roastedcapers

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Hello,

I have an EHR and billing software that are not linked together. My biller sends me statements each month that state the appointment date, what was billed, how much was adjusted, how much has been paid so far. The appointments are in order by patient. It seems kind of time-consuming, but I guess the best way to make sure they billed all the appointments is to go through each pt's dates of appointment and compare them to the excel doc he sends me? This would require me to go into each patient's account one at a time and look at their appointments from the month and compare to the spreadsheet. I suppose it would take 2 hours.

Do your billers do anything different to make the ability to actually see what was billed/paid for each appointment less obtuse for me? I guess I'm not trusting that they are doing everything right, maybe I just need to trust them...

Just wondering if anyone has come up with a solution.

Thanks!
 
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PsyDr

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Take a piece of paper: fold it in half to create a crease. write down each appointment on one side. write down an associated CPT code on hte other side (e.g., 99214, whatever).

Throw each paper in a pile. Scan that stuff once a week or whenever your admin time is. Compare to billing.
 
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Sushirolls

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1) When ever I finish my note, whether that day or several days later, I assign the E&M code, and any other E&M additions like 96127, or 99406, 90833 etc. 2) I create a task on Luminello for my assistant to do the billing. She then creates a bill statement for that date of service, and uploads it to the billing company I use.
3) Billing company does the data entry and submission thru their clearing house to the appropriate insurance company.
4) I get an EFT (electronic fund transfer) and/or emails from the various insurance companies saying they have paid or been processed.
5) I then create a task for my assistant to go to that Insurance company to pull the freshest PDF of the EOB (explanation of benefits) also sometimes called an ERA. Some companies I still get mailed EOBs and check. I deposit the check, and hand the EOB to the assistant to process.
6) Assistant then inputs those numbers from the EOB into our billing apparatus in our Luminello EMR.
7) Next we generate the bill statement PDF to electronically send thru Luminello the remaining balance due by the patient, and rarely send a paper bill to patients if needed.
8) Easiest is patient entry into luminello and they pay with their credit card and balance is 0, and automatically reflected on Luminello. Or we get mailed a check that I then deposit, and have assistant data entry on Luminello as a payment.

We keep 3 electronic folders. One for the initial bill generated on the date of service. Once insurance generates an EOB we move the bill and the EOB statement to a second folder. Once the patients pay off their portion for that date of service we move it to a finalized folder.

By having these three folders we can very quickly assess what's pending process by insurance, and what's pending payment by patients. Look for the oldest dated items and sniff out any issues needing correction. Any identified issues or odd EOBs or we direct back to the billing company to help sort out what's going on.

At no point is my assistant depositing checks or tinkering with the bank account, which drastically reduces issues of embezzlement.

In the first few months of my practice I did all this myself, so I know the process well, before I handed it over to my assistant who figured it out in less than a month.

My work flow is different from many people and heavier on us than the billing company. I set it up this way to reduce patient frustrations, because my own experiences in life have shown poor billing practices quickly tick people off and this work flow prevents the billing company from sending their bills inappropriately that than fuels patients calling the office wondering what's going on. We always have a few odd billing cases simmering in the background waiting on some random stuff that the less people involved the better.
 
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Sushirolls

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At some point I plan to transition away from using a 3rd party billing company to use the integrated clearing house within Luminello. I'll still do the usual E&M entry, and initial submission with Luminello. My assistant will do the follow up / quality control review to make sure things are processed appropriately and no bills fall thru the cracks.

For now I delay this due to uncertainty of processing medicare thru this integrated Luminello feature.
 

RomanticScience

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Here's how I'm able to do my own billing without staff using office ally.

1) Complete note in the EMR module, designate ICD and CPT codes.
2) Sign note and "create visit"
3) Go to the "visit" and "create claim;" claims are automatically submitted to the clearinghouse.
4) Payments from insurance companies directed deposited to my bank accounts.
5) Later, electronic ERAs are received in the EMR and can be posted to pt's accounts/visits automatically.
6) If there's a remaining balance, update it so pt can pay through the patient portal using a credit card.
7) Apply the remaining patient payment.
8) From time to time, look through "visits" to see if there are "outstanding balances"
 
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roastedcapers

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Here's how I'm able to do my own billing without staff using office ally.

1) Complete note in the EMR module, designate ICD and CPT codes.
2) Sign note and "create visit"
3) Go to the "visit" and "create claim;" claims are automatically submitted to the clearinghouse.
4) Payments from insurance companies directed deposited to my bank accounts.
5) Later, electronic ERAs are received in the EMR and can be posted to pt's accounts/visits automatically.
6) If there's a remaining balance, update it so pt can pay through the patient portal using a credit card.
7) Apply the remaining patient payment.
8) From time to time, look through "visits" to see if there are "outstanding balances"

Do you generally like Office Ally?
 

