Telepsychiatry private practice

[jbomba]

I've committed to doing a lot of training in a sub-specialty niche my pgy4 so I'm hoping I can be one of a small handful of docs providing this care in the community I'll be in. Thinking this may open up referrals and hopefully sources will be happy to simply have someone to send their patients to. My thought on paper is this should help me stand out amongst all the generalists and increase how quickly I fill.

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[Atreides]

Have you done Google ads and SEO?

@wolfvgang22

Nope, I have not. I'm trying to not dip into personal funds right now so was waiting until the practice turned a profit before investing more money into it. I'm in the black now though so definitely something I'll be doing now.

Do you show up as in network for the insurances you're on through Alma? That's usually why people fill quickly because they show up in the insurance company's physician look-up as in network. Since Alma has the contract and not you I wonder if you're not showing up for some reason... you should be if they credentialed you with the insurer but I'd take a look and verify just to be sure.

@trophyhusband

I thought I did since my patients told me they found me through their insurance. However, I just went and checked my own insurance look-up page (I have Aetna) and I do not show up at all even though I'm credentialed through Alma. Thanks, this is a huge catch. I'll contact the Alma people and see what's up. This might be another reason to consider credentialing on my own rather than renewing Alma when the free trial ends.

I think emailing clinicians is a waste of time. I automatically hit delete with emails. I won’t refer to someone that I’ve never met. If I refer someone and you are creepy, awkward, or rude, my reputation takes a hit. If people want my attention, they need to show up or schedule a time to briefly meet with me.

@TexasPhysician

Yeah, totally get where you're coming from. Realistically, I don't have the time to physically drive all over the metro area (could be 2-3 hours depending on the distance) but maybe I'll try reaching out to set up virtual meetings.

 

[randomdoc1]

Another pearl on insurance. The smaller, newer, more locally based ones in my experience tend to be better to work with. They seem more vested in the well being of their community and you often have more negotiating power. And frankly, I like supporting the little guys if they're trying to do good. The insurance in my experience which can have the most hoops to jump through to get paid are the Optum products/family. Especially the one called "United Behavioral Health." Their cousins like UMR, All Savers, Golden Rule, Oxford etc. have hoops too but not as many as United Behavioral Health. United Behavioral Health has also requested the most records be sent for their reviews which can impact reimbursement decisions. Technically all insurances can do this, but I've seen the most coming from....you know....dun dun dun....
Unfortunately Optum is one of THE most common insurances carried throughout the country, which is why they are able to hold firmer ground on their reimbursement rates and policies. Providers are afraid to be more assertive because so many of their patients are on that insurance. More reason to help the little guy insurances!

Have you done Google ads and SEO?

good ideas. Those are high yield moves although no matter how much time I personally spent trying to figure it out, it's soooo complicated to ever personally get good at it unless you do it as your career. And the google algorithm changes quite regularly, so unfortunately it's not a one and done thing. It's a tough spot, because it's so expensive to pull off. But agree with wolfvgang, once the finances are favorable enough, SEO is a must. It opens a flood gate of referrals and you can be more picky about your pricing, insurances, patient selectivity, hours you wanna work, etc. because the demand shoots through the roof.

Insurance Credentialing

I wasn't sure how to go about doing this so literally googled "[insurance name] + credentialing." Here's the outcome:

Aetna: my application has been in limbo since I started the process. I was told I'd get a response in 60 days. Well, contacted them 60 days later and they said they'd put a ticket in. Contacted them a week later and they said you have to wait 30 business days from when a ticket is put in to follow up (??). It's been 30 business days since then, called again, said they'd escalate. So literally haven't even had any potential rates offered from them.

Cigna: they sent me rates, very low ones (like 60% of Medicare). I tried negotiating but they were pretty firm saying that as a matter of policy, they don't offer anything different to anyone during the first year. I've since found that's not actually true. But at the time, I figured I'd accept one insurance and get an idea of pros/cons of working with an insurance panel. So I signed the contract. This was like in March. I got an email like 10 days ago officially saying I'm credentialed.

Optum: didn't try to credential with them after hearing horror stories

Anthem: sent me rates, really low ones. Tried negotiating but radio silence from them, not even a "No, we don't negotiate" like Cigna did. This was after Cigna so I didn't pursue it any further as I only wanted to try one insurance as a trial run.

As a solo provider, it's not uncommon for insurances to try to f_ck you over with low rates, especially these big names. When I started I got paneled with everything and tried to negotiate right off the bat after they sent their first offer. Even if it was a low offer, I took it most times. Then after getting more patients, asked for a higher rate, using the argument of "well well well, where else are they gonna go?" One insurance I took low rates, then tried to negotiate a year later, they said no, so I threatened to drop them (and meant it) and they raised it.

Aetna never responds, you have to hound them, keep reference and ticket numbers and you will get in. Same thing with Humana. With getting paneled on many of these insurances, unless you follow up with them every two weeks, you will likely get radio silence forever.
@Atreides another funny point, when you are fully paneled, insurance does a terrible job of notifying you if at all. Many times I look on their website and your name magically appears there lol.

Many insurances will give you radio silence (especially if it has to do with getting paneled or negotiating rates). Just keep calling, emailing, faxing, even write a letter with quill pen and mail it, anyway you can get a hold of anyone. What you are describing is very typical. Unless they firmly say no negotiating, negotiating is still possible.

Starting off as a small practice, with a small patient census, a solo provider does not hold much swag. But once the panel grows, so does your influence and the need for your continued high quality medical care and that's what you use to negotiate, if that makes sense.

And if the insurances that automatically pay good deny you, reapply, reapply, reapply. Get letters from colleagues who are paneled to recommend you. I've had a couple where I applied three years in a row and on the 4th try, got in.

I won't lie, Optum has been a big factor that accelerated the growth of my practice. But as it grows, so does the amount they pay you. I think large insurance companies will be more likely to audit/review records, so keep that in mind as you get bigger. Running your place is very much like some sort of chess game.

It's truly a test of endurance and the mind.

 

[medhead1990]

2) I (or anyone else with a psychologytoday profile) can give you a referral link for 6 months free if you PM your email address, just don't create a profile ahead of time or else it won't let you use the link. Psychologytoday is gonna be your best source of referrals I bet, since you're not going to likely want to spend the money to try to drive google search term traffic to your personal website. People who search on psychologytoday for psychiatrists in your state will get you on their search results if you put you're available for telemedicine for the whole state.

@calvnandhobbs68 could you give me access to sending you a DM, I would love to get the psychologytoday referral link you mentioned.

 

[Atreides]

Another pearl on insurance. The smaller, newer, more locally based ones in my experience tend to be better to work with. They seem more vested in the well being of their community and you often have more negotiating power. And frankly, I like supporting the little guys if they're trying to do good. The insurance in my experience which can have the most hoops to jump through to get paid are the Optum products/family. Especially the one called "United Behavioral Health." Their cousins like UMR, All Savers, Golden Rule, Oxford etc. have hoops too but not as many as United Behavioral Health. United Behavioral Health has also requested the most records be sent for their reviews which can impact reimbursement decisions. Technically all insurances can do this, but I've seen the most coming from....you know....dun dun dun....
Unfortunately Optum is one of THE most common insurances carried throughout the country, which is why they are able to hold firmer ground on their reimbursement rates and policies. Providers are afraid to be more assertive because so many of their patients are on that insurance. More reason to help the little guy insurances!

good ideas. Those are high yield moves although no matter how much time I personally spent trying to figure it out, it's soooo complicated to ever personally get good at it unless you do it as your career. And the google algorithm changes quite regularly, so unfortunately it's not a one and done thing. It's a tough spot, because it's so expensive to pull off. But agree with wolfvgang, once the finances are favorable enough, SEO is a must. It opens a flood gate of referrals and you can be more picky about your pricing, insurances, patient selectivity, hours you wanna work, etc. because the demand shoots through the roof.


As a solo provider, it's not uncommon for insurances to try to f_ck you over with low rates, especially these big names. When I started I got paneled with everything and tried to negotiate right off the bat after they sent their first offer. Even if it was a low offer, I took it most times. Then after getting more patients, asked for a higher rate, using the argument of "well well well, where else are they gonna go?" One insurance I took low rates, then tried to negotiate a year later, they said no, so I threatened to drop them (and meant it) and they raised it.

Aetna never responds, you have to hound them, keep reference and ticket numbers and you will get in. Same thing with Humana. With getting paneled on many of these insurances, unless you follow up with them every two weeks, you will likely get radio silence forever.

