Telepsychiatry private practice

[TexasPhysician]

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

I think that will come down to individual taste. I know other clinicians that prefer Luminello. I prefer Charm.

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[clausewitz2]

Luminello has been solid and incredibly functional for me. The template creation is quite easy and I love the ability to bombard intakes with questionnaires I adapted from public domain screening instruments.

 

[Sushirolls]

The Sleep Doc I used to have sublease from me used Charm. And being able to see bits of their EMR setup and their complaints/hiccups, I'm glad I went with Luminello. I'd try to help out and troubleshoot their issues when I had time, but was a bit more complex then what we actually need for majority of psych practices. Luminello has it simple, efficient, and now can even expand to do group practice if you want.

But if you know you'll be solo, and want cheap, there are better other ways to piece meal things together for a more simplified setup that other posters have described what they do.

Just today, another one of my higher functioning patients praised the user operations for Luminello - especially opening up the calendar and letting patients self schedule.

 

[romanticscience]

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..

I think you should try a few out. I like simple practice because my psychiatry brand shares more in common with therapists than psychopharmacologists, that like luminello and charm. For instance, simple practice's direct messaging resembles instant messaging instead of email. It's also a bit more optimized for use through an phone app. I could send messages with luminello but I'd have to use the browser. Guys correct me if I'm wrong about charm or luminello mobile apps. SP also is cheaper for me who submits their own insurance claims.

Simple practice also has a professional website builder which is integrated with the patient portal.

 

[TexasPhysician]

Luminello has been solid and incredibly functional for me. The template creation is quite easy and I love the ability to bombard intakes with questionnaires I adapted from public domain screening instruments.

Expect price hikes soon. Luminello was just acquired.

 

[romanticscience]

It was acquired by simple practice

 

[Sushirolls]

Curious to see if they just exist in parallel or if one consumes the other.

 

[deleted1129370]

I love SP...I run my online practice solely with SP.

 

[clement]

Which malpractice companies typically cover 100% tele? Doctor’s has preliminarily informed me they have to check with their underwriter. The phone representative sounded a bit unfamiliar with psychiatry practice models, in fairness. My longterm goal is hybrid but want to minimize overhead before accumulating patients.

 

[clausewitz2]

Which malpractice companies typically cover 100% tele? Doctor’s has preliminarily informed me they have to check with their underwriter. The phone representative sounded a bit unfamiliar with psychiatry practice models, in fairness. My longterm goal is hybrid but want to minimize overhead before accumulating patients.

MagMutual seems to have no problem with it.

 

[Atreides]

Which malpractice companies typically cover 100% tele? Doctor’s has preliminarily informed me they have to check with their underwriter. The phone representative sounded a bit unfamiliar with psychiatry practice models, in fairness. My longterm goal is hybrid but want to minimize overhead before accumulating patients.

Interesting, The Doctor's Company told me they don't cover more than 10% telemedicine. I told them that effectively rules out them covering outpatient psychiatry at all because I don't know of any outpatient psychiatrist doing less than 10% telemedicine. They were just liked, "This is our policy." I looked into them twice; when I first started my practice and then again recently, when I needed to switch. They said the same thing both times.

MagMutual and PRMS will cover 100% tele. I liked MagMutual because they give you a free UpToDate subscription but unfortunately, hey don't cover medicolegal work so I had to drop them.

 

[hamstergang]

Interesting, The Doctor's Company told me they don't cover more than 10% telemedicine. I told them that effectively rules out them covering outpatient psychiatry at all because I don't know of any outpatient psychiatrist doing less than 10% telemedicine.

I do tele 5% at most. Many patients are seeing me specifically because I'm in-person and they can only find mostly tele practices out there.

 

[calvnandhobbs68]

Interesting, The Doctor's Company told me they don't cover more than 10% telemedicine. I told them that effectively rules out them covering outpatient psychiatry at all because I don't know of any outpatient psychiatrist doing less than 10% telemedicine. They were just liked, "This is our policy." I looked into them twice; when I first started my practice and then again recently, when I needed to switch. They said the same thing both times.

MagMutual and PRMS will cover 100% tele. I liked MagMutual because they give you a free UpToDate subscription but unfortunately, hey don't cover medicolegal work so I had to drop them.

MedPro didn't seem to care about how much tele I did, just wanted a form saying if I did tele or not and some questions about the practice...but I have an actual in person office too so idk if it matters that I have somewhere to see people in person.

 

[lol.psych]

There’s also the American professional agency — the insurer that APA endorses/affiliates with — they have a “cyber suite” add-on option

 

[clement]

Doctor’s was also unexpectedly hard to get a hold of to discuss quotes with a human. That was kind of a turnoff. In addition to the fact that they still haven’t replied for days… after telling me they’ll check with their underwriter re tele. The phone rep did say, “Oh…but you’re psychiatry so let me find out.” My long term goal is of course hybrid.

I was counseled to go with companies that are very familiar with psychiatry practice models and assumed Doctor’s was. FWW I found out CAP covers 100% tele but not in all states.

 

[When is graduation again?]

