Tools for starting a private practice

[zolof]

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Curious about this too. My understanding is that yes, you can most definitely fire your patients, whether they’re paying cash or on United/some other insurance if they’re not following your prescribed treatment plan.

I have never had any issues with firing patients who don't follow treatment recommendations, and none have very complained, and I have never seen any issues with it when I researched it. If it ever comes to it, I clearly tell them this up front and say you welcome to find another psychiatrist for a consult. But the real secret is I screen all new patients and refuse to even schedule the potential nightmare patients. Of course the practice builds slower but if you take some insurance its still fast.

 

[Mastac741]

I was also thinking of screening them as well and sending them kind of an online brief intake. What is your strategy for not scheduling them if you've identified a probable bad patient? Do you just never call them back? Tell them it's not a good fit?

Also, Zolof -> I've been trying to figure out how much insurance reimburses for say a 99213, 99214, 90792, 99204. Physician fee schedules are only available to providers who already signed a contract. I called them up today, and they refused to tell me their in-network reimbursement. I was like "How do I know I want to join your network if you won't tell me how much you reimburse?" They wouldn't tell me. It's so messed up.

I know it varies by location, but any idea of BlueCross/Blue Shield, Aetna, or UnitedHealthCare how much they reimburse?

 

[zolof]

I was also thinking of screening them as well and sending them kind of an online brief intake. What is your strategy for not scheduling them if you've identified a probable bad patient? Do you just never call them back? Tell them it's not a good fit?

Also, Zolof -> I've been trying to figure out how much insurance reimburses for say a 99213, 99214, 90792, 99204. Physician fee schedules are only available to providers who already signed a contract. I called them up today, and they refused to tell me their in-network reimbursement. I was like "How do I know I want to join your network if you won't tell me how much you reimburse?" They wouldn't tell me. It's so messed up.

I know it varies by location, but any idea of BlueCross/Blue Shield, Aetna, or UnitedHealthCare how much they reimburse?

Its such BS. They did the same to me. So at one point i just decided to try some of them out. It is very regional, and extremely individualized by each patients plan to the point one person aetna plan pays different than another's Aetna plan. So it's unpredictable. One thing for sure, is you will get slammed with patients so getting full is not a problem if that is what you want but of course will need some office help in that event.

 

[Mastac741]

+ Quote

It's good to know they treat us all poorly equally. What software do you use to get reimbursed? Do you have your own biller or do you Bill yourself?

Sorry for all the questions. Trying to figure this out before I quit my job.

 

[splik]

Hi, still mulling over starting my practice. I think I'm getting close to making the dive. Just another insurance question: Is it true that once you take one Medicare patient that you have to take all of them (if you're accepting new patients)?

Is this true for Blue Cross/Blue Shield or UnitedHealthCare? If you are contracted with them in-network, can you refuse to see nightmare patients who have their insurance?

I would like the ability to fire patients if it's not working out.

You can see whomever the hell you want and terminate (I don't like the term "fire" since you work for them, not the other way round) without even giving a reason as to why, but must provide referrals and if appropriate refills as well as copies of records to the new psychiatrist and send a letter of termination by certified mail. It is really much better to screen out nightmare patients in the first place rather than terminate with them, which could lead to headaches (e.g. stalking, medical board complaints, frivolous lawsuits, violent/threatening behavior etc).

If you accept medicare then you do have to be open to taking medicare patients but that does not mean you have to take every medicare patient who comes your way. it isn't worth your time to see literally one medicare patient (it would have to be a decent % of your patients), but you probably do not want to fill your practice with them unless you are in area of sh*tty insurances where medicare pays similar or better to private insurances.

 

[TexasPhysician]

Also, Zolof -> I've been trying to figure out how much insurance reimburses for say a 99213, 99214, 90792, 99204. Physician fee schedules are only available to providers who already signed a contract. I called them up today, and they refused to tell me their in-network reimbursement. I was like "How do I know I want to join your network if you won't tell me how much you reimburse?" They wouldn't tell me. It's so messed up.

