Seeking career advice for those experienced with Private Practice

[finalpsychyear]

I have already established a part time PP along with a side telepsych job but ultimately the area I will be moving to is roughly 90 minutes away from the 1 day a week PP ( 10 hour day) which is a bit of a drive. The area I am moving to is much more population dense ( 2x min maybe 3-4x and growing) than where I set up my initial PP and I am in the Midwest. Here are my 3 options:

1. Join a psych hospital (20-30% medicaid) which basically uses a nursing home model where you bill on your own for all the services you provide. I believe the unit which is open has a census of 24 and your provided an NP by the facility but some of the providers get their own NP. Providers get there as early as 5am and leave by noon only needing to be available by phone till 6pm and most do their own PP in afternoon. No nights and 1 wknd a month paid extra. I thought initially this would make sense by sort of indirectly advertising you in the new area and they are ok with you having your own PP but this facility has started its own outpatient med management run by NPs employed by them so i am not sure how many patients I would necessarily get by working here or assuming i would get referrals vs just marketing myself on my own. The doc in option 2 says most of his referrals did not come from this facility.

2. One of the docs working at that hospital has 4 NPS under him and wants to "hire" me as a partner but i would have the option of salary vs productivity model. He started 8 months ago and has nearly 1000 pts and he says its due to demand in area and not referrals really from hospital. He already mentioned he wants to grow and expand to multiple offices since so much demand in area and he mentioned with me on board he could have 5 more NPS in theory down the road as i would be the collaborating doc and he is nearly maxed out. I am not sure how this really benefits me unless it was a true 50/50 partnership model otherwise I feel he will try to do like a 60/40 or 70/30 productivity model which since i am already up and running not sure if that is all that lucrative going forward for me as my current PP is about slightly less than 20% overhead.


3. Continue with my current set up doing the 90 min drive 1x a week once i move but just market myself like crazy through counseling services, PCPS, schools, other hospital systems, and of course i am taking private insurance panels only and just let it slowly expand once i am in new area and only consider the psych hospital idea if for some reason i don't fill up my goal of 2 day a week PP after 1 year of doing that. I am only looking for max 2 days of PP in this area with 20 pts a day as my definition of success here.


Thoughts?

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[dl2dp2]

I have already established a part time PP along with a side telepsych job but ultimately the area I will be moving to is roughly 90 minutes away from the 1 day a week PP ( 10 hour day) which is a bit of a drive. The area I am moving to is much more population dense ( 2x min maybe 3-4x and growing) than where I set up my initial PP and I am in the Midwest. Here are my 3 options:

This kind of geography (where you are moving to) is the type of place where an average psychiatrist can grow a private practice very quickly.

1. Join a psych hospital (20-30% medicaid) which basically uses a nursing home model where you bill on your own for all the services you provide. I believe the unit which is open has a census of 24 and your provided an NP by the facility but some of the providers get their own NP. Providers get there as early as 5am and leave by noon only needing to be available by phone till 6pm and most do their own PP in afternoon. No nights and 1 wknd a month paid extra. I thought initially this would make sense by sort of indirectly advertising you in the new area and they are ok with you having your own PP but this facility has started its own outpatient med management run by NPs employed by them so i am not sure how many patients I would necessarily get by working here or assuming i would get referrals vs just marketing myself on my own. The doc in option 2 says most of his referrals did not come from this facility.

You can do this as a side gig, but I imagine the work itself is pretty awful in this arrangement.

2. One of the docs working at that hospital has 4 NPS under him and wants to "hire" me as a partner but i would have the option of salary vs productivity model. He started 8 months ago and has nearly 1000 pts and he says its due to demand in area and not referrals really from hospital. He already mentioned he wants to grow and expand to multiple offices since so much demand in area and he mentioned with me on board he could have 5 more NPS in theory down the road as i would be the collaborating doc and he is nearly maxed out. I am not sure how this really benefits me unless it was a true 50/50 partnership model otherwise I feel he will try to do like a 60/40 or 70/30 productivity model which since i am already up and running not sure if that is all that lucrative going forward for me as my current PP is about slightly less than 20% overhead.