To return to an earlier topic in this thread, I'm curious about how people are handling labs. I have a Labcorp account and I ask patients for medical records, but with these methods I rarely have the labs at the first appointment. Do you all typically prescribe at the 1st appointment, with the expectation that you'll have labs by the 2nd visit? What do you do if the patient never gets the labs? I'm assuming this is the only approach, but it feels strange to do since I've been trained to have labs pretty much at the time of the 1st encounter in residency.

 

[ObsequiousAplomb]

To return to an earlier topic in this thread, I'm curious about how people are handling labs. I have a Labcorp account and I ask patients for medical records, but with these methods I rarely have the labs at the first appointment. Do you all typically prescribe at the 1st appointment, with the expectation that you'll have labs by the 2nd visit? What do you do if the patient never gets the labs? I'm assuming this is the only approach, but it feels strange to do since I've been trained to have labs pretty much at the time of the 1st encounter in residency.

I guess I wasn't trained that way. For most issues, I prescribe before the labs. I also don't do things at the first visit that would make me uncomfortable without labs (e.g. start lithium). Just due to lack of opportunities to try I've never gotten around to prescribing Tegretol. I wouldn't give clozapine without labs. If I have strong suspicion of a secondary cause for the symptoms I tell the patient and we have a discussion and they make an informed choice. Just about everything else (I'm sure I'm forgetting some stuff), based on the way I was taught, the labs can wait.

Are you waiting to start Zoloft until you have a normal chemistry panel?

 

[When is graduation again?]

I guess I wasn't trained that way. For most issues, I prescribe before the labs. I also don't do things at the first visit that would make me uncomfortable without labs (e.g. start lithium). Just due to lack of opportunities to try I've never gotten around to prescribing Tegretol. I wouldn't give clozapine without labs. If I have strong suspicion of a secondary cause for the symptoms I tell the patient and we have a discussion and they make an informed choice. Just about everything else (I'm sure I'm forgetting some stuff), based on the way I was taught, the labs can wait.

Are you waiting to start Zoloft until you have a normal chemistry panel?

That makes sense. It's not so much I was trained to have labs, so much as they were always there or I could get them pretty quickly after prescribing. I'm still early private practice days, so haven't prescribed anything yet, but I'm starting to get some potentially complex cases in the weeks to come, so I'm preparing my workflows/processes now.

 

[ObsequiousAplomb]

That makes sense. It's not so much I was trained to have labs, so much as they were always there or I could get them pretty quickly after prescribing. I'm still early private practice days, so haven't prescribed anything yet, but I'm starting to get some potentially complex cases in the weeks to come, so I'm preparing my workflows/processes now.

That's a smart thing to do. We're in the same boat, this is my first year of private practice. The medically complicated patients (I have a few who are dying) can be really tough when there's no system. It's very tough to get most things like that. Thankfully, I'm in Maryland and in Maryland the labs are usually reported into the central registry, so I can see them sometimes. Do you have anything like that in your region?

 

[When is graduation again?]

That's a smart thing to do. We're in the same boat, this is my first year of private practice. The medically complicated patients (I have a few who are dying) can be really tough when there's no system. It's very tough to get most things like that. Thankfully, I'm in Maryland and in Maryland the labs are usually reported into the central registry, so I can see them sometimes. Do you have anything like that in your region?

I wish. That sounds amazing. Maybe it'll happen someday.

 

[clement]

Medicare came up on here and is ever present on such threads. For those accepting Medicare in their main gig… Would a side hybrid cash practice serving medically ill patients (advanced and serious illnesses, caretakers, survivors) be a Medicare living hell…and ultimately a poor business model? I.e. accepting no Medicare pts and notifying them of such at the onset. Obviously folks can qualify for Medicare under 65 if on SSDI.

 

[calvnandhobbs68]

Medicare came up on here and is ever present on such threads. For those accepting Medicare in their main gig… Would a side hybrid cash practice serving medically ill patients (advanced and serious illnesses, caretakers, survivors) be a Medicare living hell…and ultimately a poor business model? I.e. accepting no Medicare pts and notifying them of such at the onset. Obviously folks can qualify for Medicare under 65 if on SSDI.

Are you saying that you're trying not to get patients who are covered under medicare in this practice or asking if you can accept medicare in one setting and not another?

Medicare is all in or all out. You can't cash charge Medicare patients in any capacity if you accept Medicare anywhere. If you're seeing a lot of medically or psychiatrically complex patients, you do increase your chances you might inadvertently pick up some Medicare patient.

Also yes this would probably be a very time consuming and poor dollars per hour spent business model, unless you're slowly building up a practice of rich sick people I guess. Even the high end concierge PCPs don't really want a bunch of sick people though, they want a bunch of "worried well" rich people who will pay them thousands of bucks a month to order fancy tests/full body MRIs or get the COVID shot early.

 

[clement]

Are you saying that you're trying not to get patients who are covered under medicare in this practice or asking if you can accept medicare in one setting and not another?

Medicare is all in or all out. You can't cash charge Medicare patients in any capacity if you accept Medicare anywhere. If you're seeing a lot of medically or psychiatrically complex patients, you do increase your chances you might inadvertently pick up some Medicare patient.

