 90834s seems crazy low. So say I did six 90837s M, W, Fri and two ADHD or other psychological assessments on Tues/Thurs - does that seem realistic? I know there's a lot of variables in this. But I see three 90837s in the evenings after working at the VA all day some nights a week now, and I don't feel overwhelmed by that. I do feel overwhelmed at the VA, but it's not the patient care that's doing it.

I would find this schedule very very doable. Some people would not.

The owners might have the following concerns:
1) Problems with getting that volume of patients, on a long term basis, with the right insurance (i.e., Filling a clinic with medicaid patients= easy, filling a clinic with cash pay patients=hard).
2) Getting admin staff to stay past 5pm
3) If you burn out/leave, they have a caseload that they cannot add to their schedule. Same for call schedule/coverage, if your state requires after hours coverage.
4) Your standards for documentation/testing. The neuropsych evals done in the VA tend to be more abbreviated than anywhere else. Same for psychotherapy notes. I could write a VA note in 30 seconds "All members checked in, stated they were not suicidal. Introductions were done. A brief primer on feelings was given as a handout. Patient participated in the session. Kthanx, that's my note."

 

[Therapist4Chnge]

Surgeons would consider that note “too long winded.”

 

[WisNeuro]

I would find this schedule very very doable. Some people would not.

The owners might have the following concerns:
1) Problems with getting that volume of patients, on a long term basis, with the right insurance (i.e., Filling a clinic with medicaid patients= easy, filling a clinic with cash pay patients=hard).
2) Getting admin staff to stay past 5pm
3) If you burn out/leave, they have a caseload that they cannot add to their schedule. Same for call schedule/coverage, if your state requires after hours coverage.
4) Your standards for documentation/testing. The neuropsych evals done in the VA tend to be more abbreviated than anywhere else. Same for psychotherapy notes. I could write a VA note in 30 seconds "All members checked in, stated they were not suicidal. Introductions were done. A brief primer on feelings was given as a handout. Patient participated in the session. Kthanx, that's my note."

I agree, in general. But, I see a lot of midlevel "diagnostic assessments" that basically say "Pt has some anxiety while driving, and had a nightmare, they have PTSD." And cue never-ending therapy that somehow never seems to document actually treating the "trauma" and instead focuses on family issues that have been present for decades.

 

[Sanman]

I agree, in general. But, I see a lot of midlevel "diagnostic assessments" that basically say "Pt has some anxiety while driving, and had a nightmare, they have PTSD." And cue never-ending therapy that somehow never seems to document actually treating the "trauma" and instead focuses on family issues that have been present for decades.

God that was eerily accurate for most of my patient transfers.

 

[Therapist4Chnge]

I recently saw a new referral with an “adjustment disorder” diagnosed by a PA. The patient survived a botched robbery bc the gun jammed, so they just got pistol-whipped instead. It was the second time they were held at gunpoint in less than a year, same store. They were “encouraged”not to file a WC claim the first time. Classic PTSD presentation, so it’s not like they had to dig too deep. Usually I get their PTSD referral for a worker who got yelled at by their mean boss.

Pro Tip: Avoid working as an overnight gas station attendant if at all possible.

 

[Sanman]

I recently saw a new referral with an “adjustment disorder” diagnosed by a PA. The patient survived a botched robbery bc the gun jammed, so they just got pistol-whipped instead. It was the second time they were held at gunpoint in less than a year, same store. They were “encouraged”not to file a WC claim the first time. Classic PTSD presentation, so it’s not like they had to dig too deep. Usually I get their PTSD referral for a worker who got yelled at by their mean boss.

Pro Tip: Avoid working as an overnight gas station attendant if at all possible.

Z56.6 - other physical and mental strain related to work

 

[WisNeuro]

I recently saw a new referral with an “adjustment disorder” diagnosed by a PA. The patient survived a botched robbery bc the gun jammed, so they just got pistol-whipped instead. It was the second time they were held at gunpoint in less than a year, same store. They were “encouraged”not to file a WC claim the first time. Classic PTSD presentation, so it’s not like they had to dig too deep. Usually I get their PTSD referral for a worker who got yelled at by their mean boss.

Pro Tip: Avoid working as an overnight gas station attendant if at all possible.

