Questions to ask when Joining a Private Practice Group

[Majesty]

Hi Everyone,

I am thinking about slowly starting to join a private practice and am going to meet with the the CEO and president of the group. About 20 psychiatrists (roughly) many part time who have other jobs as well and its basically them taking a large chunk of billing (30%) in return for credentialing, billing, insurance, secretarial work and office space. They also will provide the patients to a slight degree although this is not clear yet.
Initially I would only be working 2 half days a week. I plan to add saturdays and then get out of dodge with respect to inpatient or have inpatient as only a backup option.

What questions should I ask?
Based on some things I already know I plan to ask about EMR or lack thereof.
How much of billing is recovered?
Support when I am not there and I work about 30 hours a week, all during the day, inpatient.
Reimbursement rates for different insurance plans...do they take medicare? I know they don't take medicaid.
Contract issues like non compete clauses etc.

Any words of advice or would anyone expound on the questions.

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[Manicsleep]

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[whopper]

What arrangements do they have in case a patient gets agitated in the office?

 

[Majesty]

What arrangements do they have in case a patient gets agitated in the office?

Good one. Wouldn't have thought to ask that even though I work with really sick people all the time.

 

[OldPsychDoc]

Nursing coverage for triage, refills, etc?

 

[Majesty]

Not sure if they would negotiate on the 30%.
I would be an employee I think and get a w-2 not a 1099. I am only feeling this one out.

My other option is to check out various credentialing services in the area where I live and get credentialed by myself through the panels. I can rent a small space.

The problem of safety, coverage etc arises then but I don't have to put up with all the nonsense of this high overhead, w-2, etc.

 

[Majesty]

Nursing coverage for triage, refills, etc?

Its provided in the 30% which is why its good for the short term.

 

[TexasPhysician]

Not sure if they would negotiate on the 30%.
I would be an employee I think and get a w-2 not a 1099. I am only feeling this one out.

My other option is to check out various credentialing services in the area where I live and get credentialed by myself through the panels. I can rent a small space.

The problem of safety, coverage etc arises then but I don't have to put up with all the nonsense of this high overhead, w-2, etc.

Is there a way to make it through a 1099?

 

[Majesty]

Can't hurt to ask but I think thats how they have it set up.
What is the benefit from their standpoint. I dont really get that part.

 

[Manicsleep]

Not sure. Ask them.
Maybe they got in trouble with the IRS and maybe they want control that only an employee-employer relationship provides.

Thats interesting. If I was hiring a physician in good faith, I would prefer to hire them with a 1099 if its truly a contract basis. However, the IRS has strict rules about business paying out as contractors and using people as employees.

 

[TexasPhysician]

Can't hurt to ask but I think thats how they have it set up.
What is the benefit from their standpoint. I dont really get that part.

1099 has potential tax advantages for you if you maximize them.

 

[Majesty]

I understand for me.
What about for them. Why would they not want to make me 1099?

Thanks for your input manic.

 

[TexasPhysician]

I understand for me.
What about for them. Why would they not want to make me 1099?

Thanks for your input manic.

I'm not aware of any other than some institutions have stupid policies.

 

[Majesty]

I guess that is good to know. Maybe they would be more willing to negotiate that point.

 

[zenman]

Make sure they have a 40 ft yacht named "Consultation"so your secretary won't be lying when she tells people where you're at.

 

[whopper]

The most frustrating thing I've so far experienced in private practice is the patient who is agitated or suicidal in the office....

And there's no security back up.

 

[Manicsleep]

x

 

[whopper]

The overhead is weird. It's 40% for the insurance stuff, but the cash stuff I get to keep all of it. All in all, that's probably about 20% overhead.

There are things I love about PP, things I hate about it. I can say if that was all I was doing, I'd go nuts. My current forensic unit hospital position combined with PP makes me happy. I know if I just did hospital I'd go nuts too. Each specific scenario gives me things I like the other does not.

With PP, I get to know patients over the long-term, do real psychotherapy, have a large base of psychotherapists I can refer patients, and each one has a particular specialty in psychotherapy such as DBT, and see patients improve and grow. I also developed a working relationship with a local private psychiatric center that has a strong reputation because we frequently refer patients to and from each other.