Also yes this would probably be a very time consuming and poor dollars per hour spent business model, unless you're slowly building up a practice of rich sick people I guess. Even the high end concierge PCPs don't really want a bunch of sick people though, they want a bunch of "worried well" rich people who will pay them thousands of bucks a month to order fancy tests/full body MRIs or get the COVID shot early.

Forget the body scans.
Yes, I’m saying that my intent is NO Medicare patients (at least for the first year or two). This stinks because the early phase of PP is marketing and well I’d be excluding a lot (I suspect). The aim is concierge psychotherapy, mindfulness focused (my niche being palliative care/ psycho onc).
So I should:
-provide notice that I don’t accept Medicare patients and will fire them if they get on Medicare
-check front and back of their cards
-ask if they’re looking to get ssdi

Or like some gero practices, go with a biller and take Medicare? I guess that’s inevitable in the long run.

Invariably I’ll run into people that have it but are desperate for care or don’t know they have Medicare.

All of this said, how do people run into hot water if accidentally taking a pt on Medicare in such a practice model? Is it the pt trying to get reimbursed? In other words, how does Medicare find out if I inadvertently treat such a pt? I imagine it’s more likely to happen for those whose practice is more heavily psychopharm based.

 

[TexasPhysician]

Forget the body scans.
Yes, I’m saying that my intent is NO Medicare patients (at least for the first year or two). This stinks because the early phase of PP is marketing and well I’d be excluding a lot (I suspect). The aim is concierge psychotherapy, mindfulness focused (my niche being palliative care/ psycho onc).
So I should:
-provide notice that I don’t accept Medicare patients and will fire them if they get on Medicare
-check front and back of their cards
-ask if they’re looking to get ssdi

Or like some gero practices, go with a biller and take Medicare? I guess that’s inevitable in the long run.

Invariably I’ll run into people that have it but are desperate for care or don’t know they have Medicare.

All of this said, how do people run into hot water if accidentally taking a pt on Medicare in such a practice model? Is it the pt trying to get reimbursed? In other words, how does Medicare find out if I inadvertently treat such a pt? I imagine it’s more likely to happen for those whose practice is more heavily psychopharm based.

I don’t like the plan as a cash side gig. You are marketing toward the population that will likely get Medicare at random times thus causing massive headaches for you.

This is better designed as a Medicare practice. A fragile medical population is also not a great population to have limited hours and support staff. This is a group that may struggle more with remembering appointments and dealing with technology issues.

This population is better geared toward an opted-out psychiatrist that can spend time and ignore Medicare issues or a higher volume practice that accepts Medicare with ample support staff to manage issues.

 

[clement]

I don’t like the plan as a cash side gig. You are marketing toward the population that will likely get Medicare at random times thus causing massive headaches for you.

This is better designed as a Medicare practice. A fragile medical population is also not a great population to have limited hours and support staff. This is a group that may struggle more with remembering appointments and dealing with technology issues.

This population is better geared toward an opted-out psychiatrist that can spend time and ignore Medicare issues or a higher volume practice that accepts Medicare with ample support staff to manage issues.

All very valid points. Still wonder what the stakes are with a therapy-only practice.

 

[Atreides]

Update #6
2024 Income: $191,187.49
2024 Expenses: $ 24,211.32
Average clinical load: 20 patient hours/week

Net income by month:

EMR

Firmly in Charm EMR now. I tried to switch to PracticeQ early in the year and it was a disaster of Epic proportions. The forms are extremely robust and very useful but that's where the benefit ended. Billing (the primary reason I switched) was no better than it was in Charm. Notes were much more clunky and prescribing took much longer. I had the "sunk cost fallacy" drilled into my head in my younger years so even though it took me hours and hours to set up PracticeQ, I switched back to Charm in a week. No point in sticking with an EMR that's not working just because I put in an embarrassing number of hours getting it set up. Silver lining is that the forms are useful enough that I've incorporated them into my Charm intake workflow as I find they're able to do things I simply can't with Charm.


Billing
I met with the recommended billing company from the Physician Community FB group, Cosentus. What a steaming pile of trash. They were pretty enthusiastic at first but quoted a high rate given the size of my practice, 10%. They offered a free review of billing so I was like, sure, why not, let's start with that and then see if the 10% is going to be worth it. They told me they'd get back to me in a week. I gave them two weeks and still no response so emailed them back. No response. Emailed again, no response. Took it that I was ghosted. The moderator of the group reached out on my behalf and they sent me a terse email saying my practice makes too little money, less than $6000 a year, but that they could refer me to a billing company that works with small practices. I have no idea where he pulled that number from, my revenue at that point in the year had been about 70k. I pointed that out but said, sure, if it's too low for your threshold, I'd appreciate the referral. He ghosted me again, never gave the referral. Great.