It's GENERALLY not a great idea to go into a partnership with a stranger off the bat. Also, 1000 patients with 1 MD and 4 NP is a highish case load even for psychopharm and assumes a lot of NP competency. Depending on the case mix it can be either chill or very intense. Is this the kind of job you want? How much do you like to be a med mgmt person vs. doing psychotherapy? The equity arrangement can be worked out in all kinds of ways, but mainly it's a matter of whether you'd trust this person enough to open your financial drawers once your practice starts to fill. This is the most risky option as it will also expose you to the assortment of business risks (i.e. litigations, regulatory risks, personnel turnovers, etc), and as such may or may not be the best fit for a lot of people such as those who are starting a young family or those who carry a lot of student debt.

The plus side is that there is a level of overhead you'd need to consider regardless of how you do your practice: insurance billing, secretarial support, HR compliance etc. So if you go start your own practice it is perhaps more efficient to do it with a partner. Again trust/communication and alignment of long term vision is critical in this.

It is very possible however in this scenario where you might end up with a situation where you only work very light hours, acting as a medical director for consultation on complicated cases as well as quality assurance. You end up making a lot of passive income. This is not really a possibility in the third scenario.

3. Continue with my current set up doing the 90 min drive 1x a week once i move but just market myself like crazy through counseling services, PCPS, schools, other hospital systems, and of course i am taking private insurance panels only and just let it slowly expand once i am in new area and only consider the psych hospital idea if for some reason i don't fill up my goal of 2 day a week PP after 1 year of doing that. I am only looking for max 2 days of PP in this area with 20 pts a day as my definition of success here.

Do you mean you'll start a new practice at the new location and gradually stop your current practice that's far away? You will fill. And I think very quickly. In this model, you'll take 100-200 patient on your own, and you may or may not need a secretary (possibly part time/outsourced). You will need a biller, but likely the billing can be outsourced (not a full time job). You'll need an office, but not an office SUITE. It's a lean startup model.

You'll never get to the passive income model of option number 2, but it's very possible at least initially that hour by hour you'll make more money as a clinician. You will also have more control over the type of work you want to do (i.e. therapy vs. meds, what type of patients, etc), since you are not under pressure to fill open NP spots with easy med mgmt cases.


BTW none of this is so black and white and can change. You can do a mix---for example, you can say I'm happy to join your practice as a partner later and share your cost with you, but I prefer to not take on an NP (or god forbid, 5). Here's the amount of overhead I'd be willing to pay for your help. You'd still be a partner but you will not get any dividend from supervising his NPs or any passive income, unless it's a shared passive income (i.e. if you jointly buy an office suite and pay down the mortgage together, and this office then is rented out to a third person, etc). You can also ask the MD to front you some salary support for a while until you can trust his ethics and you work strictly as an employee. You can take one NP on and test the waters etc.

Generally, in the long run the most money you can make will come out of passive income (some kind of K1 partnership dividend, the ceiling is much much higher there. Most of the psychiatrists who clear over 500k a year are probably owners of practices), unless your clinical niche is very in demand or you live in a large market (i.e. big wealthy cities can support boutique cash practices that rival large group practice ownership in total all-in Schedule C cash comp -- this is rare even in these markets). But the style of work is very different. In a small cash based practice, MARKETING is key because you are trying to identify a segment of the population who's not apparent, and a lot of work will be involved (as you said yourself). In large group practices with lots of NPs, the main issue isn't marketing--people find you all the time very quickly, the main issue is operation: how do you efficiently dispense labor, how do you manage staff to minimize turnover and minimize cost, how do you maximize clinical outcome and minimize risk, that sort of issues. What kind of a person are you, are you a good sales person (who can schmooze with a wealthy clientele and their associated service providers) or an operations person who loves to "run" things?

 

[finalpsychyear]

This kind of geography (where you are moving to) is the type of place where an average psychiatrist can grow a private practice very quickly.




You can do this as a side gig, but I imagine the work itself is pretty awful in this arrangement.