I know it varies by location, but any idea of BlueCross/Blue Shield, Aetna, or UnitedHealthCare how much they reimburse?

Your questions have no answers. Insurances will have quite different rates for providers on the same street. In addition, you sign a non-disclosure agreement that says you won’t discuss rates.

 

[PistolPete]

I have never had any issues with firing patients who don't follow treatment recommendations, and none have very complained, and I have never seen any issues with it when I researched it. If it ever comes to it, I clearly tell them this up front and say you welcome to find another psychiatrist for a consult. But the real secret is I screen all new patients and refuse to even schedule the potential nightmare patients. Of course the practice builds slower but if you take some insurance its still fast.

What patients do you screen out?

 

[zolof]

What patients do you screen out?

Usually Pts on crazy regimens for example, morphine and xanax, from a MD who is retiring, and they want to continue the regimen, and by the way they have no medical hx, fully healthy, no pain hx, no surgeries, no substance use history according to them, or someone who is frequently hospitalized, needs injectables, or someone who needs additional services, case management etc, that my office doesn't have. I am only part time and already beyond full as it is with pretty high functioning pts.

 

[PistolPete]

Usually Pts on crazy regimens for example, morphine and xanax, from a MD who is retiring, and they want to continue the regimen, and by the way they have no medical hx, fully healthy, no pain hx, no surgeries, no substance use history according to them, or someone who is frequently hospitalized, needs injectables, or someone who needs additional services, case management etc, that my office doesn't have. I am only part time and already beyond full as it is with pretty high functioning pts.

Cool. Your local area pharmacist can’t give them injections in-pharmacy? Do you screen out patients with personality disorders, such as Cluster B, and if so, how?

 

[Indodo]

I was also thinking of screening them as well and sending them kind of an online brief intake. What is your strategy for not scheduling them if you've identified a probable bad patient? Do you just never call them back? Tell them it's not a good fit?

Also, Zolof -> I've been trying to figure out how much insurance reimburses for say a 99213, 99214, 90792, 99204. Physician fee schedules are only available to providers who already signed a contract. I called them up today, and they refused to tell me their in-network reimbursement. I was like "How do I know I want to join your network if you won't tell me how much you reimburse?" They wouldn't tell me. It's so messed up.

I know it varies by location, but any idea of BlueCross/Blue Shield, Aetna, or UnitedHealthCare how much they reimburse?

Don't be in too much of a hurry to screen out patients.
See them and if you don't have a good rapport after a few visits, then you can let them go. Nobody can tell you to keep seeing someone. I don't know if it varies but for the most part you don't (and shouldn't) have to give a reason for ending the relationship.

We are the end of the line in mental health. We are trained to be able to do everything.
If they can't come to us, where else are they going to go?
This is especially true early on when you have time.
How do you think these patient's PCPs feel?
Now you come in and suddenly there's pink fluffy unicorns dancing on rainbows.

 

[psyguru]

This is in Houston, $200-350 for new eval and $100-150 for 30 min f/u

I know the quote is from 2016. At this new practice I am joining, for the out of pocket patients, they will be charging $600 for new eval and 200 for follow up on the SW side of Houston. Of course we will be taking insurance as well. Have prices gone up?

 

[TexasPhysician]

I know the quote is from 2016. At this new practice I am joining, for the out of pocket patients, they will be charging $600 for new eval and 200 for follow up on the SW side of Houston. Of course we will be taking insurance as well. Have prices gone up?

No, not much. I expect that the majority of your patients will use insurance which will not reimburse at those rates.

 

[Shufflin]

I know the quote is from 2016. At this new practice I am joining, for the out of pocket patients, they will be charging $600 for new eval and 200 for follow up on the SW side of Houston. Of course we will be taking insurance as well. Have prices gone up?

Is this for C&A? Those intakes can easily run 90 to 120 minutes, hence the $600 price tag.

In the adult world, in some of the most expensive parts of California, top rates seem to be $500 an hour for initial intakes.

 

[psyguru]

Adult. 45 minutes per the schedule but with charting maybe more.