At my forensic unit gig, I can stabilize acutely dangerous patients, manage staff, do malingering testing and evaluation (that I love---I love it when I got a murderer and I figured out he's malingering; likewise I love it when there's a person who truly deserves a mental illness defense and I can establish that this person truly deserves that), get some very interesting forensic cases, have a treatment team that I work with and I kinda feel like a Captain on Trek, several CMEs I can sit through where I'm still getting paid while I sit, have collaborations with doctors from the local university hospital that has some of the best doctors in the country, and I have several colleagues I work with that can help me in tough spots.

I've just picked up a court gig where I provide expert witness testimony on Wednesday mornings. I also work as a forensic consultant for the fellowship, and a county-designated center.

In the office, in terms of security, we got nothing except for the police. I've made it very clear that we could only handle patients that are stable. While the GAF, as we know is highy nebulous, I told the office that we should not be taking patients with a GAF less than 60. Unfortunately, you really don't know what you got until they show up. We have no med management, no case management and I'm only in the office 3 days out of the week. We certainly should not be handling, for example, frequently non-compliant psychotic patients or borderline PD patients that are frequently suicidal. I've had a few of those patients, and I've referred them elsewhere. Made me feel bad because I don't mind treating that type of patient at all so long as the infrastructure exists.

 

[Chimed]

In the office, in terms of security, we got nothing except for the police. I've made it very clear that we could only handle patients that are stable. While the GAF, as we know is highy nebulous, I told the office that we should not be taking patients with a GAF less than 60. Unfortunately, you really don't know what you got until they show up. We have no med management, no case management and I'm only in the office 3 days out of the week. We certainly should not be handling, for example, frequently non-compliant psychotic patients or borderline PD patients that are frequently suicidal. I've had a few of those patients, and I've referred them elsewhere. Made me feel bad because I don't mind treating that type of patient at all so long as the infrastructure exists.

Thanks for sharing your set-up, whopper. This is interesting. I know that some of the local psychiatrists will refuse to take back a patient who has been hospitalized for a suicide attempt or it's their 2nd hospital stay, regardless of the reason for admission. I have to admit that I used to frown on this, but the further along I get in psychiatry, the more I understand why they do that. The amount of time and energy to care for a chronically suicidal patient really would be challenging as a part-time outpatient doc in PP.

 

[whopper]

I just had a guy who took his entire prescription of Ambien and snorted it a few days ago. He ended up in the ICU. He needs medication management. I can't provide it.

Trust me, if I had medication management in the office I'm at, I would gladly take him back, especially because IMHO, the only doctors in the community in the specific locality where I practice that have it aren't doing a good job (E.g. depressed patient gets antipsychotic and is dx'd as schizophrenic despite the person meeting no criteria for that disorder), except that private facility I mentioned but they don't take his insurance.

When you got a frequently suicidal patient that needs case and med management (I'm talking where the patient's meds are directly sent to the facility and they can only get a few days at a time), and you don't provide it, you're just putting yourself and your patient at risk.

I've also handled a psychiatric ACT team during fellowship where all the patients were mentally ill and committed crimes while psychotic or manic. These were very difficult patients. I was fully up to handling this situation because I had a great team of case managers and medication management.

Trust me though. I have seen doctors wanting "easy" patients because they too were lazy. I crave for difficult patients in the hospital becuase there I have the time, resources, and infrastructure to get them better. I don't have that in the private office.

 

[medium rare]

Whats the overhead like where you practice Whopper?

For me, the psychiatry office only overhead is about 18% with maximum 3 psychiatrists at any given time. For sleep, the overhead is much, much higher and I am working on trying to lower it any way I can.

Majority of the overhead generally goes to Billing/Secretarial (combine if possible) and office space/utilities/upkeep. Insurance etc is not that high. We don't have a guard (don't know how many places do) but we have a silent alarm system in 2 rooms for moderate to high risk patients. Have had to use it twice between several psychiatrists in several years.

I run a full-time, self-pay private practice. My total overhead over the past 4 years has only run between 9-12%. There are many ways you can keep your expenses minimal in psych.

 

[zenman]

I run a full-time, self-pay private practice. My total overhead over the past 4 years has only run between 9-12%. There are many ways you can keep your expenses minimal in psych.

You da man! Don't forget that if you have extra office space...and you're in a decent location...let's talk.