It's GENERALLY not a great idea to go into a partnership with a stranger off the bat. Also, 1000 patients with 1 MD and 4 NP is a highish case load even for psychopharm and assumes a lot of NP competency. Depending on the case mix it can be either chill or very intense. Is this the kind of job you want? How much do you like to be a med mgmt person vs. doing psychotherapy? The equity arrangement can be worked out in all kinds of ways, but mainly it's a matter of whether you'd trust this person enough to open your financial drawers once your practice starts to fill. This is the most risky option as it will also expose you to the assortment of business risks (i.e. litigations, regulatory risks, personnel turnovers, etc), and as such may or may not be the best fit for a lot of people such as those who are starting a young family or those who carry a lot of student debt.

The plus side is that there is a level of overhead you'd need to consider regardless of how you do your practice: insurance billing, secretarial support, HR compliance etc. So if you go start your own practice it is perhaps more efficient to do it with a partner. Again trust/communication and alignment of long term vision is critical in this.

It is very possible however in this scenario where you might end up with a situation where you only work very light hours, acting as a medical director for consultation on complicated cases as well as quality assurance. You end up making a lot of passive income. This is not really a possibility in the third scenario.



Do you mean you'll start a new practice at the new location and gradually stop your current practice that's far away? You will fill. And I think very quickly. In this model, you'll take 100-200 patient on your own, and you may or may not need a secretary (possibly part time/outsourced). You will need a biller, but likely the billing can be outsourced (not a full time job). You'll need an office, but not an office SUITE. It's a lean startup model.

You'll never get to the passive income model of option number 2, but it's very possible at least initially that hour by hour you'll make more money as a clinician. You will also have more control over the type of work you want to do (i.e. therapy vs. meds, what type of patients, etc), since you are not under pressure to fill open NP spots with easy med mgmt cases.


BTW none of this is so black and white and can change. You can do a mix---for example, you can say I'm happy to join your practice as a partner later and share your cost with you, but I prefer to not take on an NP (or god forbid, 5). Here's the amount of overhead I'd be willing to pay for your help. You'd still be a partner but you will not get any dividend from supervising his NPs or any passive income, unless it's a shared passive income (i.e. if you jointly buy an office suite and pay down the mortgage together, and this office then is rented out to a third person, etc). You can also ask the MD to front you some salary support for a while until you can trust his ethics and you work strictly as an employee. You can take one NP on and test the waters etc.

Generally, in the long run the most money you can make will come out of passive income (some kind of K1 partnership dividend, the ceiling is much much higher there. Most of the psychiatrists who clear over 500k a year are probably owners of practices), unless your clinical niche is very in demand or you live in a large market (i.e. big wealthy cities can support boutique cash practices that rival large group practice ownership in total all-in Schedule C cash comp -- this is rare even in these markets). But the style of work is very different. In a small cash based practice, MARKETING is key because you are trying to identify a segment of the population who's not apparent, and a lot of work will be involved (as you said yourself). In large group practices with lots of NPs, the main issue isn't marketing--people find you all the time very quickly, the main issue is operation: how do you efficiently dispense labor, how do you manage staff to minimize turnover and minimize cost, how do you maximize clinical outcome and minimize risk, that sort of issues. What kind of a person are you, are you a good sales person (who can schmooze with a wealthy clientele and their associated service providers) or an operations person who loves to "run" things?

Appreciate your response. In option 3 yes I would start a new practice in this new area but likely won't give up my current practice until i reach 40 pts a week which given the geography seems like a very doable number of cases even worst case scenario after 1 year of marketing. Somehow I found one of those rent a center just the office room furnished 16 hrs a month only costing me under 200 dollars with phone, utilities, and central lobby for pts to wait and a shared reception lady who will only greet your patients and would call or text you for 100 monthly charge. My EMR is cheap and allows me to do billing as part of its package which is very easy for me at this point after getting used to it with my first Private practice.

The best part is i leave my current schedule in tact and will only work 4pm-6 pm Mondays and Wednesdays for the developing PP just to see the response. Your right about trusting a stranger right off the bat. I almost think that option can wait and i can at least try it on my own and then later perhaps come back to the table and maybe have more to offer in the partnership as the patients will come based on what he is saying since the demand is there. I ran my other office with only 1 support person. I am already credentialed on nearly all private insurance. Any idea if adding a new practice location to my current insurance panels again takes 3 months like the initial process did ??