RomanticScience

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Do you generally like Office Ally?

It gets the job done for a solo practice, only because I've set it up to work for my workflow. It would be too cumbersome to share use with other staff.

It's exceptional from a billing standpoint (accounting, billing, EOBs, claim submission) so when it comes to prioritizing ease of use with $, I prioritized the latter.

If I were cash only, I'd probably be using luminello.


Sent from my iPhone using SDN
 
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Sushirolls

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Luminello does have the same integration, too. I just opted out of it initially because I was billing Medicare and had a vision of bringing on another doctor and dealing with inpatient/hospital locations for ECT procedure. That level of complexity with multiple locations I wanted an external billing service. At some point I'll switch to 100% Luminello because I'm not doing that now.
 

RomanticScience

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Luminello does have the same integration, too. I just opted out of it initially because I was billing Medicare and had a vision of bringing on another doctor and dealing with inpatient/hospital locations for ECT procedure. That level of complexity with multiple locations I wanted an external billing service. At some point I'll switch to 100% Luminello because I'm not doing that now.

What's the ApexEDI like? Have you used it at all? Is it another website?


Sent from my iPhone using SDN
 

Sushirolls

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I haven't used it yet, but some of my quick glances on Luminello help section look promising.

I'm jittery about its medicare interface. I haven't looked to see if it can submit to medicare on the Luminello help section area. If it does, I could possibly make the switch now. My understanding on the Luminello help section is almost all bill claim submissions you do thru Luminello, when you close your note electronically, are sent via luminello to ApexEDI who then sends to insurance companies. The EOBs numbers are then conversely automatically loaded back into Luminello once processed. I'm not clear if you get sent a separate message with the actual EOB, or if you have to log in to ApexEDI separately to get it.

Certain situations you'll have to revert to manual entry on both Luminello and logging into ApexEDI (another website) to submit the claim (like double insurance coverage), but I suspect for me that will be 3% or less of the claims.

My first glances looks like it will have the user ease I hope for and lower costs than my current billing arrangement. $99/month compared to my current $500-700/month.

I really hoped someone else here on SDN had been using this feature to comment more about it.
 
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finalpsychyear

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Here's how I'm able to do my own billing without staff using office ally.

1) Complete note in the EMR module, designate ICD and CPT codes.
2) Sign note and "create visit"
3) Go to the "visit" and "create claim;" claims are automatically submitted to the clearinghouse.
4) Payments from insurance companies directed deposited to my bank accounts.
5) Later, electronic ERAs are received in the EMR and can be posted to pt's accounts/visits automatically.
6) If there's a remaining balance, update it so pt can pay through the patient portal using a credit card.
7) Apply the remaining patient payment.
8) From time to time, look through "visits" to see if there are "outstanding balances"

I use the same. However, when i got out of residency i did almost every training video for the EMR/Billing/Etc must have been 20-30 hours to learn the entire suite, billing, emr, scheduling, etc inside out. I had time since i jumped straight into PP. Not sure how long it would take to teach someone else.

The best and greatest thing anyone could possibly do for billing is make an extremely thorough benefit check and then you should know almost exactly what the patient will owe prior to the visit let them know and collect it at times of visit unless their insurer wont allow that but notify them that they don't have to pay.

I have a 99% collection rate but again only doing 40-50 encounters a week so its not huge but its not small either for a part time PP.
The ones you can't collect are the patients who have insurance the day you check their benefits and don't have it anymore the day of service or they only come once and refuse to pay copays and you never hear from them again. Also carve outs for Mental health can be tricky as your staff might think they are in network but the carve out is not in network. These last points are very difficult for anyone i would think to always catch.

Cash only collection prior to appointment is the standard for 100% collection.
 
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Sushirolls

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I use the same. However, when i got out of residency i did almost every training video for the EMR/Billing/Etc must have been 20-30 hours to learn the entire suite, billing, emr, scheduling, etc inside out. I had time since i jumped straight into PP. Not sure how long it would take to teach someone else.

The best and greatest thing anyone could possibly do for billing is make an extremely thorough benefit check and then you should know almost exactly what the patient will owe prior to the visit let them know and collect it at times of visit unless their insurer wont allow that but notify them that they don't have to pay.