Many insurances will give you radio silence (especially if it has to do with getting paneled or negotiating rates). Just keep calling, emailing, faxing, even write a letter with quill pen and mail it, anyway you can get a hold of anyone. What you are describing is very typical. Unless they firmly say no negotiating, negotiating is still possible.

Starting off as a small practice, with a small patient census, a solo provider does not hold much swag. But once the panel grows, so does your influence and the need for your continued high quality medical care and that's what you use to negotiate, if that makes sense.

And if the insurances that automatically pay good deny you, reapply, reapply, reapply. Get letters from colleagues who are paneled to recommend you. I've had a couple where I applied three years in a row and on the 4th try, got in.

I won't lie, Optum has been a big factor that accelerated the growth of my practice. But as it grows, so does the amount they pay you. I think large insurance companies will be more likely to audit/review records, so keep that in mind as you get bigger. Running your place is very much like some sort of chess game.

It's truly a test of endurance and the mind.

Thanks, this is really helpful! In regards to the smaller/newer/local insurances, how do I go about finding what these are in order to credential with them?

 

[randomdoc1]

Thanks, this is really helpful! In regards to the smaller/newer/local insurances, how do I go about finding what these are in order to credential with them?

A few ways I've found them--
-check out the psychologytoday profiles in your state. See what insurances they are on. With telehealth, you can reach a much bigger territory. You'll see some insurances you've never heard of.
-your state marketplace. These are places where people purchase their own insurance (e.g. if they are self employed) and you'll see some names that are unfamiliar. Market place insurances generally are in need of psychiatrists.
-patients that call--ask what insurance they carry. You'll start hearing some new names. Even if you are currently OON, many insurances will allow for what is called a single case agreement/authorization. You can get reimbursed through them anyways and argument can often be made that there is a shortage of providers to render this medically necessary care. That will also give you power to get paneled with them.
-checking out some of the biggest employers. This can sound extreme, but I've called their HR department and learned certain major employers like grocery store chains, hospital systems, etc. have started partnering with other local insurances because they get a better deal than say with Blue Cross Blue Shield. They are often eager to get new providers because they are so small. The HR departments may also be interested in knowing about you because they can have employees having MH matters affecting their attendance/performance so having you to refer to could be a great resource.

The other part then is marketing to these people so they can find you. Takes time, but it does find it's way!

-Medicare...is it worth it? My main concern with Medicare is if I do something wrong by mistake, there can be serious legal repercussions. The rates are great tbh, close to my cash rate. I think Medicare is requiring in-person visits at least once now though so I'd need to look into renting office space.

I think Medicare is totally worth it. And you will never have to deal with high deductible plans, so the payout will be consistent. Legal consequences can be high, but knock on wood, they've never reached out to me once after 6 years of being an attending. If you're billing an absurd number of visits that sounds impossible (e.g. 500 visits a week), yes, that's a great way to get their attention.

-Is it worth it to hire a credentialing company to negotiate and credential with insurance for me? If I can get rates superior to Medicare, that would obviate any need for Alma.

I got f_cked over bad by one. He took my $6000 and only got me paneled with 3 insurances of the promised 16. Never to be heard from again. But it was a blessing in disguise because it's pretty straightforward to submit the application yourself. Just have a good method of checking their status in bulk. I credential and contract new providers here myself, every two weeks, go down the list of insurances on the spread sheet with current status and reach out to them in bulk. Saves a ton of money too.

 

[clozareal]

-Is it worth it to hire a credentialing company to negotiate and credential with insurance for me? If I can get rates superior to Medicare, that would obviate any need for Alma.

It might be. The benefit of this would be to understand the local insurance markets in your area but you can do that yourself without needing to pay someone to do that for you.

-for advertising, PCP's have had a much higher response rate than therapists. Maybe I need to switch my marketing/networking focus there instead.

Therapists have maybe 20-30 weekly patients each so not going to be a great source of referrals. I would focus more of your attention on PCPs. Not sure if you reached out to local inpatient psychiatric units or IOP/PHP programs but their social workers are often looking for psychiatrists for their patients needing to be discharged. Reaching out to other private practice psychiatrists who are full in the area would also be good too. Have you contacted your fellowship program's psychiatry clinic intake office so they can give patients seeking services your name if they don't want to be on the waitlist (if there is one)?

-Medicare...is it worth it? My main concern with Medicare is if I do something wrong by mistake, there can be serious legal repercussions. The rates are great tbh, close to my cash rate. I think Medicare is requiring in-person visits at least once now though so I'd need to look into renting office space.

If you're struggling with patients, this could be a good route to take later on. It does depend on your locality.

It may be worth it to have a private practice consultant look at your website, your psychology today profile, etc to make sure that the wording and layout are optimized for patients to contact you. It seems like this is the biggest issue that you're having right now is marketing. See @ElanaMD's post on this above.

 

[brazilianpsych]

Another pearl on insurance. The smaller, newer, more locally based ones in my experience tend to be better to work with. They seem more vested in the well being of their community and you often have more negotiating power. And frankly, I like supporting the little guys if they're trying to do good. The insurance in my experience which can have the most hoops to jump through to get paid are the Optum products/family. Especially the one called "United Behavioral Health." Their cousins like UMR, All Savers, Golden Rule, Oxford etc. have hoops too but not as many as United Behavioral Health. United Behavioral Health has also requested the most records be sent for their reviews which can impact reimbursement decisions. Technically all insurances can do this, but I've seen the most coming from....you know....dun dun dun....
Unfortunately Optum is one of THE most common insurances carried throughout the country, which is why they are able to hold firmer ground on their reimbursement rates and policies. Providers are afraid to be more assertive because so many of their patients are on that insurance. More reason to help the little guy insurances!

good ideas. Those are high yield moves although no matter how much time I personally spent trying to figure it out, it's soooo complicated to ever personally get good at it unless you do it as your career. And the google algorithm changes quite regularly, so unfortunately it's not a one and done thing. It's a tough spot, because it's so expensive to pull off. But agree with wolfvgang, once the finances are favorable enough, SEO is a must. It opens a flood gate of referrals and you can be more picky about your pricing, insurances, patient selectivity, hours you wanna work, etc. because the demand shoots through the roof.


As a solo provider, it's not uncommon for insurances to try to f_ck you over with low rates, especially these big names. When I started I got paneled with everything and tried to negotiate right off the bat after they sent their first offer. Even if it was a low offer, I took it most times. Then after getting more patients, asked for a higher rate, using the argument of "well well well, where else are they gonna go?" One insurance I took low rates, then tried to negotiate a year later, they said no, so I threatened to drop them (and meant it) and they raised it.

Aetna never responds, you have to hound them, keep reference and ticket numbers and you will get in. Same thing with Humana. With getting paneled on many of these insurances, unless you follow up with them every two weeks, you will likely get radio silence forever.
@Atreides another funny point, when you are fully paneled, insurance does a terrible job of notifying you if at all. Many times I look on their website and your name magically appears there lol.

Many insurances will give you radio silence (especially if it has to do with getting paneled or negotiating rates). Just keep calling, emailing, faxing, even write a letter with quill pen and mail it, anyway you can get a hold of anyone. What you are describing is very typical. Unless they firmly say no negotiating, negotiating is still possible.

Starting off as a small practice, with a small patient census, a solo provider does not hold much swag. But once the panel grows, so does your influence and the need for your continued high quality medical care and that's what you use to negotiate, if that makes sense.

And if the insurances that automatically pay good deny you, reapply, reapply, reapply. Get letters from colleagues who are paneled to recommend you. I've had a couple where I applied three years in a row and on the 4th try, got in.

I won't lie, Optum has been a big factor that accelerated the growth of my practice. But as it grows, so does the amount they pay you. I think large insurance companies will be more likely to audit/review records, so keep that in mind as you get bigger. Running your place is very much like some sort of chess game.

It's truly a test of endurance and the mind.

Just wanted to say that I really appreciate your posts. Great stuff!!

On a side note, beginner question for everyone:

Why everyone is concerned about medicare? Are the codes different? Why is the risk of getting sued bigger?

 

[calvnandhobbs68]

Just wanted to say that I really appreciate your posts. Great stuff!!

On a side note, beginner question for everyone:

Why everyone is concerned about medicare? Are the codes different? Why is the risk of getting sued bigger?