Last point, If i were to partner I would want to pay the direct costs like rent, portion of front desk staff salary, etc as i would consider a flat 30-40% ridiculous for psych. I wouldn't want a non-compete. I just doubt the guy would want to do that as I want to remain my own entity as much as possible and that is worth more than $ to me.

Thanks again for all the valuable input.

 

[dl2dp2]

The best part is i leave my current schedule in tact and will only work 4pm-6 pm Mondays and Wednesdays for the developing PP just to see the response. Your right about trusting a stranger right off the bat. I almost think that option can wait and i can at least try it on my own and then later perhaps come back to the table and maybe have more to offer in the partnership as the patients will come based on what he is saying since the demand is there. I ran my other office with only 1 support person. I am already credentialed on nearly all private insurance. Any idea if adding a new practice location to my current insurance panels again takes 3 months like the initial process did ??

It shouldn't, but obviously call them to get the most definitive answer. Given that you are already doing insurance based practice you are very well poised to just replicate your current set up.

Last point, If i were to partner I would want to pay the direct costs like rent, portion of front desk staff salary, etc as i would consider a flat 30-40% ridiculous for psych. I wouldn't want a non-compete. I just doubt the guy would want to do that as I want to remain my own entity as much as possible and that is worth more than $ to me.
Thanks again for all the valuable input.

The guy would be willing to do it if you pay him for something with which he would provide value. For example, if you supervise an NP with which he (and presumably you also) derives some dividend, then the more you work the more money he would make.

If he's a real partner, he should be willing to open the books to you to see how much the costs really are and what are the current billing rates/no show rates/claim denial rates, etc. etc. etc. If you WANT to go down that route, you can always say yes I can give you a higher dividend for my profit for the first year or so for "building" this practice, but once things get running I'd like to just pay my portion of the cost.

 

[TexasPhysician]

The answer lies in what you value in a job. Anything I can offer is more speculation as there are a lot of details in every job. What would make you happy?

 

[finalpsychyear]

The answer lies in what you value in a job. Anything I can offer is more speculation as there are a lot of details in every job. What would make you happy?

Ultimately a 4-5 day private practice doing a combination of med management and brief therapy with TMS. Don't want to do nights, weekends or holidays ever. However, there is some level of security in "having" an inpt unit. Just got offered from another facility (the competitor to the one above) an 18 unit depression, anxiety only floor with only private insurance/medicare which they claim is a very sought after unit in general. (they have a medicaid only floor run by employed NPs which i have nothing to do with) The facility will allow you to do your own billing, directorship stipend, and ok with those patients following you to your outpt practice. Also, for someone planning TMS it would be an ideal unit with pathology and insurance that would actually pay for it.
Down the road I could have the option to have an NP who would round on my unit or help out as I would focus more on the outpt portion. My telepsych is a cush job but i know getting 160 per hour is lost money compared to PP and eventually i need to let that go as hard as that may be.

 

[TexasPhysician]

With TMS and no call, you need a high volume insurance based practice. If you don’t mind extra work on administrative issues, start your own practice to maximum $. It won’t take long to fill an insurance practice. If you don’t want call, I’d pass on inpatient work.

 

[Candidate2017]

The best part is i leave my current schedule in tact and will only work 4pm-6 pm Mondays and Wednesdays for the developing PP just to see the response. Your right about trusting a stranger right off the bat. I almost think that option can wait and i can at least try it on my own and then later perhaps come back to the table and maybe have more to offer in the partnership as the patients will come based on what he is saying since the demand is there. I ran my other office with only 1 support person. I am already credentialed on nearly all private insurance. Any idea if adding a new practice location to my current insurance panels again takes 3 months like the initial process did ??

As a solo, what does insurance billing involve and cost?

 

[Shufflin]

As a solo, what does insurance billing involve and cost?

It involves headaches, headaches, and more headaches basically. Once you have the headaches part down, then you'll advance to the next step, advanced headaches.

 

[TexasPhysician]

What's an average hourly rate for a generic insurance pp in a large city? Very ballpark I realize.