Sent from my SM-G965U using Tapatalk

 

[Sushirolls]

Let's add this thread to the lineup:

Private Practice in Progress

Building a private practice, N of 1. Enjoy. Month zero: Grand plan was to use money from inpatient gig where independent contractor doing own billings to expedite insurance paneling, so all I had to do was switch over the practice address once opened. Long story short, not a quality place I...

forums.studentdoctor.net

 

[Sushirolls]

Information on companies that will allow you to process credit cards

Payment Processing in private practice

I'm curious to learn what those of you in private practice are using for your payment processing, what the rates are, how your experience has been, etc. I've been using the processor integrated into luminello called blue fin. I've had a few speed bumps with them. Overall it's relatively smooth...

forums.studentdoctor.net

 

[Sushirolls]

Niche Specialty Clinic for Economic Success?

.

forums.studentdoctor.net

 

[Sushirolls]

90833 documentation requirement with E&M code?

How do you document time spent? For example total 18 minutes spent on therapy or do you need to specify start and end time in specific spent on therapy? I am billing E&M based on complexity but not clear on therapy add-on. Also what else do you document about therapy interventions? Do you...

forums.studentdoctor.net

Experience billing +90833 when patient already has a therapist

So of course I am asking people locally as well, but I wanted to get a sense from the hive mind about how much pushback you get when using the +90833 add on code to 99213/4/5. Any advice or wisdom appreciated. As I mentioned in another thread I am looking at a position with a specialized...

forums.studentdoctor.net

 

[Sushirolls]

Coding Question 99205

I've read some coding threads, however, still have questions on coding a 99205 for a new outpatient visit. I recently started a solo practice, and have never had to code for myself and then rely on myself with definitive certainty that I am coding correctly. I easily spend over 60+ minutes with...

forums.studentdoctor.net

 

[Sushirolls]

Some Private Practice Pet Peeves

1) Patient is clearly dangerous and the police refuse to take the patient to the hospital saying it's not their job even when I show them where in the state statutes it is their job, and they still refuse. 2) Patient changes their phone number (and/or address) doesn't tell us they changed it...

forums.studentdoctor.net

 

[Sushirolls]

LAI in solo/small private practice

Logistically, how does that work? Do you prescribe and have a pharmacy administer the injection or do you stock the medication in your office? Or do you just avoid/refer out to larger practices?

forums.studentdoctor.net

 

[Sushirolls]

Teaching med students in the private world

I’ve had a medical school approach me about having 1 medical student rotate through my cash private practice. It would be a slow transition with year 1 being 1 student for about 3 weeks. 3 weeks break between students. Part of me thinks that I could utilize med students to get some history on...

forums.studentdoctor.net

 

[Sushirolls]

Brief Emotional-Behavioral Assessment 96127

My understanding is this can be submitted for reviewing and documenting results of the PHQ-9 and GAD-7. And submitted for each assessment. Even for the columbia suicide screen. Have others used this yet or learned anything about its documentation needs in order to submit? Low lying fruit...

forums.studentdoctor.net

 

[MLT2MT2DO]

Internet advertising questions:

Does anyone have any good resources for SEOs or other tips regarding social media and internet advertising? I am looking at moving to a practice that has a great/albeit older psychiatrist that I feel could use a bit more internet advertisement, especially since I'll be coming on soon with a panel I'm looking to fill early rather than later. There is already a website and while it is bright and pleasing to the eye it has some broken hyperlinks. Additionally the practice changed names 2 years ago and if you search by the older name it doesn't bring up the website (hence how I stumbled across SEOs).

While I'm not a spring chicken I feel I have enough technical computer skills that this is something I could help with immediately, but would also prefer not to use an "agency", I'm just struggling where to start as everything I come across seems to be pseudo advertisements for companies that want to get paid to do this for you.

 

[Sushirolls]

The practice needs to be the one to contract with a website/SEO firm to tidy things up and possibly consider the monthly costs of SEO. That can be $50-5000/month.

 

[hebel]

For people who have patients fill out screening/information packets prior to the patient's first appointment, what medicolegal responsibilities are there if a patient endorses suicidal ideation when they complete the packet?