 

[WhoisJohnGalt]

I run a full-time, self-pay private practice. My total overhead over the past 4 years has only run between 9-12%. There are many ways you can keep your expenses minimal in psych.

I think "self-pay" is the keyword here... without dealing with insurance you can keep overhead much lower. Unfortunately, the economy can't support a self-pay practice everywhere

 

[Manicsleep]

I run a full-time, self-pay private practice. My total overhead over the past 4 years has only run between 9-12%. There are many ways you can keep your expenses minimal in psych.

Self pay is the keyword.
Otherwise you add about 6% plus any losses for billing and you get to about 18%-25%. Pretty normal.

 

[whopper]

Very much agree with the self-pay thing. Insurance companies are a pain in the butt. If you accept insurance, you're going to have to have an employee spending full-time to just fight them for money you are legitimately owed.

 

[medium rare]

Very much agree with the self-pay thing. Insurance companies are a pain in the butt. If you accept insurance, you're going to have to have an employee spending full-time to just fight them for money you are legitimately owed.

This is very true and the main reason I don't deal with insurance.

Yes, self-pay isn't doable for everyone (for a variety of reasons), but I've also never known a good clinician who wanted to be totally self-pay who wasn't able to do it - it just takes longer to build a practice.

That said, you can easily minimize your insurance headaches by being on 1-3 panels or so - if you must do insurance. The insurance companies are so hard up for psychiatric prescribers (especially child & adolescent) that membership on only a couple panels could fill a practice pretty quickly.

Interestingly, I've had more and more insurance companies calling me recently to ask if I will see one of their insured and be willing to do a "single-case agreement" with them. In each of these instances, the insurance company contacted me directly, paid my full fee no questions asked, and the patient was required to pay nothing. I'm not really sure exactly how this works and I don't really care; I just know that they've paid the bill in full in each of these instances.

Anyone else had similar experiences?

 

[digitlnoize]

This is very true and the main reason I don't deal with insurance.

Yes, self-pay isn't doable for everyone (for a variety of reasons), but I've also never known a good clinician who wanted to be totally self-pay who wasn't able to do it - it just takes longer to build a practice.

That said, you can easily minimize your insurance headaches by being on 1-3 panels or so - if you must do insurance. The insurance companies are so hard up for psychiatric prescribers (especially child & adolescent) that membership on only a couple panels could fill a practice pretty quickly.

Interestingly, I've had more and more insurance companies calling me recently to ask if I will see one of their insured and be willing to do a "single-case agreement" with them. In each of these instances, the insurance company contacted me directly, paid my full fee no questions asked, and the patient was required to pay nothing. I'm not really sure exactly how this works and I don't really care; I just know that they've paid the bill in full in each of these instances.

Anyone else had similar experiences?

Just how long did it take you to grow your practice? What is your fee?

Can you tell us more about your setup (sq. Ft., staff, rent, emr, rough location (NE? SE? Big city? Suburb?), other expenses)?

 

[medium rare]

Just how long did it take you to grow your practice? What is your fee?

Can you tell us more about your setup (sq. Ft., staff, rent, emr, rough location (NE? SE? Big city? Suburb?), other expenses)?

I'm in the Southwest; there is huge demand out here.

I think we're paying about $17/sq.ft. - I'd have to check my lease. I share a suite with 3 other psychologists and we each pay 1/4 of the total expenses including a full-time office manager/receptionist who handles all of the secretarial/billing duties.

Search for the "Psychiatry Salary Discrepancies" thread from a couple months back. Most of this is discussed there.

 

[whopper]

Took me about 3 months for my hours to get filled completely. Took me about 6 months before I felt I was riding the wave so to speak. During the first few months, everyone is new, you are still figuring things out.

After awhile the balance between brand new patients where you're still figuring things out and patients where you've figured it out. In the beginning, it's going to be somewhat stressful because it's puzzle after puzzle after puzzle, where as months later it's puzzle....stable patient, stable patient, stable patient...puzzle.

But I don't just accept private patients. I also accept insurance and that has a heck of a lot to do with it. Accepting insurance floods your appointment lists with several several patients.

 

[medium rare]

But I don't just accept private patients. I also accept insurance and that has a heck of a lot to do with it. Accepting insurance floods your appointment lists with several several patients.