Can a doc pretty much fill enough to do 50 clinical hours a week?

You negotiate your rates with insurance companies and then establish how many patients you want to see per hour. Depending on insurance mix, volume, billing codes, and negotiated rates, you could bill $60-600/hour.

 

[TexasPhysician]

As a solo, what does insurance billing involve and cost?

First: Learn how coding works.
Second: Hire someone to handle billing either by salary or outsource. Outsourcing will cost about 6% of gross revenue.
Third: Spend time checking to ensure accuracy of your billing staff.

 

[Shufflin]

Fourth: Figure out how to demonstrate adequate medical/psychiatric necessity and the line each insurance company draws between reimbursable visits and those they refuse to pay you for. Unfair you say? Welcome to the wild world of insurance.

 

[TexasPhysician]

That's quite the ballpark. How in the world does someone make $600 in private practice taking insurance??? Cash pay usually isn't even 75% of that..

The right geography and negotiation skills with the right patients can do this. 99214 + 90833 could equal $200. It’s possible to have 3 in 1 hour. You will have high overhead to manage insurance issues and the volume of patients. The problem is that insurance companies don’t divulge the best locations and they make physicians sign non-disclosure agreements.

 

[jbomba]

The right geography and negotiation skills with the right patients can do this. 99214 + 90833 could equal $200. It’s possible to have 3 in 1 hour. You will have high overhead to manage insurance issues and the volume of patients. The problem is that insurance companies don’t divulge the best locations and they make physicians sign non-disclosure agreements.

Very interesting - I wish more of this stuff was taught in medical schools and residency. Had no idea about the NDA's.

Assuming this type of insurance set up, and a desire to see 20 patients a day (2.5 per hour), it sounds like $3-400 an hour is attainable in even the non-highest paying geographic regions. Once you're on the insurance panels, how long does it usually take to fill to see 20 pts a day in a large metro area?

Overhead is roughly 15% correct?

 

[finalpsychyear]

Very interesting - I wish more of this stuff was taught in medical schools and residency. Had no idea about the NDA's.

Assuming this type of insurance set up, and a desire to see 20 patients a day (2.5 per hour), it sounds like $3-400 an hour is attainable in even the non-highest paying geographic regions. Once you're on the insurance panels, how long does it usually take to fill to see 20 pts a day in a large metro area?

Overhead is roughly 15% correct?

billing companies alone can be 5-8%, staff, malpractice,documentation ( license, cme, dea), disability/building insurances, benefits, business car, business equipment, rent, utilities, EMR, furniture, supplies, lawyer, accountant ( not mandatory but you will probably want them both) also any and all time you take for vacation or federal holidays is a loss for you as you dont make income but your employees are probably still going to be coming in for their 20-40 hour weeks. If your running a busy PP you probably need 1-2 staff for the billing alone. I would say 25% minimum not counting funding your own retirement. Remember you pay your own retirement out of your gross income which i am not sure in a way could sorta be counted as overhead since you can't touch it till 59.5.

Also don't get fixated on hourly rates as insurances will vary alot. In my area the combined coding is more like 130-140 using level 4 plus therapy and maybe 100-110 if using level 3. It gets even more complicated as certain insurances have many subtypes so even if they pay x dollars normally for their regular type, the subtype you will only get like 0.8 or 0.7 of that. I made the mistake of just thinking hmm 20 pts x 110-150 gives you a set amount but you will have have 3-4 pts no show or call to cancel and reschedule so most days if i scheduled 20 pts only in reality anywhere from 14-18 probably show. You can do no show fees and all that but some of the pts i did this to just went to other providers or never came back.

I love PP mostly for the autonomy. Pay is better than most employed positions per hour or time you do it yes but there is a lot of work in PP to be done and the less you do yourself the more your overhead will go. I also stress about always getting new patients and making sure my days are full which i have been lucky so far but its also in the back of my head as an additional worry. Ideally, have one or two side jobs while you start a 1 day a week PP and you will not have the financial pressure to fill your office.

P.S. I keep hearing rumors about the therapy codes being gone or reduced in pay for the future not sure if there is some basis to this but if that were to happen cut those amounts quoted above in half in my area.