I muddled through and then went through Charm's list of recommended billing companies. Emailed a few and landed on one that responded promptly and worked almost exclusively with Charm. He said his rate was 5% or 500/month, whichever was more. That was fine with me so hired him. Really kicked myself for not doing it earlier. The rate was much lower than I was expecting and I'm pretty happy with the service. Not sure I'll use him long long-term but pretty good for now. Have gotten most of my Charm billing issues sorted out. ERA's are still not flowing properly though (nice to know it wasn't just me not understanding Charm). He's been meeting with Charm weekly to get it sorted out. It didn't help that the Change cyberattack happened right around the time I hired him. I did change clearinghouses from Change to Optum. Just this week, our first set of ERA's are flowing in (from one insurance). Hoping the rest follow. Cigna is sending me paper checks ever since the cyberattack so now trying to get that fixed.

Hardware
Scored an amazing deal of Facebook marketplace, got two 27" Thunderbolt displays for $50 total ($25/each). They're about 7-8 years old at this point but Apple definitely makes some quality monitors that last. I had to buy a new camera mount though, the display is too thick for my old camera mount. My wife's iPhone shattered but the camera is still functional so now that's my permanent webcam.

Website

Redesigned my website from scratch. I had used Wix before and wasn't super happy with how it looked. Much happier with the new website but given how long it took me (two full weekends) it might be worth paying someone to design the website in the future if I ever think I need a new one. This should last for quite some time though.

Malpractice

Switched to PRMS. I really liked MagMutual (especially the free UpToDate access) but they don't cover forensic psychiatry.

Insurance

After dragging my heels, I dropped Optum, end date in mid-June. I tried negotiating but they would not budge an inch. Forget about budging, it took more effort for me to even get ahold of an actual person via email or phone than it took for me to negotiate rates with all other insurances. I literally scoured LinkedIn to find the right person to contact.

As a result of dropping Optum, I no longer need Alma (was only keeping Alma for Optum) so dropping that after June.

I may be joining a local IPA that has decent contracts with Optum so who knows, may be back in-network at some point. I've told my patients about leaving the network. Quite a few are applying for network gap exceptions. Afaik, none are planning on staying if it converts to private pay. That's about what I was expecting and totally get it. I was surprised by a few patients who requested network gap exceptions (who I expected to just shrug and look for a new psychiatrist) and also surprised by a few who didn't request a network gap exception and were just like, "Ok, cool, I'll find someone else." Most were as predicted though (i.e. I expected them to try to get an exception and they did try or I expected them to not try and they didn't).

Thanks to @splik for pointing me in the direction of an EAP/"insurance" that I joined who pay close to my private pay rate. I've gotten more patients than I expected from that.

I do get the occasional private pay patient, I'd estimate less than 10% (closer to 5%) of my practice is private pay.

Despite warnings to avoid, I've gingerly dipped my toes into a few (3 so far) single case agreements. So far, it's been decent, actually. I ask for about 25% more than my private pay rate (to make up for the hassle of dealing with the extra admin work) and they've all been paid so far.


Advertising

I've put a lot less thought into this these past few months. Thankfully, I get a steady trickle of referrals. Not a stream or flood by any means, but enough to keep my practice full.

Location

I hardly ever go in, preferring to work from home, but I did move my office location. My old office was not in the best location (next to a weight loss clinic advertising their B12 shots and across from a chiropractor). I did a forensic evaluation in the office and cringed when the evaluee had to walk past a number of very quacky looking offices before getting to mine. The new office is in a much better building and surprisingly, the rent is almost $100 cheaper ($250/month). The IPA that I mentioned earlier also requires location in a specific locality to qualify for all their plans so that played a role as well (minor one though).

For some reason, my location is not updating on any of the patient portals. My availity, CAQH, and NPPES profiles are all updated with the new practice location, but no insurance portal is accurate. I need to reach out via phone it seems to figure out what's going on. It's been a full month since all these profiles were updated.

I am moving out of state but will be keeping my practice location steady. Keeping most of my patients but had a handful that either required or really wanted in-person appointments. Those patients I've transferred/given referrals to establish with a new psychiatrist.

Personnel
Hired a local (i.e., same region) virtual assistant. She was a disaster. She was expensive and incompetent. Billed hours not worked, etc. Got rid of her very quickly, end of the second week. Got some recommendations from other physicians in private practice and hired a virtual assistant from a California company (so BAA signed with them) that sources their assistants from the Philippines. Generally happy with him; he answers the phone and manages scheduling. He's been making more and more careless mistakes recently though, so need to figure out better processes to ensure he's doing his work correctly. Mistakes were initially small but are getting bigger; this week completely neglected to call our waitlist the day before to get an appointment slot filled. End result was a full hour slot going unfilled despite a long waitlist and people booking new patient appointments in July.

Structure
This has been a sole proprietorship up until now. Given how it's grown, logical step was to tax as an S-corp. In order to do that, need to make it a professional corporation. I considered doing it myself but saw a number of therapy FB groups were they strongly recommended getting a lawyer to set it up. I paid one to set it up, I think about $2000, and really regret it. They took forever, missed filing a document that they were supposed to, and still haven't gotten back to me about getting the DBA name switched over. After seeing multiple psychiatrists post on psychiatry FB groups that they set it up themselves, pretty sure I should've done that instead. Oh well.