See, this is a criterion A event. Getting bumped at a stop sign at 5 MPH with zero physical damage done to either car...not so much.

 

[oliversacks4thewin]

Surgeons would consider that note “too long winded.”

Bigger issue is that the note contained the word "feelings." No way to record blood loss related to those pesky things...

 

[PsynofTimes]

I would find this schedule very very doable. Some people would not.

The owners might have the following concerns:
1) Problems with getting that volume of patients, on a long term basis, with the right insurance (i.e., Filling a clinic with medicaid patients= easy, filling a clinic with cash pay patients=hard).
2) Getting admin staff to stay past 5pm
3) If you burn out/leave, they have a caseload that they cannot add to their schedule. Same for call schedule/coverage, if your state requires after hours coverage.
4) Your standards for documentation/testing. The neuropsych evals done in the VA tend to be more abbreviated than anywhere else. Same for psychotherapy notes. I could write a VA note in 30 seconds "All members checked in, stated they were not suicidal. Introductions were done. A brief primer on feelings was given as a handout. Patient participated in the session. Kthanx, that's my note."

Thank you - I think I'll be the owner - at least so far. I contract 1099 with an agency now for extra work, but am thinking of doing this myself. Question, and I'm sorry to sound dumb, but why does one need admin staff in a small pp?

 

[PsynofTimes]

In a perfect world (e.g., considering the factors Sanman mentioned about scheduling), and depending on your work ethic, that seems realistic. It just might mean your M/W/F workday is a bit longer than 8 hours, depending on how long of a lunch break you take and how long it takes you to chart. If you can knock out a note in 5-10 mins and take a 30-minute lunch, it's probably fine.

Although do you mean 2 ADHD/psych assessments on Tu and another 2 on Th, or 1 each day for 2 total per week? Either is probably feasible, but if you're doing 1/day, you could probably write the report that same day and stay caught up. If you're doing 2/day, you might need a separate day set aside to help you finish writing.

That would be fine, longer than 8 hours. I was thinking 2 per day and maybe do some of the writing at home on the weekends.

 

[PsynofTimes]

90834 vs 90837 is not really much more work. More about billing norms and audit concerns.

The other thing to think about is when those clients are showing up. What happens if you can't get 7 straight hours and 7 clients means 10 or 12 hours in office?

I'm ok with staying. I do live in a very highly therapy-oriented area, many practices seems to have long wait lists. But some don't - and that both surprises me and scares me.

 

[Sanman]

Bigger issue is that the note contained the word "feelings." No way to record blood loss related to those pesky things...

This seems like the appropriate time to add this:

 

[PsyDr]

Bigger issue is that the note contained the word "feelings." No way to record blood loss related to those pesky things...

70% of my work is dealing with ortho and nsg

Thank you - I think I'll be the owner - at least so far. I contract 1099 with an agency now for extra work, but am thinking of doing this myself. Question, and I'm sorry to sound dumb, but why does one need admin staff in a small pp?

You don’t if you’re willing to learn how to do billing, scheduling, and marketing. If you’re disciplined, it’s: see patient, write note, hit submit bill for CPT code blah blah blah, send bill to whoever, wait 30 days for payment, keep a MINIMUM of 30% for taxes or 60% if you’re smart, repeat.

 

[PsynofTimes]

You don’t if you’re willing to learn how to do billing, scheduling, and marketing. If you’re disciplined, it’s: see patient, write note, hit submit bill for CPT code blah blah blah, send bill to whoever, wait 30 days for payment, keep a MINIMUM of 30% for taxes or 60% if you’re smart, repeat.

Scheduling and marketing I could do, but I would prefer someone to do billing. You can hire someone who only does billing, correct?

 

[Sanman]

Scheduling and marketing I could do, but I would prefer someone to do billing. You can hire someone who only does billing, correct?

You can hire a biller or company. That said, Simple Practice and other practice management software also offer billing support.

 

[PsynofTimes]

You can hire a biller or company. That said, Simple Practice and other practice management software also offer billing support.

I think maybe it's something I'd like to take on after I've done this for awhile. I'm looking to maximize what I earn, but on the other hand, doing another assessment vs. spending that time hunting down insurance companies may be both more professionally rewarding and more fiscally rewarding.