I'm especially talking about situations where they are sending this information in prior to the day of their intake appointment.

 

[romanticscience]

For people who have patients fill out screening/information packets prior to the patient's first appointment, what medicolegal responsibilities are there if a patient endorses suicidal ideation when they complete the packet?

I'm especially talking about situations where they are sending this information in prior to the day of their intake appointment.

That is tricky. There has been a discussion on here about being strict with the language that the first appointment is only a "consultation." However, I know of a legal case or two, where the courts interpreted giving a patient an appointment as a "patient-doctor relationship." There is always medico-legal risk. You just have to mitigate it the best you can. I've added this disclaimer to the beginning of my appointment request form:

This form helps prospective patients connect more efficiently and explore whether this provider will be a good fit. Completion of this form is not a guarantee of treatment nor does it establish a doctor-patient relationship.

If you are or believe you are experiencing a medical or psychiatric emergency, including suicidal or homicidal thinking, side effects to medication, or any other urgent or time-sensitive matter in which you need an immediate response, do not use this service. Instead, call 911 or go to your closest emergency room.


* Required
I acknowledge and wish to proceed. *
Yes
No

Further reading: Marett, C. P., & Mossman, D. (2014). What are your responsibilities after a screening call?. Current Psychiatry, 13(9), 54-58.

 

[Sushirolls]

The EMR, Luminello, has this for requesting a consult electronically:


This form helps prospective patients/clients and providers connect more efficiently and explore whether the requested relationship will be a good fit. As provider skill sets, availability, and financial policies vary, this form helps ensure you find the right provider for your needs.
If you are or believe you are experiencing a medical or psychiatric emergency, including suicidal or homicidal thinking, side effects to medication, or any other urgent or time-sensitive matter in which you need an immediate response, do not use this service. Instead call 911 or go to your closest emergency room.

[check box here] This request is not an emergency or urgent matter. I wish to proceed

 

[liquidshadow22]

Is there a discharge letter that can be sent to patients through Luminello? Or do you mail your own letters to patients?

 

[Sushirolls]

Is there a discharge letter that can be sent to patients through Luminello? Or do you mail your own letters to patients?

I print a template on letter head.
Sign it.
Scan it into PDF and use Luminello to message it to patients. If my intake process is 100% online, I use the same to exit patients.
I also then take that physical copy of the letter and standard mail it to patients.
Luminello also has the ability to see if people opened their messages in the pseudo-email inbox.

 

[NPDude362]

This thread is amazing!! Thanks for all the valuable resources and insights. I am looking to open a private practice soon.

 

[rjs2131]

Joined a PP and been at it for about a month - some slow days, some busy days. Taking a few insurances + cash. CAP + adult patients. 90 min news, 30 min follow-ups. Trying to be patient as things build.

Question for those who have gone through this process - is there a way to correlate new patients/week and time until you are full? Alternatively, how many total patients should I be aiming for? Obviously more new patients is better, but I want to make sure I'm setting myself up for success and am hoping to be consistently busy by month 3 or 4. I'm currently averaging something like 6-8 news/week and aiming for 30 clinical hours/week once full.

 

[FlowRate]

Joined a PP and been at it for about a month - some slow days, some busy days. Taking a few insurances + cash. CAP + adult patients. 90 min news, 30 min follow-ups. Trying to be patient as things build.

Question for those who have gone through this process - is there a way to correlate new patients/week and time until you are full? Alternatively, how many total patients should I be aiming for? Obviously more new patients is better, but I want to make sure I'm setting myself up for success and am hoping to be consistently busy by month 3 or 4. I'm currently averaging something like 6-8 news/week and aiming for 30 clinical hours/week once full.

It's mostly dependent on your average time to follow-up.

Assumptions:
Average f/u is 6 weeks
You work 5 days per week, 12 f/u's per day
No dropout, no extension of follow ups

Then you need 6*5*12 = 360 patients to be full.

If you saw 4 new patients per day then you would hit 360 patients in 18 weeks.