So Medicare has a lot of regulations you have to abide by and know because if you violate them you’re now getting in trouble with a federal agency. Codes are also different, they also have strict prior auth/approval criteria for things like meds and labs (although very consistent unlike private insurance and much more transparent).

With private insurance, you’re never going to actually be charged with a crime unless you commit blatant insurance fraud. Not so with Medicare/Medicaid. Getting in trouble with CMS also restricts you from any other position that accepts CMS funding which is a lot of employed positions.

 

[kirkirkir]

Any info about having a DEA license in a different state? I have been looking into maybe virtual offices but not sure how legit the mailing address has to be.

 

[alina_s]

Malpractice

• The Doctor's Company no longer insures 100% telepsychiatry. They actually don't insure practices which do more than 10% telepsychiatry which I find surprising. Telepsychiatry is here to stay and I can't imagine any practice being sustainable in the future if they don't at least offer telepsychiatry for low-risk, routine follow ups. Contacted a few other malpractice companies but really leaning towards PRMS since they're the only ones who actually are giving me a quote without much hassle. Had one place that asked me to fill out a form online, then I got an email asking, "So do you want a quote or just have questions?" Uhhh, I literally clicked the "Get a quote" button on your website pal. Anyway, I responded to them that I wanted a quote and they responded back, "Ok, well, we can't give you a quote until we have more information. Please tell us xyz." If they're already so disorganized that they can't even give a proper quote, not sure I want to trust them with malpractice coverage. PRMS is coming out to about $1000/year for part-time telepsychiatry. Not bad at all I think (but my only point of reference is TDC)

I’ve been happy with the AACAP-endorsed American Professional Agency, and had an experience similar to yours with PRMS. I worked for big box hospital corp. for a few years and they made me switch to PRMS. When I was leaving and needed to discuss my policy, PRMS couldn’t find any info on me 😯. They eventually did and I was insured for those years but in retrospect, I really should’ve just paid for my own policy and kept APA. My only complaint about APA is that they’re on eastern time, and I’m 4 hours behind. As long as I remember to call early, it’s always easy to get through and to the right person.

 

[Sushirolls]

Any info about having a DEA license in a different state? I have been looking into maybe virtual offices but not sure how legit the mailing address has to be.

DEA is sending out emails again exactly about this.

You need a physical office in the state in order to prescribe controlled substances to patients in that state. They need and want and demand that you have an actual office they can knock on your door. They are aware of UPS boxes etc and will hone in on those.

If you have multiple licenses, and intend to prescribe for patients routinely in other state that aren't simply on the border, you will need a separate DEA number for that state, too, and the office in that state.

I am currently closing my office in one state, moving to another state. I have cut loose all my controlled substance patients in state of origin. And will transfer my DEA number to the next state, so I won't need more than one. I will keep my license in both states, so i can continue to do telemedicine for patients in state of origin. But I will only do controlled substances for my patients in new state, or for patients of neighbor state who trully drive over to see me in new state.

 

[kirkirkir]

DEA is sending out emails again exactly about this.

You need a physical office in the state in order to prescribe controlled substances to patients in that state. They need and want and demand that you have an actual office they can knock on your door. They are aware of UPS boxes etc and will hone in on those.

If you have multiple licenses, and intend to prescribe for patients routinely in other state that aren't simply on the border, you will need a separate DEA number for that state, too, and the office in that state.

I am currently closing my office in one state, moving to another state. I have cut loose all my controlled substance patients in state of origin. And will transfer my DEA number to the next state, so I won't need more than one. I will keep my license in both states, so i can continue to do telemedicine for patients in state of origin. But I will only do controlled substances for my patients in new state, or for patients of neighbor state who trully drive over to see me in new state.

wow. I wonder then about a shared office situation where i rent the office a few days per month...do you think that'll work?

 

[Atreides]

Update #3
Income: $17,539.90 (About $5,000 of that is the last 4 weeks)
Expenses: $4,714.55

Net profit: 12,825.35

TL;DR: Got a physical location, continuing to use Alma. Very happy with growth.

10 month update

Logistics/equipment

Charm continues to amaze me with their terrible customer service. But can’t argue with the price haha. Current add-ons are telehealth, EPCS, and PDMP. The embedded PDMP add on is more of a convenience thing but I’ve always hated manually entering things into PDMP databases to look up patient reports. Very pleased with telehealth add-on. I’ve dropped my state medical license from residency so now it’s just my current state medical license.

Insurance Credentialing

I’ve been pretty happy with Alma but don’t think it’s a viable long term solution. When they inevitably go out of business (I feel all mental health startups eventually do), I don’t want to be in a situation where I’m scrambling to contract with insurance companies. Here are the updates from last time

Aetna: Have been the most difficult insurance to work with. They’re the highest paying through Alma so I went in with high hopes. I’m coming on more than 6 months since my initial application. I ended up having to tweet their social media team who finally got someone to respond to my application……who then ignored my emails. I had to go back through social media people to get a new person to deal with. My negotiations have not been successful, they countered with a 10% increase to my request of 50% (I was hoping to settle at a 20-30% increase). The person responding had the audacity to say they had a responsibility to their shareholders to not pay me too much. At this point, I don’t intend on signing with them if they don’t go to an increase of 50% (20-30% no longer enough). Alma’s Aetna rates are solid so I have nothing to gain by signing with them directly at lower rates. Of note, I am not listed on Aetna’s insurance directory. It seems they don’t list people who are contracted through Alma.


Cigna: This is my most common insurance. I’m listed on their insurance directory and people have been getting me through that.


Anthem: Successful negotiations! Not sure if I can disclose the rates even anonymously but it’s on par with the cash rate I started off with. Officially in-network as of this week but ironically, I’m probably close to filling my practice for the 5-6 hours a week I currently have to spend on it.


Advertising

Psychology Today

I've maintained my PsychologyToday profile but this hasn’t been very useful. It has picked up over the last two months but I’m talking maybe 1-2 patients a month that I’ve gotten. The monthly fee is $30 so not too bad but the ROI isn’t as great as I would have thought. It’s not even a low conversion of calls to patients, I just don’t get calls from PsychologyToday in the first place. I’m still on the fence about dropping it. If you google my name, it pops up, so useful to have. But definitely not generating meaningful patient referrals.


Therapists

Gave up on this. I did do zoom meetings with a handful of therapists but none led to mutual patient referrals. One asked if I could see one of her family members, which I did, but no referrals from her client base.

Facebook
Joined some mental health professional groups in various metros. This has gotten me some referrals. People will post “Looking for a psychiatrist who takes X insurance for Y issue.” I’ll link to my website with an offer to chat.

PCP
No referrals from the PCP’s I mentioned earlier. I haven’t tried to reach out to any more.

Word of Mouth
My program director has referred a few patients to me when there’s been a waitlist at our academic center. I’ve also had some patients refer others they know.

Location


So turns out if you’re doing solely telehealth, your location is kind of floating in the air on insurance directories. So people who look for psychiatrists in their area won’t find you. That’s obviously a major problem and likely why I wasn’t getting patients even after taking insurance. I ended up getting a physical location. Cost is $300/month for one day a week, subleasing an office in a therapist’s suite. I’m now showing up on Cigna and Anthem’s directory. Not showing up on Aetna (contracted through Alma). I’m not sure about United but I think I show up since I’ve gotten a good number of United patients. I think this has been the best ROI. With the new DEA regulations, I probably needed to get office space anyway
----

Overall, things are going much better, speed has picked up significantly. My fellowship is supposed to increase in intensity this year so don’t want to overextend myself. I’m aiming for 5-7 hours a week and am almost hitting that as of this month.

Future plans are to contract directly with insurance at good rates. Eventually would like to hire therapists as I’m referring out and the quality of therapy is….variable. I see a good amount of PTSD and would love to have someone trained in CPT rather than the EMDR craze that’s in my area.

 

[Merovinge]

DEA is sending out emails again exactly about this.

You need a physical office in the state in order to prescribe controlled substances to patients in that state. They need and want and demand that you have an actual office they can knock on your door. They are aware of UPS boxes etc and will hone in on those.

If you have multiple licenses, and intend to prescribe for patients routinely in other state that aren't simply on the border, you will need a separate DEA number for that state, too, and the office in that state.

I am currently closing my office in one state, moving to another state. I have cut loose all my controlled substance patients in state of origin. And will transfer my DEA number to the next state, so I won't need more than one. I will keep my license in both states, so i can continue to do telemedicine for patients in state of origin. But I will only do controlled substances for my patients in new state, or for patients of neighbor state who trully drive over to see me in new state.