Accounting
Following up with the S-corp bit, need to find an accountant. The lawyer who set up my PC gave me a referral to an accountant....who charges about 20k a year. I can't imagine how complicated my tax situation would have to get before it would be worth paying 20k to a CPA. I spoke to a few other ones. They all quoted me around 5-7k a year which seems quite steep. I found one off White Coat Investor who said he wouldn't be a good fit for me if I have any plans to expand beyond a solo practice but referred me to a colleague of his. He quoted me 2k a year which would've sounded great at the beginning but after getting all these 5-7k/year quotes, idk if I'm missing something. I ended up going with him, just had my first meeting today. It was a bit of a bait-and-switch, I was assigned to work with his associate rather than him. For now I'll stick with him just because I have too many things going on in my life right now to keep looking for accountants but there's a high chance I'll move over to someone else next year if things aren't satisfactory this year.

Software
Up until now, I've been doing my bookkeeping with Quicken Simplifii (where the screenshot above is from) because it's all just my income. I categorize income by payer (Aetna, Cigna, Anthem, "Cash", etc) and keep track of my expenses there. It's worked well for me but I can't keep doing that with the S-corp. The accountant strongly recommend QuickBooks Online. Doing an online search, it seems QBO has almost universally negative reviews. All my business/startup friends also have negative things to say about it. However, it seems to have good reviews from psychiatrists on the psychiatry FB groups I'm on. So I'm considering that or Wave.

For payroll, accountant strongly recommended ADP. The sales rep tried to pull a fast one, quoting me about $90. I asked him, "So when you say it costs $90, is that monthly?" He mumbled yes and changed the subject. Asked for the quote in writing and the email just said $90 without monthly. Asked him to clarify and he's like, "Oh yeah, let me fix that in the quote" and sent over one that said $90 per payroll. I asked him how often payroll was, isn't that usually biweekly. He's like, "Well no, it's actually weekly, but you're getting a huge discount." Clarified again with him, it's actually $360/month. Really don't think that's worth it for me. I've looked at Gusto which is significantly less. QuickBooks Online has payroll and I believe Wave has their own too. I've heard mixed reviews of all of these though.


Life/future

A psychiatry resident who'll be doing the same fellowship that I did reached out about moonlighting in my practice. I know him and would be completely comfortable with him joining but need to figure out logistics. My insurance contracts are all based on my NPI1 and sole proprietor EIN. I believe I need to switch over to an NPI2 and a professional corporation EIN to start hiring people under me. That process has been started somewhat but I'm not sure if my insurance contracts can just switch over to an NPI-2. I really don't want to negotiate rates from fresh so hopefully there's some mechanism to transition from solo to group practice.

Up until now, I've been doing 20 clinical hours a week in 2024. That'll stay the same in my practice but I'm starting a 0.5 FTE academic position soon. So I'll be going to full time work. It's been nice being half clinical (although my other half gets more than full with admin and forensic work so I'm worried that now I'll be doing 1.5 FTE instead of a full time job).

 

[splik]

As a result of dropping Optum, I no longer need Alma (was only keeping Alma for Optum) so dropping that after June.

I may be joining a local IPA that has decent contracts with Optum so who knows, may be back in-network at some point. I've told my patients about leaving the network. Quite a few are applying for network gap exceptions. Afaik, none are planning on staying if it converts to private pay. That's about what I was expecting and totally get it. I was surprised by a few patients who requested network gap exceptions (who I expected to just shrug and look for a new psychiatrist) and also surprised by a few who didn't request a network gap exception and were just like, "Ok, cool, I'll find someone else." Most were as predicted though (i.e. I expected them to try to get an exception and they did try or I expected them to not try and they didn't).

Optum/UHC is terrible with gap exceptions in my experience. They keep calling me about single case agreements instead. Since you accept insurance it's probably worth it to do the SCAs and get a better rate, but I always decline. If you do the gap exceptions, warn the patients you can't guarantee that Optum will reimburse them even if they approve it.

 

[clozareal]

Really love the update! This is extremely helpful for me to read as I feel like I'm in a similar timeline as you.

Update #6
2024 Income: $191,187.49
2024 Expenses: $ 24,211.32
Average clinical load: 20 patient hours/week

Net income by month:

View attachment 387336

This means you're on track to gross ~$450k this year.

EMR

Firmly in Charm EMR now. I tried to switch to PracticeQ early in the year and it was a disaster of Epic proportions. The forms are extremely robust and very useful but that's where the benefit ended. Billing (the primary reason I switched) was no better than it was in Charm. Notes were much more clunky and prescribing took much longer. I had the "sunk cost fallacy" drilled into my head in my younger years so even though it took me hours and hours to set up PracticeQ, I switched back to Charm in a week. No point in sticking with an EMR that's not working just because I put in an embarrassing number of hours getting it set up. Silver lining is that the forms are useful enough that I've incorporated them into my Charm intake workflow as I find they're able to do things I simply can't with Charm.