I have a 99% collection rate but again only doing 40-50 encounters a week so its not huge but its not small either for a part time PP.
The ones you can't collect are the patients who have insurance the day you check their benefits and don't have it anymore the day of service or they only come once and refuse to pay copays and you never hear from them again. Also carve outs for Mental health can be tricky as your staff might think they are in network but the carve out is not in network. These last points are very difficult for anyone i would think to always catch.

Cash only collection prior to appointment is the standard for 100% collection.
Yeah, that... definitely part of the learning curve for first 6 months.
 
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AD04

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Here's how I'm able to do my own billing without staff using office ally.

1) Complete note in the EMR module, designate ICD and CPT codes.
2) Sign note and "create visit"
3) Go to the "visit" and "create claim;" claims are automatically submitted to the clearinghouse.
4) Payments from insurance companies directed deposited to my bank accounts.
5) Later, electronic ERAs are received in the EMR and can be posted to pt's accounts/visits automatically.
6) If there's a remaining balance, update it so pt can pay through the patient portal using a credit card.
7) Apply the remaining patient payment.
8) From time to time, look through "visits" to see if there are "outstanding balances"

I am very impressed how you incorporated technology to make your practice as automated as possible. How well do you think your set up would work for a practice with a heavier patient load (e.g. one that sees 24 patients / day)? Can overhead still be kept low? If it wouldn't work as well, what are the challenges you will face?
 
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RomanticScience

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I don't see why not. Check out this PCPs set-up, he probably would see the volume you mention.

My practice is psychodynamic (most receive therapy from me/everyone has some sort of therapeutic frame) and I'm working with a mostly stable, younger, tech-literate population; my total active patients are <200. It's pretty much a more contemporary analytic practice (patient portal v leaving a message on an answering machine). So, I max out $/lifestyle as a psychiatrist-psychotherapist. If I started to do heavy med management, as you mention, my logistical set-up would probably fall apart. I believe that it starts to become a qualitatively different practice. Here's a line from a blog that always resonated with me:

"If you do solo private practice, you will make a comfortable living. You will not become rich. This article is not called, "How To Rot In Your Own Self-Satisfaction."

It would be impossible to see 24 pts a day/5-days a week by yourself. The overhead ould only go up because of staff costs. There's a guy in my city who built a clinic; he uses practice fusion for his EMR and hired a biller who uses office ally. BTW, all the billing companies I know of are actually just using the software I use. I found this out in seeing a biller as a patient and my credentialling person telling me.
 
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finalpsychyear

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I don't see why not. Check out this PCPs set-up, he probably would see the volume you mention.

My practice is psychodynamic (most receive therapy from me/everyone has some sort of therapeutic frame) and I'm working with a mostly stable, younger, tech-literate population; my total active patients are <200. It's pretty much a more contemporary analytic practice (patient portal v leaving a message on an answering machine). So, I max out $/lifestyle as a psychiatrist-psychotherapist. If I started to do heavy med management, as you mention, my logistical set-up would probably fall apart. I believe that it starts to become a qualitatively different practice. Here's a line from a blog that always resonated with me:

"If you do solo private practice, you will make a comfortable living. You will not become rich. This article is not called, "How To Rot In Your Own Self-Satisfaction."

It would be impossible to see 24 pts a day/5-days a week by yourself. The overhead ould only go up because of staff costs. There's a guy in my city who built a clinic; he uses practice fusion for his EMR and hired a biller who uses office ally. BTW, all the billing companies I know of are actually just using the software I use. I found this out in seeing a biller as a patient and my credentialling person telling me.


This is spot on. To even see my volume of (40-50 med management patients weekly) with a very similar setup using the same software and dong my own billing you absolutely need a staff. Even simple things like FMLA, disabilty, patient benefit checks and pre auths, are overwhelming at that point. I guess if you were only going to do a max volume of 50 and this was your only gig then maybe it becomes more feasible. I still spend a good chunk of my telepsych down times which are a lot doing admin related things related to my part time PP.

Not sure what the definition of rich is and it also depends if your doing multiple jobs simultaneously but there a some who are seeing 100pts in 4 or 5 days but of course with that higher income you need more staff and overhead.
 

roastedcapers

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At some point I plan to transition away from using a 3rd party billing company to use the integrated clearing house within Luminello. I'll still do the usual E&M entry, and initial submission with Luminello. My assistant will do the follow up / quality control review to make sure things are processed appropriately and no bills fall thru the cracks.

For now I delay this due to uncertainty of processing medicare thru this integrated Luminello feature.