Absolutely correct. Accepting insurance will flood a practice. It took me closer to a year to maintain a full schedule, but that was from the ground up without dealing with insurance.

 

[Sharpie1]

When you choose to accept an insurance, do you have to accept all of the patients that come to you from that insurance company? Or are you still allowed to reject patients if you do not feel comfortable treating them?

 

[whopper]

You basically don't have to take anyone you don't want to take but you really won't know the patient until you interview them, and after that happens, the patient/doctor relationship is established.

You could terminate them after an interview so long as you follow the state's guidelines.

 

[Majesty]

I have been rethinking this the more I consider going full time private pay only. I may accept insurance if I can't make it productive. I am guessing I would not need a receptionist and could probably get away with either a scribe. I don't know about the legalities of that but it would be nice to have someone type away while I chat and then have the note ready for me to sign when its done or a very cheap receptionist that I could train. Perhaps a college student that I could pay 10 dollars an hour or a little more if they are well versed in something like typing or computer maintenance.

Office space with the amenities as well as an EMR.
What are people charging for hourly or increments. I usually see a 45 minute 'hour' and a 20-25 minute 'half hour.' I was thinking about setting my fees at 250 per hour and 150 per half hour with a sliding scale down to about half that.

 

[digitlnoize]

I have been rethinking this the more I consider going full time private pay only. I may accept insurance if I can't make it productive. I am guessing I would not need a receptionist and could probably get away with either a scribe. I don't know about the legalities of that but it would be nice to have someone type away while I chat and then have the note ready for me to sign when its done or a very cheap receptionist that I could train. Perhaps a college student that I could pay 10 dollars an hour or a little more if they are well versed in something like typing or computer maintenance.

Office space with the amenities as well as an EMR.
What are people charging for hourly or increments. I usually see a 45 minute 'hour' and a 20-25 minute 'half hour.' I was thinking about setting my fees at 250 per hour and 150 per half hour with a sliding scale down to about half that.

I was an ER scribe. I made $8/hr with no training except that I was a pre-med and computer literate. Honestly, you could probably have paid me less, since it was great experience for med school and looked great on applications...

 

[Manicsleep]

I was an ER scribe. I made $8/hr with no training except that I was a pre-med and computer literate. Honestly, you could probably have paid me less, since it was great experience for med school and looked great on applications...

Really? What were your duties.
I bet I could find tons of pre-meds, who are very bright and very capable. They would also inject a lot of energy into the work environment. I may hire one just for the heck of it.

 

[digitlnoize]

Really? What were your duties.
I bet I could find tons of pre-meds, who are very bright and very capable. They would also inject a lot of energy into the work environment. I may hire one just for the heck of it.

I basically just followed the ER docs into the room, took notes on a notepad about the H&P, then typed it all into the EMR. I also kept track of lab/xray/other results on our patients, and let the doc know if there was something critical. I also had to keep track of who we needed to see...very "personal assistant"-ish. But the crux of it was just entering anything that needed to be entered into the EMR.

I would pay your scribes, it'll make them more likely to show up for work. We had a GPA cutoff (3.5, I think) and admission to the program was pretty competitive...I basically lucked into it. Also, feeding them is a good idea...keeps morale up.

If you're near any type of college with a pre-med program, it's cheap labor, and a win-win all around.

 

[notdeadyet]

I have been rethinking this the more I consider going full time private pay only. I may accept insurance if I can't make it productive. I am guessing I would not need a receptionist and could probably get away with either a scribe. I don't know about the legalities of that but it would be nice to have someone type away while I chat and then have the note ready for me to sign when its done or a very cheap receptionist that I could train.

I'm not sure I understand this. Are you proposing having a scribe sitting in your appointments taking notes while you conduct psychotherapy with your patients? I would think having a third body in there (especially one that will likely be young and whose face would change every 9-12 months) would be pretty counter-therapeutic, no?

Pardon my ignorance and limited experience, I'm just not familiar with private psych practices having a third person in the room all the time.

 

[whopper]

If you hire a "scribe" you want a good one. If you really need one, you want reliable staff members. If you hire someone on the order of a soda jerk, expect to get that level of quality. E.g. someone who doesn't show up to work half the time, doesn't do a good job, etc.