I also tried SimplePractice, IntakeQ, and several others. I came back to Charm and now my intake process is extremely streamlined. Patients schedule a phone call in my patient portal, then I talk to them and activate them to be able to schedule an intake appointment (let me know if you want to know how I did this as a workaround), then they schedule an intake and pay for it during that scheduling all by themselves online, forms get sent (questionnaires, consent forms) and it gives me most of the information I would want that you can reconcile into their chart such as allergies, past medications, PMH, social history, insurance info, etc. including their pharmacy and therapist/PCP contact info. This is MUCH more automated than Luminello as I don't have to do much for the intake process anymore. After each follow-up, the patient gets the invoice/superbill automatically so I don't have to send them that either.

Billing
I met with the recommended billing company from the Physician Community FB group, Cosentus. What a steaming pile of trash. They were pretty enthusiastic at first but quoted a high rate given the size of my practice, 10%. They offered a free review of billing so I was like, sure, why not, let's start with that and then see if the 10% is going to be worth it. They told me they'd get back to me in a week. I gave them two weeks and still no response so emailed them back. No response. Emailed again, no response. Took it that I was ghosted. The moderator of the group reached out on my behalf and they sent me a terse email saying my practice makes too little money, less than $6000 a year, but that they could refer me to a billing company that works with small practices. I have no idea where he pulled that number from, my revenue at that point in the year had been about 70k. I pointed that out but said, sure, if it's too low for your threshold, I'd appreciate the referral. He ghosted me again, never gave the referral. Great.

I muddled through and then went through Charm's list of recommended billing companies. Emailed a few and landed on one that responded promptly and worked almost exclusively with Charm. He said his rate was 5% or 500/month, whichever was more. That was fine with me so hired him. Really kicked myself for not doing it earlier. The rate was much lower than I was expecting and I'm pretty happy with the service. Not sure I'll use him long long-term but pretty good for now. Have gotten most of my Charm billing issues sorted out. ERA's are still not flowing properly though (nice to know it wasn't just me not understanding Charm). He's been meeting with Charm weekly to get it sorted out. It didn't help that the Change cyberattack happened right around the time I hired him. I did change clearinghouses from Change to Optum. Just this week, our first set of ERA's are flowing in (from one insurance). Hoping the rest follow. Cigna is sending me paper checks ever since the cyberattack so now trying to get that fixed.

I only bill an EAP and credit cards. Charm billing is not as intuitive as Luminello. It takes a few more steps each day so I'm not a big fan of that as it takes more time.

Hardware
Scored an amazing deal of Facebook marketplace, got two 27" Thunderbolt displays for $50 total ($25/each). They're about 7-8 years old at this point but Apple definitely makes some quality monitors that last. I had to buy a new camera mount though, the display is too thick for my old camera mount. My wife's iPhone shattered but the camera is still functional so now that's my permanent webcam.

Nice. I use the Logitech webcam but I'm thinking about switching to Insta360 4k webcam along with the logitech dock.

Website

Redesigned my website from scratch. I had used Wix before and wasn't super happy with how it looked. Much happier with the new website but given how long it took me (two full weekends) it might be worth paying someone to design the website in the future if I ever think I need a new one. This should last for quite some time though.

You can get up to $5,000 in tax credit (read: not deduction) if you hire someone and they make your website ADA accessible. Basically it means having a button to make it more visible. It's equal to 50% or up to a max expenditure of $10,250 with the first $250 in expenses not being creditable.

Malpractice

Switched to PRMS. I really liked MagMutual (especially the free UpToDate access) but they don't cover forensic psychiatry.

Insurance

After dragging my heels, I dropped Optum, end date in mid-June. I tried negotiating but they would not budge an inch. Forget about budging, it took more effort for me to even get ahold of an actual person via email or phone than it took for me to negotiate rates with all other insurances. I literally scoured LinkedIn to find the right person to contact.

As a result of dropping Optum, I no longer need Alma (was only keeping Alma for Optum) so dropping that after June.

I may be joining a local IPA that has decent contracts with Optum so who knows, may be back in-network at some point. I've told my patients about leaving the network. Quite a few are applying for network gap exceptions. Afaik, none are planning on staying if it converts to private pay. That's about what I was expecting and totally get it. I was surprised by a few patients who requested network gap exceptions (who I expected to just shrug and look for a new psychiatrist) and also surprised by a few who didn't request a network gap exception and were just like, "Ok, cool, I'll find someone else." Most were as predicted though (i.e. I expected them to try to get an exception and they did try or I expected them to not try and they didn't).

Thanks to @splik for pointing me in the direction of an EAP/"insurance" that I joined who pay close to my private pay rate. I've gotten more patients than I expected from that.

I do get the occasional private pay patient, I'd estimate less than 10% (closer to 5%) of my practice is private pay.

Despite warnings to avoid, I've gingerly dipped my toes into a few (3 so far) single case agreements. So far, it's been decent, actually. I ask for about 25% more than my private pay rate (to make up for the hassle of dealing with the extra admin work) and they've all been paid so far.

I don't take insurance but I do take an EAP and trying to get on one or two more local popular ones. They're paying me my private practice rates, although I can only see them in a medication context rather than a weekly therapy one.

Advertising

I've put a lot less thought into this these past few months. Thankfully, I get a steady trickle of referrals. Not a stream or flood by any means, but enough to keep my practice full.