I have Luminello and use a billing service that uses a different clearinghouse. I also use a different credit card information storage/processor but might migrate the data to Luminello credit card service to simplify. My question is, does your biller go in and update all payments in Luminello so that you can see real patient balances?
 

Sushirolls

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No my billing service doesn't enter any data into Luminello on my behalf. My assistant does that for me.

If I saw a patient on 4/1/20, there will be the charge for 99214, 96127, 96127. Upon receiving the EOB & payment from insurance, she'll go back and enter 'Adjustment' with a $145 etc, and 'Insurance Payment' for $10, all for the same date. We found that entering the payment/adjustments on the same date make it so much easier to track for any future discrepancies or patient questions. The number left over is the patient balance.

I love the integrated credit card function. Typically my patients are logging in the evening or weekends and making payments then, and by having the seamless integration makes it so nice. Its also very easy for me to run a card if needed, and the very rare instances a refund. Start/end of a patient visit they might say 'what do I owe?' and offer to run the card then, simply enter payment, select their card, and presto, done. So convenient.
 

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@RomanticScience

I've been thinking about your setup for the past few days and this is my conclusion:

What you're doing (integrating technology / automation as much as possible) is the next generation of private practice and is versatile enough to be applied to any type of practice structure. I won't have to change your setup if I have an out-of-network / cash practice. I can submit claims on patient's behalf as added-value service. And I can tweak the setup to fit a high volume insurance practice and cut down on some overhead (less people are needed to answer phones or to do billing).

If implemented right, it can lead to higher patient satisfaction (e.g. patient can bypass rude support staff). And with some additions, I can also automate marketing.

And because the structure of the practice exists in the clouds, I can be anywhere and still have a practice. I can work at home doing telepsychiatry once I established a patient base or start out in a room at another doctor's office 1 day a week and grow from there.

What you shared is ground-breaking for those interested in private practice.
 

roastedcapers

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Here's how I'm able to do my own billing without staff using office ally.

1) Complete note in the EMR module, designate ICD and CPT codes.
2) Sign note and "create visit"
3) Go to the "visit" and "create claim;" claims are automatically submitted to the clearinghouse.
4) Payments from insurance companies directed deposited to my bank accounts.
5) Later, electronic ERAs are received in the EMR and can be posted to pt's accounts/visits automatically.
6) If there's a remaining balance, update it so pt can pay through the patient portal using a credit card.
7) Apply the remaining patient payment.
8) From time to time, look through "visits" to see if there are "outstanding balances"
@RomanticScience

I've been thinking about your setup for the past few days and this is my conclusion:

What you're doing (integrating technology / automation as much as possible) is the next generation of private practice and is versatile enough to be applied to any type of practice structure. I won't have to change your setup if I have an out-of-network / cash practice. I can submit claims on patient's behalf as added-value service. And I can tweak the setup to fit a high volume insurance practice and cut down on some overhead (less people are needed to answer phones or to do billing).

If implemented right, it can lead to higher patient satisfaction (e.g. patient can bypass rude support staff). And with some additions, I can also automate marketing.

And because the structure of the practice exists in the clouds, I can be anywhere and still have a practice. I can work at home doing telepsychiatry once I established a patient base or start out in a room at another doctor's office 1 day a week and grow from there.

What you shared is ground-breaking for those interested in private practice.

Based on what RomanticScience is saying, it sounds like Office Ally has a more automated claim system than Luminello does. Luminello has a clearinghouse but you still need to type in all the patient info yourself each time, it doesn't copy into the repeat claim, and when you get an EOB you would have to enter the updated balance manually, it is not automatically entered. I only very briefly attempted to do billing myself in Luminello before hiring someone so correct me if I am wrong, Sushirolls. This does make switching to Office Ally appealing.

I started with a fully telepsych private practice and am just now getting an in person office.
 

RomanticScience

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@RomanticScience

I've been thinking about your setup for the past few days and this is my conclusion:

What you're doing (integrating technology / automation as much as possible) is the next generation of private practice and is versatile enough to be applied to any type of practice structure. I won't have to change your setup if I have an out-of-network / cash practice. I can submit claims on patient's behalf as added-value service. And I can tweak the setup to fit a high volume insurance practice and cut down on some overhead (less people are needed to answer phones or to do billing).

If implemented right, it can lead to higher patient satisfaction (e.g. patient can bypass rude support staff). And with some additions, I can also automate marketing.

And because the structure of the practice exists in the clouds, I can be anywhere and still have a practice. I can work at home doing telepsychiatry once I established a patient base or start out in a room at another doctor's office 1 day a week and grow from there.