Do you any more about how the border stuff works? I work 45 min from a state boarder and was surprised when the neighboring state filled by controlled substance (certainly not licensed there). We do not get a lot of out-of-state patients and I do PHP/IOP work so it was only for a few months. Not sure if this is how it's supposed to work or what the laws around this are.

 

[Merovinge]

rather than the EMDR craze that’s in my area.

What's the deal with this lately? When I was in training EMDR was just a funny light people setup when doing TF-CBT. Anything else was just pseudoscience. Did something change in the literature to support this in the past decade?

 

[Sushirolls]

Do you any more about how the border stuff works? I work 45 min from a state boarder and was surprised when the neighboring state filled by controlled substance (certainly not licensed there). We do not get a lot of out-of-state patients and I do PHP/IOP work so it was only for a few months. Not sure if this is how it's supposed to work or what the laws around this are.

I used to, but I forgot. I'm too lazy to dig into DEA website postings to give you a real answer with real facts.

I've prescribed for people on vacation, which really is a rare occurrence. I'm not worried about these.

For people living/commuting/traveling across a border to see me. I feel that as long as these border patients are less than 5% of my outpatient panel, I'm not going to bother getting a DEA and license just for that state. I feel the real importance is that I see these patients in my state, and after that it's up to the pharmacy and insurance company if they want to fill the Rx in their state. If the pharmacy, and less so insurance company makes an issue, then I'd tell the patient to fill in my state at a nearby pharmacy.

wow. I wonder then about a shared office situation where i rent the office a few days per month...do you think that'll work?

Should work as far as I can tell.

 

[Candidate2017]

Do you any more about how the border stuff works? I work 45 min from a state boarder and was surprised when the neighboring state filled by controlled substance (certainly not licensed there). We do not get a lot of out-of-state patients and I do PHP/IOP work so it was only for a few months. Not sure if this is how it's supposed to work or what the laws around this are.

I may be wrong, but my impression is: Your in-state CS license allows you write CS scripts for patients you see in-state; the script can be sent or taken out-state, but the out-state pharmacist is licensed by their state to dispense, and it's always in their professional discretion to dispense. It's like sending a script to Amazon or other out-state mail order pharmacy.

In the past, I've sent scripts to an in-state big box pharmacy and tell the patient can pick it up on the way home, or they can call and request the pharmacist transfer it out-state.

 

[Merovinge]

I may be wrong, but my impression is: Your in-state CS license allows you write CS scripts for patients you see in-state; the script can be sent or taken out-state, but the out-state pharmacist is licensed by their state to dispense, and it's always in their professional discretion to dispense. It's like sending a script to Amazon or other out-state mail order pharmacy.

In the past, I've sent scripts to an in-state big box pharmacy and tell the patient can pick it up on the way home, or they can call and request the pharmacist transfer it out-state.

Thanks, that was my impression, Sushi seems to have similar thoughts above. Services were all rendered in the state I am licensed so I was not too worried, but I was directly sending the script to the neighboring state.

 

[hallowmann]

wow. I wonder then about a shared office situation where i rent the office a few days per month...do you think that'll work?

My understanding is things that rotate like WeWork are generally not allowed, but if it's a contracted lease for a certain amount of hours a week at one office/location, it's OK.

 

[Nitya2]

Hi Atreides,

I came across this post and wanted to add my 2 cents. FYI I’m an integrative psychiatrist in private practice in Los Angeles. Harvard undergrad, USC med school, UCLA residency. I also have self-taught myself a lot about business.

First of all, don’t be discouraged that you don’t have patients yet. To have a private practice is essentially to be an entrepreneur, and to be a successful entrepreneur you have to have an iron will and not get discouraged prematurely. Most psychiatrists (and physicians in general) suck at business -- so you only need to be average to be successful. If you are above average, you can be very successful and also feel very rewarded by the amount of impact you have with patients.

Setting Fees:

The first advice I want to give you is to reverse your thinking about how you’re setting your fees. Your thought process is “set high fees and lower them if I can’t get patients,” but instead it should be “set moderate to high fees and if I don’t get enough patients, increase my value.” People do not pay cash for a psychiatrist when they can get the same service covered by insurance -- they pay cash when either an insurance-based psychiatrist isn’t available OR when they want a level of service they can’t get elsewhere. You want to be in the latter category.

I have been surprised to discover there really is no fee that patients won’t pay, as long as you provide enough value (AND clearly communicate that value on your online assets, such as your website, but can also be youtube videos, social media, etc). When I started I charged $375 for an intake… now I charge up to $1500. And my practice is full and I have a waiting list.

Mentally, it’s easier to start with lower or moderate fees and then increase them as you become more confident in your ability to provide value. If you start with fees that are too high, you may give up too soon. But I promise you that the limiting factor is not your fees, but the patient’s perceived value of what you do (and their ability to find you).

Distractions:

Next… anything about needing the perfect website, needing to incorporate, talking to an accountant, to a lawyer, needing the perfect office policies, or any of this ridiculous back and forth about whether you’d be violating Canva’s TOC is a distraction. The ONLY important thing is that you GET PATIENTS IN THE DOOR (metaphorical door if you’re doing video only).

As physicians we can get obsessed with dotting our i’s and crossing out t’s because it feels easier and “productive,” but really what you need to do is put yourself out there and do the uncomfortable task of marketing yourself so patients can find you. You can figure all of that other stuff AFTER you’ve had your first patient.

When I got my first patient (back in the day when we did things in person) I didn’t have office furniture, a billing system, or an EHR. I figured all of that stuff after the fact. Yes, it feels more stressful (and slightly chaotic) to do it this way, but you waste WAY less time and you make progress faster. Focus on figuring out things “just in time” rather than “just in case.”

Marketing & Your Unique Selling Proposition:

Now I want to cover another topic that hasn’t been mentioned in other comments… your Unique Selling Proposition, or USP. This is a general business term. Essentially, why should a patient see you are opposed to any other psychiatrist? If you are not clear on what makes you and your practice unique, and you don’t communicate that clearly in your online assets or conversations with patients, then you are a (highly-trained) commodity.

If there is nothing that differentiates you then you will be getting the most annoying kinds of patients -- those that are shopping based on cost, lack of boundaries, willingness to prescribe controlled substances, etc. The patients you want are the ones who are shopping based on value… how much you can help them, and how positive you make the treatment process and relationship.

Getting Patients:

The fastest way to get patients, like others have already said, is Psychology Today. Make a profile that’s better than your competition. Have a clear photo that’s professional, and communicate your USP and the benefits of working with you as well as your “features,” i.e. specific treatment modalities. Don’t use medical jargon -- use the language that your patients speak.

I don’t recommend Google ads right out of the gate. Yes, you can definitely get patients and build a practice with Google ads, but it has a learning curve, and people give up to soon. To start Google ads you have to be mentally prepared to lose $500-1000 on learning before you make a positive ROI (return on investment).

The first phone conversation you have with a potential new patient is essentially a sales conversation where you are communicating your value (it’s not just about screening out bad patients). These conversations are very valuable in the beginning for learning, even if all of those patients you speak to don’t end up scheduling. Later on when you’re busier, you want to be more aggressive about screening out those who won’t schedule. Now I make it very hard for patients to schedule with me (they have to click on a couple links, check boxes that they’ve read my fees, fill out an online form, etc), but that’s because my practice is full and I don’t have time for a lot of non-clinical phone calls.

The conversation about how to have value is a longer one, but essentially you need to:

1. Sell the patients what they want so you can give them what they need
2. Value the relationship above all else… good treatment comes from a good relationship
3. Provide a level of service and care beyond what others can provide (I’m not talking about appeasing or catering to unreasonable patients, that’s something else)

To answer some of your other questions:

EHR: Luminello. I don’t know about Charm, but a couple of dollars extra is worth spending if it will save you time and reduce your headache.

Telepsych platform: Doxy free - I’m 4+ years into my practice and I still use Doxy free, and just pay for a $10 day pass on the days that I need it.

Website: Wordpress absolutely is the best, but it has a learning curve. Maybe in 6 months to a year you can upgrade, but Wix is fine for now.

Logo: who cares, I didn’t have a logo until I was 4 years into my practice. Patients don’t care about your logo or website design, they care about your website copy/content (ie the words).

Insurance: Absolutely not, it will not be worth the admin to accept insurance for such a small practice.