Location

I hardly ever go in, preferring to work from home, but I did move my office location. My old office was not in the best location (next to a weight loss clinic advertising their B12 shots and across from a chiropractor). I did a forensic evaluation in the office and cringed when the evaluee had to walk past a number of very quacky looking offices before getting to mine. The new office is in a much better building and surprisingly, the rent is almost $100 cheaper ($250/month). The IPA that I mentioned earlier also requires location in a specific locality to qualify for all their plans so that played a role as well (minor one though).

For some reason, my location is not updating on any of the patient portals. My availity, CAQH, and NPPES profiles are all updated with the new practice location, but no insurance portal is accurate. I need to reach out via phone it seems to figure out what's going on. It's been a full month since all these profiles were updated.

I am moving out of state but will be keeping my practice location steady. Keeping most of my patients but had a handful that either required or really wanted in-person appointments. Those patients I've transferred/given referrals to establish with a new psychiatrist.

This makes me terrified of changing my offices. I would HATE to update all of these accounts with the new address.

Personnel
Hired a local (i.e., same region) virtual assistant. She was a disaster. She was expensive and incompetent. Billed hours not worked, etc. Got rid of her very quickly, end of the second week. Got some recommendations from other physicians in private practice and hired a virtual assistant from a California company (so BAA signed with them) that sources their assistants from the Philippines. Generally happy with him; he answers the phone and manages scheduling. He's been making more and more careless mistakes recently though, so need to figure out better processes to ensure he's doing his work correctly. Mistakes were initially small but are getting bigger; this week completely neglected to call our waitlist the day before to get an appointment slot filled. End result was a full hour slot going unfilled despite a long waitlist and people booking new patient appointments in July.

I too fired my first assistant for egregious errors and incompetence but now have an excellent one that I found off of the private practice psychiatry FB group. I would advise against using some of these companies that hire abroad such as in the Philippines as you open yourself up to liability in many ways and they generally are not available during the times we need them to be to answer the phone.

Structure
This has been a sole proprietorship up until now. Given how it's grown, logical step was to tax as an S-corp. In order to do that, need to make it a professional corporation. I considered doing it myself but saw a number of therapy FB groups were they strongly recommended getting a lawyer to set it up. I paid one to set it up, I think about $2000, and really regret it. They took forever, missed filing a document that they were supposed to, and still haven't gotten back to me about getting the DBA name switched over. After seeing multiple psychiatrists post on psychiatry FB groups that they set it up themselves, pretty sure I should've done that instead. Oh well.

I switched to S corp this year and it's been more of a logistical headache than I thought. Switching my sole proprietorship accounts to an S corp account required me to clean up my books, any expenses that hit my sole proprietorship account needs to be considered a business to business transaction for accounting purposes, and I had to clean up my books and become more formalized/structured in my bookkeeping. I use QuickBooks Online and had their Live Bookkeeper clean up my accounts for $500 and I'm paying their monthly bookkeeping fee to keep it up to date. I can't be bothered.

I used LegalZoom and it was as much of a streamlined process as it could be. It's a bit confusing to figure out the forms, such as filing a "Notice of Transaction Exempt Pursuant to Corporations Code 25102(f)" or submitting the S corp document form 2553 within 15 days. It's confusing.

Accounting
Following up with the S-corp bit, need to find an accountant. The lawyer who set up my PC gave me a referral to an accountant....who charges about 20k a year. I can't imagine how complicated my tax situation would have to get before it would be worth paying 20k to a CPA. I spoke to a few other ones. They all quoted me around 5-7k a year which seems quite steep. I found one off White Coat Investor who said he wouldn't be a good fit for me if I have any plans to expand beyond a solo practice but referred me to a colleague of his. He quoted me 2k a year which would've sounded great at the beginning but after getting all these 5-7k/year quotes, idk if I'm missing something. I ended up going with him, just had my first meeting today. It was a bit of a bait-and-switch, I was assigned to work with his associate rather than him. For now I'll stick with him just because I have too many things going on in my life right now to keep looking for accountants but there's a high chance I'll move over to someone else next year if things aren't satisfactory this year.

My accountant charges me $2k for personal/state tax return and then $2500 for the S corp tax return.

Software
Up until now, I've been doing my bookkeeping with Quicken Simplifii (where the screenshot above is from) because it's all just my income. I categorize income by payer (Aetna, Cigna, Anthem, "Cash", etc) and keep track of my expenses there. It's worked well for me but I can't keep doing that with the S-corp. The accountant strongly recommend QuickBooks Online. Doing an online search, it seems QBO has almost universally negative reviews. All my business/startup friends also have negative things to say about it. However, it seems to have good reviews from psychiatrists on the psychiatry FB groups I'm on. So I'm considering that or Wave.