 

[Sanman]

I think maybe it's something I'd like to take on after I've done this for awhile. I'm looking to maximize what I earn, but on the other hand, doing another assessment vs. spending that time hunting down insurance companies may be both more professionally rewarding and more fiscally rewarding.

Just to clarify, I believe Simple practice has their own billing service that does it for you for a fee. That said, I strongly suggest everyone in PP learn a lot about billing and coding even if you choose send it out eventually. The time to learn is not when you get rejections and are fighting for money or during an audit.

 

[smalltownpsych]

Just to clarify, I believe Simple practice has their own billing service that does it for you for a fee. That said, I strongly suggest everyone in PP learn a lot about billing and coding even if you choose send it out eventually. The time to learn is not when you get rejections and are fighting for money or during an audit.

100% this. As the owner of the business, the more you know about all aspects, the better. At the beginning is when you have the time and energy to devote to that and if you decide it is more efficient to hire it out, then you can.

 

[PsynofTimes]

100% this. As the owner of the business, the more you know about all aspects, the better. At the beginning is when you have the time and energy to devote to that and if you decide it is more efficient to hire it out, then you can.

I could see myself switching to that after I leave VA - going to start the business before I leave so am pretty busy between the evening therapy patients and the weekend assessments I'm planning. But I agree, one should know everything from top to bottom.

 

[oliversacks4thewin]

This seems like the appropriate time to add this:

I knew there was a reason I got along with you lol. We share the same humor. Met with Dr. G before. Guy is real nice and also super tall...

 

[WisNeuro]

I knew there was a reason I got along with you lol. We share the same humor. Met with Dr. G before. Guy is real nice and also super tall...

Did you know he essentially died in his sleep and his wife revived him?

 

[oliversacks4thewin]

Did you know he essentially died in his sleep and his wife revived him?

I met him and his wife at his Wife and Death tour. They played the 911 call she made during it. Woman is an absolute hero. She gave CPR for 10 minutes, and literally learned it on the fly, from the 911 operator she was talking to. She was also super nice too 🙂

 

[Therapist4Chnge]

Yeah, it's a crazy story. They are super nice folks.

 

[PsyDr]

Random Things People Recommended To Me in PP

1) Credit Card Processing for Costco Members

2) Scanner: Snapscan.
3) Printer: Brothers'
4) Amazon Business Account + have your printing paper shipped. (This is also how I got PPE during the pandemic.)
5) Business credit card: Chase or Amex, depending on usage.
6) Used office furniture places: Herman Miller desk chairs filing cabinets, and that "bariatric" chair for the waiting room that you have to own. All on the cheap.
7) LEATHER patient seating for the office. It makes it look nice, and you can wipe off accidents.

 

[smalltownpsych]

I could see myself switching to that after I leave VA - going to start the business before I leave so am pretty busy between the evening therapy patients and the weekend assessments I'm planning. But I agree, one should know everything from top to bottom.

When you first start, before you have your first patient, that’s when you will have a chance to figure it out. Are you going to be getting on any insurance panels? They typically have a process for reimbursement that’s pretty straightforward. After you go through it the first time, then it’s pretty automatic. I actually don’t see any reason to pay someone to do billing. I do pay someone to answer phones and schedule.

 

[PsynofTimes]

When you first start, before you have your first patient, that’s when you will have a chance to figure it out. Are you going to be getting on any insurance panels? They typically have a process for reimbursement that’s pretty straightforward. After you go through it the first time, then it’s pretty automatic. I actually don’t see any reason to pay someone to do billing. I do pay someone to answer phones and schedule.

Thank you for this advice. I would love for someone to handle scheduling but that seems kind of expensive? At least at first?

 

[Sanman]

Random Things People Recommended To Me in PP

1) Credit Card Processing for Costco Members

2) Scanner: Snapscan.
3) Printer: Brothers'
4) Amazon Business Account + have your printing paper shipped. (This is also how I got PPE during the pandemic.)
5) Business credit card: Chase or Amex, depending on usage.
6) Used office furniture places: Herman Miller desk chairs filing cabinets, and that "bariatric" chair for the waiting room that you have to own. All on the cheap.
7) LEATHER patient seating for the office. It makes it look nice, and you can wipe off accidents.