Email: gmail is fine for short term but ultimately you want to use Google Apps for business (maybe $5/month to have a domain-branded email).

Corp: Not needed. Be grossing at least $10k/month before you start a corp. Benefits are for taxes only, not liability.

Billing: Credit card only. Multiple good options for merchant account, I use quickbooks (for merchant and creating invoices, not for accounting).

Intake Forms: IntakeQ. They do billing too. Yes, Luminello does intake forms but in private practice, time = money and intakeQ is much more seamless. I use this for scheduling and email reminders as well. They also do billing via Stripe. Don't be penny wise but pound foolish by trying to save a few dollars here and there on your software solutions, because the right solutions will save you a TON of time.

I hope this was helpful and good luck!

Elana

Thanks Elana! What malpractice insurances are comfortable covering the alternative/ integrative medicine? They tend to ask, whether you practice alternative medicine in their application forms. They may deny, if you say yes, but then you truly become a commodity.

 

[Atreides]

Update #4
Income: $54,882.62
Expenses: $9,026.12

Net profit: $45,856.50


TL;DR: Loving private practice. Thinking about the end of the academic year.


Logistics/equipment

Continuing to use Charm. I still haven’t gotten a complete grasp of the billing and insurance aspect of it. I’m getting checks in the mail and manually following up on patient responsibility. I should probably switch to EFT but for some reason, the EOB’s aren’t syncing with charm. I need to sit down one day and figure this out but for now, my make-shift method is working. Definitely not sustainable as the practice grows.

I’ve been looking into getting Epic via Community Connect. I’m actually surprised how hard it is to get information about it. I’d love to have Epic in private practice but they don’t make it easy to find out how. I contacted an IPA that offers it for free to members but no psychiatrists allowed in this IPA (they have a mental health carve out for their managed care plans).

I’ve been thinking it might be time to upgrade my computer setup. I’ve been using a Macbook Pro connected to an external monitor + Logitech camera. Every time I think about it though, I decide it’s not really worth it. My setup works fine and there’s no rational reason to get an upgraded setup other than the fact that I like new computers haha

Malpractice

Switched to MagMutual. Free UpToDate access is nice but redundant while I’m still in fellowship.

Insurance

I’m showing up on Cigna’s directory. Not showing up on Anthem’s anymore, no idea why. Not showing up on Aetna’s even though my contract says I’m officially in network starting a month ago. I need to call and follow up on these because Aetna and Anthem are my higher payers. Also a wrinkle, my clearinghouse through charm doesn’t support Aetna so I need to switch to their other clearinghouse. I’ve been putting this off as I’m still holding out hope that Epic will be a possibility. Going to need to bite the bullet soon though.

I’m still paying for Alma since I’m billing Aetna and Optum through it. Once I’ve got the kinks ironed out with Aetna though, I’ll be ending my Alma membership. Optum is the only insurance I’m not independently credentialed with and I haven’t been able to negotiate rates with them (granted, I didn’t try too hard). I’m guessing maybe 5% or less will stay on as private pay patients but that’s not too big of a problem now that I’ve got a steady stream of new patients coming my way.

Advertising

Psychology Today

I’ve had a few patients who’ve found me through Psychology Today so I’ll keep paying for it. I need to revamp my profile though. Add that to the growing list of administrative tasks.

Therapists

Mostly gave up on this and don’t really need it for advertising at this point. I did meet virtually with a therapist I connected with on LinkedIn today. I had a patient with a specific cultural background that I was looking for a good match for and had reached out to her. Months later, got a response. Patient had moved out of state by that point but figured it's good to keep connections with therapists. Not something I’m really focusing on right now. Hoping to eventually get to the point where I can hire my own therapists.

Facebook
Still part of the mental health professional groups in various metros but no longer using it to find patients. Balls in my court now, I use it to find therapists for patients who have specific needs.

PCP
No referrals from PCP’s. I haven’t tried to reach out to any more. Interestingly, I’ve gotten a few referrals from other psychiatrists when their patients’ insurance has changed (seems like Cigna isn’t a popular insurance in my area).

Word of Mouth
Gotten a few referrals from my old PD and another attending from last year. I’ve also had some patients refer colleagues that they work with to me.

Location

I have an office but doing almost 100% telehealth. I think I’ve seen one patient in person so far. This Thursday will be my first day seeing multiple patients in-person. Gotta see all my ADHD patients in-person by May. Not a problem for the majority but I have a handful in another metro area that I’m going to need to figure out what to do with. I’m thinking flying down there sometime in April or early May and seeing them all so satisfy the in-person requirement.

Life/future

So, for family reasons, I’m going to have to move across the country after my fellowship is over. I’m planning on keeping my practice here and flying back occasionally for any in-person appointments I may have. This may be tricky with new ADHD intakes but we’ll see how it goes.

As my fellowship comes to an end, also thinking about whether I want to scale the practice up to full time or try and do a 50/50 private practice academia split. I’ve reached out to a few institutions on the east coast and seems like it may be doable. But tbh, after having tasted the autonomy of private practice, academia is seeming less and less appealing. Maybe Adjunct Clinical Faculty will be enough?

 

[Jules A]

Update #4
Income: $54,882.62
Expenses: $9,026.12

Net profit: $45,856.50


TL;DR: Loving private practice. Thinking about the end of the academic year.


Logistics/equipment

Continuing to use Charm. I still haven’t gotten a complete grasp of the billing and insurance aspect of it. I’m getting checks in the mail and manually following up on patient responsibility. I should probably switch to EFT but for some reason, the EOB’s aren’t syncing with charm. I need to sit down one day and figure this out but for now, my make-shift method is working. Definitely not sustainable as the practice grows.

I’ve been looking into getting Epic via Community Connect. I’m actually surprised how hard it is to get information about it. I’d love to have Epic in private practice but they don’t make it easy to find out how. I contacted an IPA that offers it for free to members but no psychiatrists allowed in this IPA (they have a mental health carve out for their managed care plans).

I’ve been thinking it might be time to upgrade my computer setup. I’ve been using a Macbook Pro connected to an external monitor + Logitech camera. Every time I think about it though, I decide it’s not really worth it. My setup works fine and there’s no rational reason to get an upgraded setup other than the fact that I like new computers haha

Malpractice

Switched to MagMutual. Free UpToDate access is nice but redundant while I’m still in fellowship.

Insurance

I’m showing up on Cigna’s directory. Not showing up on Anthem’s anymore, no idea why. Not showing up on Aetna’s even though my contract says I’m officially in network starting a month ago. I need to call and follow up on these because Aetna and Anthem are my higher payers. Also a wrinkle, my clearinghouse through charm doesn’t support Aetna so I need to switch to their other clearinghouse. I’ve been putting this off as I’m still holding out hope that Epic will be a possibility. Going to need to bite the bullet soon though.

I’m still paying for Alma since I’m billing Aetna and Optum through it. Once I’ve got the kinks ironed out with Aetna though, I’ll be ending my Alma membership. Optum is the only insurance I’m not independently credentialed with and I haven’t been able to negotiate rates with them (granted, I didn’t try too hard). I’m guessing maybe 5% or less will stay on as private pay patients but that’s not too big of a problem now that I’ve got a steady stream of new patients coming my way.

Advertising

Psychology Today

I’ve had a few patients who’ve found me through Psychology Today so I’ll keep paying for it. I need to revamp my profile though. Add that to the growing list of administrative tasks.

Therapists

Mostly gave up on this and don’t really need it for advertising at this point. I did meet virtually with a therapist I connected with on LinkedIn today. I had a patient with a specific cultural background that I was looking for a good match for and had reached out to her. Months later, got a response. Patient had moved out of state by that point but figured it's good to keep connections with therapists. Not something I’m really focusing on right now. Hoping to eventually get to the point where I can hire my own therapists.

Facebook
Still part of the mental health professional groups in various metros but no longer using it to find patients. Balls in my court now, I use it to find therapists for patients who have specific needs.

PCP
No referrals from PCP’s. I haven’t tried to reach out to any more. Interestingly, I’ve gotten a few referrals from other psychiatrists when their patients’ insurance has changed (seems like Cigna isn’t a popular insurance in my area).

Word of Mouth
Gotten a few referrals from my old PD and another attending from last year. I’ve also had some patients refer colleagues that they work with to me.