For payroll, accountant strongly recommended ADP. The sales rep tried to pull a fast one, quoting me about $90. I asked him, "So when you say it costs $90, is that monthly?" He mumbled yes and changed the subject. Asked for the quote in writing and the email just said $90 without monthly. Asked him to clarify and he's like, "Oh yeah, let me fix that in the quote" and sent over one that said $90 per payroll. I asked him how often payroll was, isn't that usually biweekly. He's like, "Well no, it's actually weekly, but you're getting a huge discount." Clarified again with him, it's actually $360/month. Really don't think that's worth it for me. I've looked at Gusto which is significantly less. QuickBooks Online has payroll and I believe Wave has their own too. I've heard mixed reviews of all of these though.

I use QuickBooks Online and really like it. $30/mo. It automatically pulls in all my credit card and bank accounts into expenses and income and then tries to guess at which category to put them in. You can make profit and loss reports easily on it so I can tell how much I'm netting.

I use Gusto for Payroll and really like it. $40/mo regardless of biweekly, bimonthly, or monthly.

Life/future

A psychiatry resident who'll be doing the same fellowship that I did reached out about moonlighting in my practice. I know him and would be completely comfortable with him joining but need to figure out logistics. My insurance contracts are all based on my NPI1 and sole proprietor EIN. I believe I need to switch over to an NPI2 and a professional corporation EIN to start hiring people under me. That process has been started somewhat but I'm not sure if my insurance contracts can just switch over to an NPI-2. I really don't want to negotiate rates from fresh so hopefully there's some mechanism to transition from solo to group practice.

I'm thinking about this too. I'm not sure how to do it from an insurance standpoint though.

Up until now, I've been doing 20 clinical hours a week in 2024. That'll stay the same in my practice but I'm starting a 0.5 FTE academic position soon. So I'll be going to full time work. It's been nice being half clinical (although my other half gets more than full with admin and forensic work so I'm worried that now I'll be doing 1.5 FTE instead of a full time job).

I'm going to stay at around 20 hours per week and spend the rest of my time with family/friends/golfing.

 

[brazilianpsych]

I am reading this thread and considering opening a tele private practice next year, would also be accepting insurance. This thread has been very very helpful.

Would you guys recommend getting a NPI-2 from the start, to save future headaches? Also, is it worth to do an LLC or something at first? Or just sole proprietorship, and worry about LLC/S Corp when/if I hire more people in the future?

I cannot practice in the state I currently live, but also cannot leave because of my wife. I am considering opening a PP in another state, considering Florida due to no income tax. From what I am researching, seems some states would require me to file tax there. Appreciate any thoughts regarding that.

 

[Sushirolls]

NPI-II keeps options open for expansion if needed.
Harder to revert/change contracts to accommodate NPI-II down the road, then if you just do it form the start.
LLC or PLLC allows any leases or contracts to be tied to just your business. I.e. avoiding personal guarantees. I had leases that would try to sneak in personal guarantee. So if you die your spouse or 'estate' gets stuck cleaning up your mess. Easier to have a corp that burns to ashes than things spilling over into personal.

 

[brazilianpsych]

Bumping this threat as I found very helpful. I am on a very similar path and had some questions in case anyone is able to answer:

- I was thinking about opening a tele private practice during residency (PGY4,). Is it possible to panel myself with insurances still in residency? My goal would be to have things moving so I could safely start my PP after residency. Otherwise going full PP is too much of a risk for me, since I would have zero income for a while.
- There is some great info in this thread, but which insurances have been the best ones for tele psych? Or it doesn't matter that is tele? I will review the thread and get a list of insurances recommended here as well.

Appreciate if anyone knows about the first question.

 

[brazilianpsych]

Bumping this threat as I found very helpful. I am on a very similar path and had some questions in case anyone is able to answer:

- I was thinking about opening a tele private practice during residency (PGY4,). Is it possible to panel myself with insurances still in residency? My goal would be to have things moving so I could safely start my PP after residency. Otherwise going full PP is too much of a risk for me, since I would have zero income for a while.
- There is some great info in this thread, but which insurances have been the best ones for tele psych? Or it doesn't matter that is tele? I will review the thread and get a list of insurances recommended here as well.

Appreciate if anyone knows about the first question.

I am now thinking I asked the first question before and I was told you do need to be done with residency. Pretty sure about it, but not 100%. Guess I won't be able to open a practice as soon as possible. Another possibility for me is to do cash pay, but OP tried that and had a hard time.

 

[calvnandhobbs68]

Bumping this threat as I found very helpful. I am on a very similar path and had some questions in case anyone is able to answer:

- I was thinking about opening a tele private practice during residency (PGY4,). Is it possible to panel myself with insurances still in residency? My goal would be to have things moving so I could safely start my PP after residency. Otherwise going full PP is too much of a risk for me, since I would have zero income for a while.

I am now thinking I asked the first question before and I was told you do need to be done with residency. Pretty sure about it, but not 100%. Guess I won't be able to open a practice as soon as possible. Another possibility for me is to do cash pay, but OP tried that and had a hard time.

Medicare/Medicaid possibly if you have an unrestricted medical license, you're right with private insurances almost certainly not. They all want to know if you're board certified or board eligible. This is usually the issue with your first job if you're working for a private group where you'll bill under your own registration, it takes a while to get registered with insurance plans and you can't do it until you've graduated from a residency.

OP was a fellow so was board eligible for general psych.