Your actual attrition rate, no-show rate, and average time to f/u will be dependent on personal practice and patient population.

FWIW the above describes my typical practice (typically 6 weeks f/u for initial or big changes). At first I was seeing up to 6 intakes per day. I've been at my job for a little over a year and now I see about 0-3 per day (maybe average 2 intakes per day.) I have about 550 patients on my panel and can schedule people pretty comfortably.

 

[rjs2131]

It's mostly dependent on your average time to follow-up.

Assumptions:
Average f/u is 6 weeks
You work 5 days per week, 12 f/u's per day
No dropout, no extension of follow ups

Then you need 6*5*12 = 360 patients to be full.

If you saw 4 new patients per day then you would hit 360 patients in 18 weeks.

Your actual attrition rate, no-show rate, and average time to f/u will be dependent on personal practice and patient population.

FWIW the above describes my typical practice (typically 6 weeks f/u for initial or big changes). At first I was seeing up to 6 intakes per day. I've been at my job for a little over a year and now I see about 0-3 per day (maybe average 2 intakes per day.) I have about 550 patients on my panel and can schedule people pretty comfortably.

Appreciate the input!

I'm actually seeing almost all of my patients back in ~1 week from the initial eval and will generally space things out to 3-4 weeks after this point unless they need more frequent visits. I think I've got close to 40 patients at this point so hoping to keep ramping up for a few months.

 

[Sushirolls]

My solo practice is in a saturated area. My rate of growth is slow largely from that and partially from my intake process.
I do about 2.7 new consults per week.
Usual attrition and also dropping a low paying insurance recenlty, I'm up to about ~135 patients at the 2.5 year mark.

When I do calculations I look at total weeks of the year, which is 52.
Subtract weeks of vacation, 6, leaving 46 weeks.
46 weeks /4 = 11.5, because I require at minimum to see all my stable patients once every 3 months.
11.5 weeks * 54 the number of potential follow up slots per week (in my 27hr clinical schedule) = 621

So in theory, my hypothetical ultra max patient panel size is 621 unique patients. From that you need to chin stroke and reflect on how many people are coming in every 4 weeks or 6 or 8 or 10, etc and not every 12 weeks. I suspect I'll be full for my 27 clinical hours per week at some where between 300-400 patients, depending on follow up frequencies of the patient panel.

 

[trixter888]

Sorry if this may have been covered elsewhere. But I was wondering if others may be able to help.

I am currently a 1099 through a private practice located in my community. I am currently undergoing credentialing with the private practice, and as such my NPI, Malpractice Insurance, etc. is currently through this private practice.

I wanted to start branching out and building my own private practice (cash only) on the side. Can someone help me with/if my information needs to be updated. I would like to stay credentialed with this practice for now as a 1099, however I am not sure if I need to change my NPI, create another NPI (NPI I and II) or if there are other things I am missing. I assume I will have to update my malpractice insurance.

Can someone write out things you think I would need to do to start a micro cash practice on the side?

Thanks!

 

[Zyprexa100]

I am noticing that community mental health centers pay more than private practice hourly rate

 

[TexasPhysician]

I am noticing that community mental health centers pay more than private practice hourly rate

I would assume your location is an anomaly.

 

[ElanaMD]

There's a lot of really good advice on this thread and I just wanted to add a little about my experience since starting my private practice in 2017, because the type of practice I have seems a little different from what other people are describing they do so I wanted to share just another option of how you could design and structure your ideal practice.

I have a cash pay, concierge/"high touch" psychiatry private practice. I am in Los Angeles, which is a large, urban area but I mentor a group of early career psychiatrists starting private practice and there are people with similar successful practices in Iowa, Indiana, Wisconsin, Nevada, etc, so geography is NOT a limitation for setting up this kind of practice.

I practice integrative psychiatry, which is NOT alternative psychiatry or homeopathy - it's standard of care psychiatry with "extras," and a way of thinking about the patient from a holistic, relationship-oriented perspective. I do functional evaluations and integrate low-risk evidence-informed complementary approaches into my treatment plans, like mind-body practices, nutraceuticals, dietary interventions, and of course psychotherapy.