Location

I have an office but doing almost 100% telehealth. I think I’ve seen one patient in person so far. This Thursday will be my first day seeing multiple patients in-person. Gotta see all my ADHD patients in-person by May. Not a problem for the majority but I have a handful in another metro area that I’m going to need to figure out what to do with. I’m thinking flying down there sometime in April or early May and seeing them all so satisfy the in-person requirement.

Life/future

So, for family reasons, I’m going to have to move across the country after my fellowship is over. I’m planning on keeping my practice here and flying back occasionally for any in-person appointments I may have. This may be tricky with new ADHD intakes but we’ll see how it goes.

As my fellowship comes to an end, also thinking about whether I want to scale the practice up to full time or try and do a 50/50 private practice academia split. I’ve reached out to a few institutions on the east coast and seems like it may be doable. But tbh, after having tasted the autonomy of private practice, academia is seeming less and less appealing. Maybe Adjunct Clinical Faculty will be enough?

Great work! Where do you plan to physically see controlled substance patients when you fly to other metro area or return after you relocate? I have heard of physicians prescribing bup out of hotel rooms which seems sketch to me.

 

[Atreides]

Great work! Where do you plan to physically see controlled substance patients when you fly to other metro area or return after you relocate? I have heard of physicians prescribing bup out of hotel rooms which seems sketch to me.

Haha, def not out of a hotel room. Ideally, I’d find another doctor or therapist whose office I could rent. Otherwise, maybe a we-work type shared office I would rent.

 

[Sushirolls]

Just drop the controlled substance patients in that locale.
You'll get more in the new locale.
It's what I did when I moved my office out of state.
Not worth the extra expenses: plane flight? hotel stay? food costs? time costs? Fatigue/wear down of air travel in general? Cost of needing an additional DEA in that state. I just renewed mine... $888. Additional cost of a lease in that state. Additional headache of 2 offices in 2 states with all your insurance companies which is a doable but a complete pain.

My vote, drop the controlled substance patients in that state.

 

[ObsequiousAplomb]

Great work! Where do you plan to physically see controlled substance patients when you fly to other metro area or return after you relocate? I have heard of physicians prescribing bup out of hotel rooms which seems sketch to me.

It's a lot less sketchy if you rent out a business / conference room (like the ones with fewer than 12 chairs at a table) in a hotel. Still would be easier and less questionable to find a doctor who will let you rent out their office for a Saturday or something like that.

 

[Atreides]

Update #5
Total Income: $92,298.33
Total Expenses: $13,055.96
2023 Income: $59,633.95
2023 Expenses: $4,732.97

Logistics/equipment

Continuing to use Charm. Had a meeting with Epic Community Connect at two hospital systems. Cost would be 50k for initial setup plus about 600-650/month/doctor. For a large group practice, that’s not a bad expense actually. However, for a solo private practice, that’s definitely not an expense that makes sense to me. So Charm it is for now.

Billing continues to be an issue. I’m still getting checks in the mail and manually following up on patient responsibility. Switched to EFT for my highest paying insurance and now I’m having trouble getting EOB’s (they don’t sync easily with Charm). At this point, I’m thinking it’ll be worth it to just hire a biller even if it is a hefty 6-8% that they take. An 8% cut of my insurance rate would put me below my cash rate though. Definitely a downside of taking insurance.

Computer setup stays the same. Logitech camera conked out randomly. To be fair, I’ve been using it almost 5 days a week, every week, since Covid started. Went to buy a new webcam but the prices are ridiculous and then I started wondering if I really need on. Decided to try the new iPhone as webcam feature and I’m converted. Paid for a $25 magnetic camera mount for my phone and now I just use my iPhone as my camera. Much, much better quality than any webcam you can buy.

Malpractice

Continuing with MagMutual but need to increase this to full time as I graduate fellowship.


Insurance

Switched Clearinghouse to Change from Optum. I’ve gotten a few Medicare patients but the billing isn’t working properly for some reason. Need to get it figured out. Don’t want to turn down referrals so I’ve been seeing them but haven’t gotten paid for a single one yet.


I’m still paying for Alma since I’m billing Optum through it. Their rates increased recently so it’s actually only slightly below the rest now (pretty close if you take out the 8% I might end up paying billing company). So I might end up staying with them for Optum.


Patient Population

I’ve been enjoying the patient population I’ve been seeing. However, I’ve been getting lots of referrals for a specific disorder that I have diminishing interest in. A large part of my fellowship was focused on that disorder and there aren’t too many psychiatrists with the training to treat it so I’ve been seeing those patients. However, it’s draining and I feel it’s beginning to burn me out. I can see 18 follow up patients back to back in a 9 hour day and feel just as fresh as I started. But 2 patients with this disorder in the same day and I feel like I’m ready to leave psychiatry altogether.

I’m wondering if I should just close my clinic to that disorder and say I don’t treat it? I can’t see myself sustaining a private practice if that makes up even 5% of my patient population.

Advertising

Psychology Today

Significant increase patients who’ve found me through Psychology Today so I’ll keep paying for it..

Therapists

I get a steady trickle but really it’s me referring out to therapists rather than vice versa at this point.

PCP
No referrals from PCP’s. As I expand, need to start working on connecting with PCP’s.

Word of Mouth
Getting patients referring other patients so that’s nice.

Location

Ryan Haigh exceptions extended until November but I’m seeing patients in person who have ADHD as it comes up. I'll be moving so that adds a whole new wrinkle. I think I'll keep this office though and just close to new ADHD patients.

Life/future

Went back and forth on next steps. Would have loved to do a 50/50 academic/private split at my current institution but that did not work out. Institution would not allow me to do remote from another state. I know for a fact that they do allow this so seems a bit personal. Anyway, interviewed at a few other places, found one that would let me be closer to family and also continue the private practice. Benefits kick in at 0.5 FTE so that’s perfect. I don’t know if I’ll keep the 50/50 split indefinitely or go over to private practice full time at some point but I know for sure I’ll never be full time academia.

 

[psychemdoc]

Update #5
Total Income: $92,298.33
Total Expenses: $13,055.96
2023 Income: $59,633.95
2023 Expenses: $4,732.97

Logistics/equipment

Continuing to use Charm. Had a meeting with Epic Community Connect at two hospital systems. Cost would be 50k for initial setup plus about 600-650/month/doctor. For a large group practice, that’s not a bad expense actually. However, for a solo private practice, that’s definitely not an expense that makes sense to me. So Charm it is for now.

Billing continues to be an issue. I’m still getting checks in the mail and manually following up on patient responsibility. Switched to EFT for my highest paying insurance and now I’m having trouble getting EOB’s (they don’t sync easily with Charm). At this point, I’m thinking it’ll be worth it to just hire a biller even if it is a hefty 6-8% that they take. An 8% cut of my insurance rate would put me below my cash rate though. Definitely a downside of taking insurance.

Computer setup stays the same. Logitech camera conked out randomly. To be fair, I’ve been using it almost 5 days a week, every week, since Covid started. Went to buy a new webcam but the prices are ridiculous and then I started wondering if I really need on. Decided to try the new iPhone as webcam feature and I’m converted. Paid for a $25 magnetic camera mount for my phone and now I just use my iPhone as my camera. Much, much better quality than any webcam you can buy.

Malpractice

Continuing with MagMutual but need to increase this to full time as I graduate fellowship.


Insurance

Switched Clearinghouse to Change from Optum. I’ve gotten a few Medicare patients but the billing isn’t working properly for some reason. Need to get it figured out. Don’t want to turn down referrals so I’ve been seeing them but haven’t gotten paid for a single one yet.


I’m still paying for Alma since I’m billing Optum through it. Their rates increased recently so it’s actually only slightly below the rest now (pretty close if you take out the 8% I might end up paying billing company). So I might end up staying with them for Optum.


Patient Population

I’ve been enjoying the patient population I’ve been seeing. However, I’ve been getting lots of referrals for a specific disorder that I have diminishing interest in. A large part of my fellowship was focused on that disorder and there aren’t too many psychiatrists with the training to treat it so I’ve been seeing those patients. However, it’s draining and I feel it’s beginning to burn me out. I can see 18 follow up patients back to back in a 9 hour day and feel just as fresh as I started. But 2 patients with this disorder in the same day and I feel like I’m ready to leave psychiatry altogether.

I’m wondering if I should just close my clinic to that disorder and say I don’t treat it? I can’t see myself sustaining a private practice if that makes up even 5% of my patient population.

Advertising

Psychology Today

Significant increase patients who’ve found me through Psychology Today so I’ll keep paying for it..