I second Brother printers and laser only. That is what I have for personal use and it has lasted forever. Never by HP or regular desk jet printers. As a guy that used to fix this stuff, they are all junk.

 

[AcronymAllergy]

I second Brother printers and laser only. That is what I have for personal use and it has lasted forever. Never by HP or regular desk jet printers. As a guy that used to fix this stuff, they are all junk.

Thirded. If you print a lot, the high capacity cartridges are definitely worth it.

Also second the recommendation for Snapscan; they're well worth the cost. Most of the Brother business printers are also scanners, which can get you by in a pinch, but the Scapscan devices are so much faster. They have better software, too.

 

[medium rare]

Thirded. If you print a lot, the high capacity cartridges are definitely worth it.

Also second the recommendation for Snapscan; they're well worth the cost. Most of the Brother business printers are also scanners, which can get you by in a pinch, but the Scapscan devices are so much faster. They have better software, too.

Fourthed.

 

[smalltownpsych]

Thank you for this advice. I would love for someone to handle scheduling but that seems kind of expensive? At least at first?

Correct. I hired someone for scheduling when I had the revenue to justify it and then I started handing some of the billing and other stuff to them as they acquire the knowledge. I have had three admin people so far, each for about a year. Am hoping this one stays because she is the best so far. We just started handing over some basic accounting tasks to help ease the load on my wife.

 

[PsynofTimes]

Does anyone have thoughts on balancing a faculty position with a private practice? does this seem like a bad idea? There's a position open in my area that I would be well qualified for, but I don't want to walk away from clinical work.

 

[PsyDr]

Does anyone have thoughts on balancing a faculty position with a private practice? does this seem like a bad idea? There's a position open in my area that I would be well qualified for, but I don't want to walk away from clinical work.

What kind of faculty position?

Why not apply, and see what they have to say?

 

[smalltownpsych]

Does anyone have thoughts on balancing a faculty position with a private practice? does this seem like a bad idea? There's a position open in my area that I would be well qualified for, but I don't want to walk away from clinical work.

I know some of the posters on here will have some direct experience with this, but from what I have seen in the field, it is a fairly common practice. In fact, at my PsyD program all of the faculty were expected or possibly even required to have active clinical practice. At a more research focused institution that would likely be different so PsyDr’s advice makes the most sense. Find out what their current faculty does. Should be some who are more into research, some who are more into training or teaching students and some who are more into outside work. Even one of our research heavy faculty did his research at another institution. There are a lot of creative collaborative arrangements that can be made between talented psychologists with our broad skill set and academic institutions. Personally, that is what I would be looking for is the flexibility and openness for those types of opportunities.

 

[PsynofTimes]

What kind of faculty position?

Why not apply, and see what they have to say?

I suppose because it could turn into a lot of work for something I may not like. On the other hand, I suppose it could go well.

 

[PsynofTimes]

I know some of the posters on here will have some direct experience with this, but from what I have seen in the field, it is a fairly common practice. In fact, at my PsyD program all of the faculty were expected or possibly even required to have active clinical practice. At a more research focused institution that would likely be different so PsyDr’s advice makes the most sense. Find out what their current faculty does. Should be some who are more into research, some who are more into training or teaching students and some who are more into outside work. Even one of our research heavy faculty did his research at another institution. There are a lot of creative collaborative arrangements that can be made between talented psychologists with our broad skill set and academic institutions. Personally, that is what I would be looking for is the flexibility and openness for those types of opportunities.

Thank you for this advice. I feel like I could possibly like the balance but am also trying to get away from being overwhelmed, like I am at the VA.

 

[PsyDr]

I suppose because it could turn into a lot of work for something I may not like. On the other hand, I suppose it could go well.

What if I told you, that you can say “no” to any job offer?

 

[PsynofTimes]

What if I told you, that you can say “no” to any job offer?

Of course I can say no. But it is a lot of time, effort, and resources on my part and on their part to go through the interview process for a job there's no chance I would take, so I wanted to get the opinions of some here on whether it has worked out well for people or not, basically.

 

[Sanman]

Of course I can say no. But it is a lot of time, effort, and resources on my part and on their part to go through the interview process for a job there's no chance I would take, so I wanted to get the opinions of some here on whether it has worked out well for people or not, basically.

Whether it works out depends on the schedule for both positions and your meaning of private practice.