 

[splik]

P.S. I keep hearing rumors about the therapy codes being gone or reduced in pay for the future not sure if there is some basis to this but if that were to happen cut those amounts quoted above in half in my area.

There are no proposals to remove the psychotherapy add on codes. However there is a proposal to flatten reimbursement for E/M codes at level 2 (i.e. increase RVUs for a level 2 code, and have the same RVU for 99212-5 and 99202-5). Which will incentivize people to do 5-10 minute med checks and disincentivize spending longer with patients. On the plus side, it would dramatically reduce the burden of documentation as you would only need to document at a level 2 for every visit. This is currently under review, but could come into force in 2019. See here: Evaluation and management (E/M) coding and documentation burden could lighten in 2019 under CMS proposed rule
and here: Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019 | CMS

 

[finalpsychyear]

There are no proposals to remove the psychotherapy add on codes. However there is a proposal to flatten reimbursement for E/M codes at level 2 (i.e. increase RVUs for a level 2 code, and have the same RVU for 99212-5 and 99202-5). Which will incentivize people to do 5-10 minute med checks and disincentivize spending longer with patients. On the plus side, it would dramatically reduce the burden of documentation as you would only need to document at a level 2 for every visit. This is currently under review, but could come into force in 2019. See here: Evaluation and management (E/M) coding and documentation burden could lighten in 2019 under CMS proposed rule
and here: Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019 | CMS

Interesting. I alternate between 3 and 4 usually. Your right the 5-10 minute medcheck would be in full throttle. I just hope the next 5-10 years of fee for service stay more or less what they are now as the fear of massive overhauls like further cuts in payments, NPs taking over psychiatrist positions, or some socialized system where incomes are limited regardless of pt visits. The last one is not going to happen in the next 10 years but the other 2 who knows. It drives me to want to work harder now so i can after 10 years be in a place where whatever happens to healthcare I made the most of what was there even if that means 55-60 hr weeks. Some specialties reading that would laugh as that is a minimum standard for them. I am thankful that for us its considered busting your hump.

 

[TexasPhysician]

Very interesting - I wish more of this stuff was taught in medical schools and residency. Had no idea about the NDA's.

Assuming this type of insurance set up, and a desire to see 20 patients a day (2.5 per hour), it sounds like $3-400 an hour is attainable in even the non-highest paying geographic regions. Once you're on the insurance panels, how long does it usually take to fill to see 20 pts a day in a large metro area?

Overhead is roughly 15% correct?

It shouldn’t take long to fill, but you won’t hit 15% overhead unless in a trim cash pay set-up. Typical insurance overhead is closer to 25% or above.

 

[finalpsychyear]

This kind of geography (where you are moving to) is the type of place where an average psychiatrist can grow a private practice very quickly.




You can do this as a side gig, but I imagine the work itself is pretty awful in this arrangement.




It's GENERALLY not a great idea to go into a partnership with a stranger off the bat. Also, 1000 patients with 1 MD and 4 NP is a highish case load even for psychopharm and assumes a lot of NP competency. Depending on the case mix it can be either chill or very intense. Is this the kind of job you want? How much do you like to be a med mgmt person vs. doing psychotherapy? The equity arrangement can be worked out in all kinds of ways, but mainly it's a matter of whether you'd trust this person enough to open your financial drawers once your practice starts to fill. This is the most risky option as it will also expose you to the assortment of business risks (i.e. litigations, regulatory risks, personnel turnovers, etc), and as such may or may not be the best fit for a lot of people such as those who are starting a young family or those who carry a lot of student debt.

The plus side is that there is a level of overhead you'd need to consider regardless of how you do your practice: insurance billing, secretarial support, HR compliance etc. So if you go start your own practice it is perhaps more efficient to do it with a partner. Again trust/communication and alignment of long term vision is critical in this.

It is very possible however in this scenario where you might end up with a situation where you only work very light hours, acting as a medical director for consultation on complicated cases as well as quality assurance. You end up making a lot of passive income. This is not really a possibility in the third scenario.