Therapists

I get a steady trickle but really it’s me referring out to therapists rather than vice versa at this point.

PCP
No referrals from PCP’s. As I expand, need to start working on connecting with PCP’s.

Word of Mouth
Getting patients referring other patients so that’s nice.

Location

Ryan Haigh exceptions extended until November but I’m seeing patients in person who have ADHD as it comes up. I'll be moving so that adds a whole new wrinkle. I think I'll keep this office though and just close to new ADHD patients.

Life/future

Went back and forth on next steps. Would have loved to do a 50/50 academic/private split at my current institution but that did not work out. Institution would not allow me to do remote from another state. I know for a fact that they do allow this so seems a bit personal. Anyway, interviewed at a few other places, found one that would let me be closer to family and also continue the private practice. Benefits kick in at 0.5 FTE so that’s perfect. I don’t know if I’ll keep the 50/50 split indefinitely or go over to private practice full time at some point but I know for sure I’ll never be full time academia.

Thanks for the update! I’m assuming if billing is taking that much time from you then seems like a biller is necessary for you growth or you just do cash only and pay upfront but that’s not where you want to go with accepting insurance so I understand. Keep us posted posted. We’re rooting for you!

 

[Sushirolls]

luminello has better integration that Charm, from my experience of discussing with my former sleep medicine sublease doc who used Charm.

Time is flying, your original post until now. I thought you started like 3 months ago. Wow. Congrats on the progress!

2023 looks like 7.8% overhead? WOW. Just wow. So low.

Project out for rest of year, ~109K Net Income for ~7 hours of clinical work, that's phenomenal - if my math is right?

 

[Atreides]

@psychemdoc : Yes, biller does seem increasingly necessary for growth. Well, that or I need to figure out if I can optimize my billing workflow.

@Sushirolls : Haha, yes, time goes quickly! Overhead thankfully is kept minimal due to only needing office space 1 day a week and not having any staff. But also makes the idea of paying a billing company harder to stomach. I might well end up doubling my overhead by paying for billing.

The math is close, but I've probably averaged closer to 10 hours of clinical work a week. I started booking patients for a day and a half some weeks.

 

[Celexa]

Whichever the disorder is that you don't want to treat--if you were cash only, I would say determine if there is an amount of money or schedule changes that would make treating it not hateful to you (ie, pts have to book a double follow up? Higher rates? Do they have more frequent out of visit work that needs to be directly billed for?) but I don't know enough about insurance based practice to know if that would be as easily implemented.

 

[Psychresy]

What are y'all using for credit card processing?

 

[Atreides]

Ivy Pay for now. I'll probably switch to Bluefin at some point since it's integrated into Charm but waiting for billing to get figured out before I go that route.

 

[clozareal]

Elavon

 

[romanticscience]

Primary: Stripe (integrated into EHR)
Secondary: Intuit Quickbooks (invoices for consulting work)

 

[SeniorWrangler]

Hey Atreides, and others too, what do you use for phone services? I'm trying to stand up a cash based practice and don't want to pay for a receptionist but also don't want to answer clinic phone calls all day either. I'm trying to find an alternative to letting everything go to voicemail and checking it myself frequently. Virtual receptionists are pretty expensive, too. I have been looking at an "AI virtual receptionist" but not sure people will be willing to work with a bot. I am honestly thinking of just getting a barebones VOIP system and strongly encouraging patients to do as much as possible online using the patient portal.

 

[romanticscience]

Google Voice for Business.

 

[Atreides]

Google Voice. The BAA for G Suite covers it.

My wife handles all phone calls. I've been trying to minimize phone calls but patients like calling to make appointments for some reason. I've made it very easy to schedule online through Charm's scheduling widget but nope, I'd say easily 75% of new patients prefer calling to make the intake appointment. Even when they contact me through email via Psychology Today or Alma, they want to call to make the actual appointment over the phone.

 

[Sushirolls]

Google Voice. The BAA for G Suite covers it.

My wife handles all phone calls. I've been trying to minimize phone calls but patients like calling to make appointments for some reason. I've made it very easy to schedule online through Charm's scheduling widget but nope, I'd say easily 75% of new patients prefer calling to make the intake appointment. Even when they contact me through email via Psychology Today or Alma, they want to call to make the actual appointment over the phone.

I'd concur.
I had luminello streamlined for online intake, and some tech savvy will knock it out of the park and complete all paper work and are able to schedule a future appointment in the same day.

My assistant really is the frontline customer service. She advocated offering patients a 'tentative' appointment when they call, but have the requirement they'll be canceled out 24 hours before if they haven't finished all the paperwork. A bulk of her job is really the intake flow for patients and nudging them to progress with paperwork. We used to be hardline and no appointment until all paperwork complete.

She also sniffs out lets benzo patients know, they'll be tapered off at Sushi Clinic.

Honestly, if you don't do these onboarding calls yourself, you will need a good assistant (or spouse?).

 

[texanpsychdoc]

Option 3: Take insurance.

I’ve been trying to avoid this because, well, on the reasons psychiatrists avoid insurance. But it’s beginning to look more and more like a good idea. I was thinking of paneling with one commercial insurance and seeing how it goes. Medicare reimburses pretty well in my area too so maybe one commercial (Aetna?) plus Medicare.


I’m leaning towards Option 3, especially since my long term plan is to continue to grow this practice after finishing fellowship, likely transitioning from just telepsychiatry to in-person as well. I also don’t like the feeling of turning away so many people who are looking for a psychiatrist but can’t pay a few hundred dollars for an evaluation.

I guess I’ll mull on this and post an update in 3 months with whichever option I end up going with. Any thoughts or feedback is welcome.

I work at the VA and hold a joint faculty appointment as my day job, however, I opened my private practice right when I started my full time gig with the hope that I could feel safe building it while having a steady income with benefits. My start up capital came directly from my income at my day job. I had no business line of credit (until recently actually). My practice is 100% online for therapy and testing/assessments. I first started out insisting I would be private pay only since most psychologists and psychiatrists in the greater Houston area are also private pay. Very few take insurance. I had zero patients for about 6 months. I heard all the horror stories about taking insurance which further kept me from moving forward with it. Then I finally realized, an insurance-based practice would be very feasible if I set it up in a manner that allowed me do so, meaning, I needed to keep my expenses very low, I needed to have a routine in place and policies to keep everybody/everything in line. I can tell you that since I accepted BCBS, United, and Cigna, I went from zero patients to more than I can handle, and over the course of actively seeing patients for 3 months, I have earned $12K by just seeing about 9-12 patients a week (with some cancellations in between). I have a strict no show/late cancellation policy ($125). I do a very thorough and repeated informed consent up front, especially in my 15 minute phone consultation where I am also screening out patients. I built my entire infrastructure (e.g., website, logo, basic accounting), use a good all in one EHR/video platform (SimplePractice). My practice is literally "plug and play" and I earn almost what I was charging for my private pay fee. I have had no rejections or denial of claims, and I am typically paid within 1 to 7 business days from when I submit my claims. In sum, if you have clear and transparent policies and expectations from your prospective patients, then everything else falls into place. For my 53 minute sessions, I am typing into my note throughout the session so by the time we are wrapping up (usually around the 45 minute mark), I am putting their note into the chart, I schedule their follow up session for next week, I collect their co-pay, then click 2 buttons to submit the claim to the insurance and paid pretty quickly. I do this for every patient. I don't spend tons of time on admin stuff or "catching up" on notes, chasing down claims, etc. I don't have an admin assistant as I can handle the volume I have. Hasn't failed me yet. In related news, I've hired on 3 more contract psychologists to delegate patients so, so now I am a group practice and I skim a % from their earnings as passive income.