This may involve higher pay or decent credentials.

 

[digitlnoize]

If you hire a "scribe" you want a good one. If you really need one, you want reliable staff members. If you hire someone on the order of a soda jerk, expect to get that level of quality. E.g. someone who doesn't show up to work half the time, doesn't do a good job, etc.

This may involve higher pay or decent credentials.

Agreed. Our screening process was pretty rigorous, and every scribe I can think of that I worked with went on to medical or PA school. I thought $8/hr was pretty low, honestly, but we all did it because it was a GREAT experience, and looked awesome on our med school applications...and we all know how competitive that is getting...

I also agree that it's one thing to have a scribe in an ED, but another to have one in a psych session. I've had a hard time finding someone to let me shadow them outpatient for a couple days, just to see what it's like.

 

[Manicsleep]

I basically just followed the ER docs into the room, took notes on a notepad about the H&P, then typed it all into the EMR. I also kept track of lab/xray/other results on our patients, and let the doc know if there was something critical. I also had to keep track of who we needed to see...very "personal assistant"-ish. But the crux of it was just entering anything that needed to be entered into the EMR.

I would pay your scribes, it'll make them more likely to show up for work. We had a GPA cutoff (3.5, I think) and admission to the program was pretty competitive...I basically lucked into it. Also, feeding them is a good idea...keeps morale up.

If you're near any type of college with a pre-med program, it's cheap labor, and a win-win all around.

I think I would be willing to pay 8 or 10 dollars an hour as well as do some teaching. I would probably not try to replace any of my regular staff with this but it may make my life easier and certainly more interesting. I wouldn't allow just anyone to do it either because I wouldn't use these purely for labor. It would be like a paid internship in a medical group.

I don't think it would be a problem with shadowing for psychotherapy as long as its not psychodynamic. I don't do analysis so thats not going to be a problem. Med management with brief therapy, CBT and IPT can be done with students. I probably wouldn't do DBT until after they were familiar with the process and had been around psych patients for a while.

I followed an outpatient internist for 6 months in undergrad for about 10 hours a week. I wonder what the legal implications would be but I would get them HIPAA cleared and I think that should be it. They would be a legal employee, it should not be a problem.

 

[medium rare]

I don't think it would be a problem with shadowing for psychotherapy as long as its not psychodynamic. I don't do analysis so thats not going to be a problem. Med management with brief therapy, CBT and IPT can be done with students. I probably wouldn't do DBT until after they were familiar with the process and had been around psych patients for a while.

It has been my experience that self-pay patients are typically not accepting of having anyone else in the room during their session other than the doctor/therapist. I have observed this to be the case across all patient demographics (individual, couples, family, child) and with all therapeutic modalities - even pure medication management. So much so that I have stopped even considering have a trainee/student in my practice; the patients routinely declined to have the student in the room and the student couldn't get any hours. I don't know how this would be different for a scribe. Just part of the nature of private psych practice.

 

[digitlnoize]

It has been my experience that self-pay patients are typically not accepting of having anyone else in the room during their session other than the doctor/therapist. I have observed this to be the case across all patient demographics (individual, couples, family, child) and with all therapeutic modalities - even pure medication management. So much so that I have stopped even considering have a trainee/student in my practice; the patients routinely declined to have the student in the room and the student couldn't get any hours. I don't know how this would be different for a scribe. Just part of the nature of private psych practice.

I think it's funny (and sad) that it's easier to get experience doing pelvic and rectal exams than to observe outpatient psych.

 

[TexasPhysician]

I think it's funny (and sad) that it's easier to get experience doing pelvic and rectal exams than to observe outpatient psych.

True. I feel a little weird knowing that no one has ever turned me down for a rectal exam (done at least 50). Only 1 out of 50+ has turned me down for a pelvic. Yet I have been "fired" as a physician for not giving a patient "a giant bottle of Ativan" (picture hands spread 5 feet wide). The mind is the most delicate and private of all organs.

 

[Majesty]

Well, I decided against joining that group. I think its better if I do my own thing. I think the reason for the W-2 is so the patient's 'belong' to them even though they say I am my own boss and they only charge for overhead. This way, if I decide to leave, I can't take the patients.

Would have been nice but...it's never easy. Keep trying I guess.