Do you mean you'll start a new practice at the new location and gradually stop your current practice that's far away? You will fill. And I think very quickly. In this model, you'll take 100-200 patient on your own, and you may or may not need a secretary (possibly part time/outsourced). You will need a biller, but likely the billing can be outsourced (not a full time job). You'll need an office, but not an office SUITE. It's a lean startup model.

You'll never get to the passive income model of option number 2, but it's very possible at least initially that hour by hour you'll make more money as a clinician. You will also have more control over the type of work you want to do (i.e. therapy vs. meds, what type of patients, etc), since you are not under pressure to fill open NP spots with easy med mgmt cases.


BTW none of this is so black and white and can change. You can do a mix---for example, you can say I'm happy to join your practice as a partner later and share your cost with you, but I prefer to not take on an NP (or god forbid, 5). Here's the amount of overhead I'd be willing to pay for your help. You'd still be a partner but you will not get any dividend from supervising his NPs or any passive income, unless it's a shared passive income (i.e. if you jointly buy an office suite and pay down the mortgage together, and this office then is rented out to a third person, etc). You can also ask the MD to front you some salary support for a while until you can trust his ethics and you work strictly as an employee. You can take one NP on and test the waters etc.

Generally, in the long run the most money you can make will come out of passive income (some kind of K1 partnership dividend, the ceiling is much much higher there. Most of the psychiatrists who clear over 500k a year are probably owners of practices), unless your clinical niche is very in demand or you live in a large market (i.e. big wealthy cities can support boutique cash practices that rival large group practice ownership in total all-in Schedule C cash comp -- this is rare even in these markets). But the style of work is very different. In a small cash based practice, MARKETING is key because you are trying to identify a segment of the population who's not apparent, and a lot of work will be involved (as you said yourself). In large group practices with lots of NPs, the main issue isn't marketing--people find you all the time very quickly, the main issue is operation: how do you efficiently dispense labor, how do you manage staff to minimize turnover and minimize cost, how do you maximize clinical outcome and minimize risk, that sort of issues. What kind of a person are you, are you a good sales person (who can schmooze with a wealthy clientele and their associated service providers) or an operations person who loves to "run" things?

Option 2 the guy who wanted to "hire" me said the following: basically the first year he would want me to be on a production basis where he covered the overhead. I didn't ask what that would be even though i heard he charges his Nps 50 or 55% of collections but i guess that also considers supervision of them as well. Then he would "consider" a formal partnership. However, I am sure this first year contract would limit me and I'd have a non compete and all the new patients i would see would not be able to follow me later which is a complete waste to me. I just found 2 different office spaces in this area part time use of 16 hours a week granted for 500-600 bucks a MONTH and one of them has a support staff included and both offices includes all utilities, internet, furnished etc so i think its a steal and I am in a top 15 city in terms of population to boot.


Alternate Option: A new inpt psych competitor hospital for just depression/anxiety offered me an 18 bed unit where they claim 95% are private insurance and they support me following those patients in my outpt practice. They prefer providers spend time with their pts ( 20 min) and want u to utilize the 90833 add on codes but I am not sure if its covered inpt like it is outpt.
Ultimately, there is a large NP school nearby where most of these docs on these units hire a new recruit and train them from scratch to eventually handle a chunk of the unit. I believe this idea could be very good long term or am i being naive here?

 

[finalpsychyear]

With TMS and no call, you need a high volume insurance based practice. If you don’t mind extra work on administrative issues, start your own practice to maximum $. It won’t take long to fill an insurance practice. If you don’t want call, I’d pass on inpatient work.

I was approached by a pain med doctor wondering if he was allowed to buy a TMS machine and utilize it for his chronic pain patient with depression patients. Is their any issue with this as I am not sure but i would guess probably not.

 

[Shufflin]

I was approached by a pain med doctor wondering if he was allowed to buy a TMS machine and utilize it for his chronic pain patient with depression patients. Is their any issue with this as I am not sure but i would guess probably not.

Unsure what he means by being "allowed" to buy one. You have to be trained and certified to use one, and you'd want to anyway because the challenge with TMS is targeting. To pinpoint the right places to be effective for depression and pain requires expensive targeting technology. Using your fingers to approximate locations is not reliable enough.