 

[Celexa]

I work at the VA and hold a joint faculty appointment as my day job, however, I opened my private practice right when I started my full time gig with the hope that I could feel safe building it while having a steady income with benefits. My start up capital came directly from my income at my day job. I had no business line of credit (until recently actually). My practice is 100% online for therapy and testing/assessments. I first started out insisting I would be private pay only since most psychologists and psychiatrists in the greater Houston area are also private pay. Very few take insurance. I had zero patients for about 6 months. I heard all the horror stories about taking insurance which further kept me from moving forward with it. Then I finally realized, an insurance-based practice would be very feasible if I set it up in a manner that allowed me do so, meaning, I needed to keep my expenses very low, I needed to have a routine in place and policies to keep everybody/everything in line. I can tell you that since I accepted BCBS, United, and Cigna, I went from zero patients to more than I can handle, and over the course of actively seeing patients for 3 months, I have earned $12K by just seeing about 9-12 patients a week (with some cancellations in between). I have a strict no show/late cancellation policy ($125). I do a very thorough and repeated informed consent up front, especially in my 15 minute phone consultation where I am also screening out patients. I built my entire infrastructure (e.g., website, logo, basic accounting), use a good all in one EHR/video platform (SimplePractice). My practice is literally "plug and play" and I earn almost what I was charging for my private pay fee. I have had no rejections or denial of claims, and I am typically paid within 1 to 7 business days from when I submit my claims. In sum, if you have clear and transparent policies and expectations from your prospective patients, then everything else falls into place. For my 53 minute sessions, I am typing into my note throughout the session so by the time we are wrapping up (usually around the 45 minute mark), I am putting their note into the chart, I schedule their follow up session for next week, I collect their co-pay, then click 2 buttons to submit the claim to the insurance and paid pretty quickly. I do this for every patient. I don't spend tons of time on admin stuff or "catching up" on notes, chasing down claims, etc. I don't have an admin assistant as I can handle the volume I have. Hasn't failed me yet. In related news, I've hired on 3 more contract psychologists to delegate patients so, so now I am a group practice and I skim a % from their earnings as passive income.

The administrative burden for psychology is much much lower than for psychiatry, though. Far fewer patients, no labs to order or track down, no prescriptions and therefore no prior auths, much less information to be obtained or coordinate per patient hour (patient hospitalized? Need to review all the med changes. Medical comorbidity? May need to talk to pcp or another specialist. Or just Google whatever new med theyre on that you never learned in medical school).

When I was contemplating joining with a medium sized therapy practice and sat down to talk through the admin needs for a psychiatrist rather than a therapist the pracrice owner genuinely blown away when I started listing out the variety of things we handle in the course of patient care. It was just so much more than the admin requirements for a therapy pt.

Also psychiatrists dont have to see the patients as often so the cash rate can be more tolerated because the total yearly amount is lower.

 

[wolfvgang22]

I work at the VA and hold a joint faculty appointment as my day job, however, I opened my private practice right when I started my full time gig with the hope that I could feel safe building it while having a steady income with benefits. My start up capital came directly from my income at my day job. I had no business line of credit (until recently actually). My practice is 100% online for therapy and testing/assessments. I first started out insisting I would be private pay only since most psychologists and psychiatrists in the greater Houston area are also private pay. Very few take insurance. I had zero patients for about 6 months. I heard all the horror stories about taking insurance which further kept me from moving forward with it. Then I finally realized, an insurance-based practice would be very feasible if I set it up in a manner that allowed me do so, meaning, I needed to keep my expenses very low, I needed to have a routine in place and policies to keep everybody/everything in line. I can tell you that since I accepted BCBS, United, and Cigna, I went from zero patients to more than I can handle, and over the course of actively seeing patients for 3 months, I have earned $12K by just seeing about 9-12 patients a week (with some cancellations in between). I have a strict no show/late cancellation policy ($125). I do a very thorough and repeated informed consent up front, especially in my 15 minute phone consultation where I am also screening out patients. I built my entire infrastructure (e.g., website, logo, basic accounting), use a good all in one EHR/video platform (SimplePractice). My practice is literally "plug and play" and I earn almost what I was charging for my private pay fee. I have had no rejections or denial of claims, and I am typically paid within 1 to 7 business days from when I submit my claims. In sum, if you have clear and transparent policies and expectations from your prospective patients, then everything else falls into place. For my 53 minute sessions, I am typing into my note throughout the session so by the time we are wrapping up (usually around the 45 minute mark), I am putting their note into the chart, I schedule their follow up session for next week, I collect their co-pay, then click 2 buttons to submit the claim to the insurance and paid pretty quickly. I do this for every patient. I don't spend tons of time on admin stuff or "catching up" on notes, chasing down claims, etc. I don't have an admin assistant as I can handle the volume I have. Hasn't failed me yet. In related news, I've hired on 3 more contract psychologists to delegate patients so, so now I am a group practice and I skim a % from their earnings as passive income.

How long have you had your private practice going now? How often are you seeing each patient?

 

[texanpsychdoc]

How long have you had your private practice going now? How often are you seeing each patient?

Technically, I started it October of 2022 but actually functional was 3 months ago. I see my patients once weekly for 53 minutes. I have a steady case load of 13 patients and I usually have 4-6 new patient inquiries every day, most of whom I have to decline.

 

[texanpsychdoc]

The administrative burden for psychology is much much lower than for psychiatry, though. Far fewer patients, no labs to order or track down, no prescriptions and therefore no prior auths, much less information to be obtained or coordinate per patient hour (patient hospitalized? Need to review all the med changes. Medical comorbidity? May need to talk to pcp or another specialist. Or just Google whatever new med theyre on that you never learned in medical school).

When I was contemplating joining with a medium sized therapy practice and sat down to talk through the admin needs for a psychiatrist rather than a therapist the pracrice owner genuinely blown away when I started listing out the variety of things we handle in the course of patient care. It was just so much more than the admin requirements for a therapy pt.

Also psychiatrists dont have to see the patients as often so the cash rate can be more tolerated because the total yearly amount is lower.

Makes sense. I also know of some psychiatrists (who we refer to each other) who are INN with insurance, so they are doing something that allows them to make it work. They are a completely online psychiatry practice here in the Houston area. They are one of my biggest referral sources, and are very consistent and refer good quality patients to me.

 

[texanpsychdoc]

I should also add that just doing therapy, the rate I get from insurance I am easily able to gross $185k working 40 weeks out of the year seeing 25 patients a week. Not bad.

 

[hamstergang]

The administrative burden for psychology is much much lower than for psychiatry, though. Far fewer patients, no labs to order or track down, no prescriptions and therefore no prior auths, much less information to be obtained or coordinate per patient hour (patient hospitalized? Need to review all the med changes. Medical comorbidity? May need to talk to pcp or another specialist. Or just Google whatever new med theyre on that you never learned in medical school).

When I was contemplating joining with a medium sized therapy practice and sat down to talk through the admin needs for a psychiatrist rather than a therapist the pracrice owner genuinely blown away when I started listing out the variety of things we handle in the course of patient care. It was just so much more than the admin requirements for a therapy pt.

Also psychiatrists dont have to see the patients as often so the cash rate can be more tolerated because the total yearly amount is lower.

Also, since a psychiatric caseload will be larger than a therapy-only caseload, we will have a higher intake:follow up ratio, and intakes take more work per hour than follow ups (from the scheduling, information gathering, coordination of care, note writing, and just not yet knowing the person).

 

[romanticscience]

The administrative burden for psychology is much much lower than for psychiatry, though. Far fewer patients, no labs to order or track down, no prescriptions and therefore no prior auths, much less information to be obtained or coordinate per patient hour (patient hospitalized? Need to review all the med changes. Medical comorbidity? May need to talk to pcp or another specialist. Or just Google whatever new med theyre on that you never learned in medical school).

When I was contemplating joining with a medium sized therapy practice and sat down to talk through the admin needs for a psychiatrist rather than a therapist the pracrice owner genuinely blown away when I started listing out the variety of things we handle in the course of patient care. It was just so much more than the admin requirements for a therapy pt.

Also psychiatrists dont have to see the patients as often so the cash rate can be more tolerated because the total yearly amount is lower.

A reason to consider a more psychodynamic psychiatry practice. I take care of the following but the amount of which is much less. I also use SimplePractice, as a psychiatrist in solo no-staff PP. To do what I do you need a firm understanding of your scope and finesse handling relationships. Who would have thought my psychodynamic training would help with running a business?

 

[Psychresy]

A reason to consider a more psychodynamic psychiatry practice. I take care of the following but the amount of which is much less. I also use SimplePractice, as a psychiatrist in solo no-staff PP. To do what I do you need a firm understanding of your scope and finesse handling relationships. Who would have thought my psychodynamic training would help with running a business?

I'm deciding on an EMR now. I'm going to be pretty small. 8-10 hours a week. No staff. 90% tele. Would you recommend simple practice or potentially look at something else? I'm hoping to find an emr that allows prescribing, patient scheduling, portal messaging, submission of billing..

 

[Sushirolls]

luminello fan here.

 

[PsyMD]

Ultimately, for me, it boiled down to Luminello vs Charm. Would love to hear ppl insight abt Luminello Vs Charm.