What I do is not for everybody, so the kind of practice I describe may or may not resonate with you. I can say though that I absolutely love what I do and I'm happy every day I get to do it. I was never going to be someone happy in a regular job like a community setting or academic center or HMO system like Kaiser. I'm a control freak and an entrepreneur and heart and there's nothing better to me than having total autonomy to create my dream practice exactly as I want it.

First things first: f you want to have a successful private practice WITHOUT accepting insurance the first thing you need to understand is that if you are not clear on what differentiates you from other psychiatrists, there is no real reason why a patient will pick YOU to see as opposed to someone else. If you are just like any old psychiatrist, then growing your practice will be a haphazard process of who randomly stumbles upon you via referral or psychology today or whatever, as opposed to people actively seeking you out.

You will essentially be a commodity (although a highly trained one), which means that patients will see you as interchangeable with any other psychiatrist and will therefore shop based on who is cheapest/has the worst boundaries/will just prescribe them Xanax or whatever.The more you communicate what makes you unique on your website or when communicating with patients, the more the "right" kind of patients for you will self-select into your practice.

There are certain ducks you need to get in a row before starting your practice (I reviewed my recommended software solutions for starting a private practice in this thread: What EMR to use in solo private practice?) but the biggest mistake I see early career psychiatrists make is trying to be too perfect right out of the gate. The limiting factor to filling your practice will almost certainly NOT be your clinical skills (although you should always grow your clinical skills) or the fact that you haven't yet incorporated or written the perfect office policies or opened your business bank account. It will be that you don't know enough about marketing. In the beginning, your main focus should be getting patients in the door and mastering some basic marketing fundamentals.

Someone asked here about social media/online marketing or potentially hiring ad ad agency. I don't think this is necessary. I filled my entire practice though 1) Psychology Today, 2) referral sources, and 3) Google ads. Now I get patients mostly through organic search traffic, but those first 3 things are how I built my practice initially.

Honestly, if you really master those 3 marketing strategies you will fill your practice. Look at your competition on Psychology Today in your geographic area and write a better profile than them (it shouldn't be that hard - avoid jargon and speak the language your patients speak). For referral sources, don't limit yourself to therapists or PCPs, think bigger -- where are your ideal patients hanging out, and what services do they use? Do they see functional MDs, go to hot yoga, go to acupuncturists? Do they go to gyms, hire personal trainers, see massage therapists? Put yourself in the shoes of your ideal patient and imagine where they go and see if you can find them there.

If you are considering paid ads, you really, really need to understand the concept of return on investment/ROI. I teach people how to do Google ads and inevitably everyone starts and puts in $100 and then freaks out when they don't have a patient yet and then they quit. That's WAY too soon to give up. There is a learning curve with paid ads and but once you get it down it's like a spigot you can turn on/off to get patients. On the other side, people will throw away thousands monthly on an ad agency and not get a single patient. As long as you are making more money off the patients you see than you are spending on ads, you are in good shape.

Social media is useful not because you will find patients that way (think about it-- social media is international, where are you are probably licensed only in one or maybe a few states). Social media is useful because after a patient hears your name (say via a referral source) they will Google you (when's the last time you used a service provider without Googling them first??). So if you have social media posts/videos/blog posts/etc available it will be more data that patients can use to learn more about you and decide to see you as opposed to someone else. I often have potential new patients tell me they decided before even talking to me that they wanted to see me just because of something they read on my website or social media that resonated with them.

This brings me to my next point, which is, if you have a med management only practice (without doing psychotherapy) it will take you FOREVER to fill and you will need 500+ patients to have a full practice. If you do therapy, you can have a full practice with 50-100 patients. I love it because I can be a "one stop shop" for my patients -- I don't just tweak their meds and send them on their way, I work with them in a comprehensive way to improve their lives. So if you are remotely comfortable, consider adding psychotherapy services to your practice. Even if you aren't comfortable, get some additional supervision/training and learn as you go.

I hope this helps!