What you shared is ground-breaking for those interested in private practice.

It's very satisfying to operate a mircropractice using only a 300sqft consulting room, a home office, and a laptop. When I go to the dentist or my PCP, I'm always thinking, "Woah, this is what I'm doing, with so much less." Sometimes, I get this feeling that I need the big office and a large waiting room with a front office in the shiny medical office building. Those thoughts are less frequent now as I hear of the COVID shutdowns.
 
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Roasted, Luminello has the same seamless integration as RomanticScience outlined above in post #5. I just didn't opt into that feature from the start. Due to a different practice goals that would have had much more complex billings. That's why my work flow looks a bit more complex. My larger practice goals didn't materialize, and now I'm looking to streamline my billing using Luminello to its fullest - just like RomanticScience post #5. However, no one on here yet has posted they they are already using the integrated billing feature on Luminello to attest to its functionality. I wish some one does and could post to that...

Roasted, with your use of the billing in Luminello, did you use the additional billing package you pay for thru the ApexEDI? Or did you do as I did, and skip that?

A question I have RS, is when you have odd things happen with the billing, are you the one calling the insurance company to figure out what just happened, or do you call the OfficeAlly clearinghouse for help on understanding the snag? Right now, whenever I have issues with claims, I'm able to punt the majority of them to my billing company, and they spend the time making the phone calls and report back to us. I'm worried about giving up this support for the issues. How much time are you spending on hiccups?
 

roastedcapers

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Roasted, Luminello has the same seamless integration as RomanticScience outlined above in post #5. I just didn't opt into that feature from the start. Due to a different practice goals that would have had much more complex billings. That's why my work flow looks a bit more complex. My larger practice goals didn't materialize, and now I'm looking to streamline my billing using Luminello to its fullest - just like RomanticScience post #5. However, no one on here yet has posted they they are already using the integrated billing feature on Luminello to attest to its functionality. I wish some one does and could post to that...

Roasted, with your use of the billing in Luminello, did you use the additional billing package you pay for thru the ApexEDI? Or did you do as I did, and skip that?

A question I have RS, is when you have odd things happen with the billing, are you the one calling the insurance company to figure out what just happened, or do you call the OfficeAlly clearinghouse for help on understanding the snag? Right now, whenever I have issues with claims, I'm able to punt the majority of them to my billing company, and they spend the time making the phone calls and report back to us. I'm worried about giving up this support for the issues. How much time are you spending on hiccups?

I paid the $30 for a month (though I think got it refunded) before switching to my biller who uses a different clearinghouse. I found that each claim, I had to re-type all the patient info, and this was too much work.

5) Later, electronic ERAs are received in the EMR and can be posted to pt's accounts/visits automatically.
6) If there's a remaining balance, update it so pt can pay through the patient portal using a credit card.

So this is the part you hire an assistant for, I assume? How many hours a week do you need an assistant to accomplish this? To me, the ultimately goal of automation would be to not need an assistant for this task- I am wondering if any EHR can do this part in an automated fashion.

How much in overhead do you guys spend per year?

I have a telepsych practice for past 6 months, just got an office a few weeks ago. Here is my breakdown per month: (0=free or I cancelled the service) On top of the table below, I spend $310 on marketing (PsychologyToday and Google Ads), $70 on average per month on accountant, $50 on average on licensing in 3 states/DEA in 1 state. This amounts to $1970 total, or barely over 1000 before I got an office space.

Traveling Mailbox25
Bluehost8.8
Wordpress7.3
Cinch Insurance88.75
Luminello82
RingRX19
Doxy.me0
GSuite Email10
Apex0
Payment Depot50
LegalShield0
Firewall12.41
Intuit Quickbooks25
VPN2.8
Rent790
My health/dental insurance419
 
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RomanticScience

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A question I have RS, is when you have odd things happen with the billing, are you the one calling the insurance company to figure out what just happened, or do you call the OfficeAlly clearinghouse for help on understanding the snag? Right now, whenever I have issues with claims, I'm able to punt the majority of them to my billing company, and they spend the time making the phone calls and report back to us. I'm worried about giving up this support for the issues. How much time are you spending on hiccups?


Having a billing company may be more valuable for you because of the diversity of your payers and services. I only take 2 insurances. They each have their own provider portal where I can log-in, look up the claim, and get more info about rejections. These companies are also known to be fair and to not play dirty tricks. Also, I only use 2 codes, EM and psychotherapy add-ons (once in a blue moon, I use interactive complexity). Issues that I've been able to remedy by simply submitting a new claim:

  • The patient has BCBS from another state. The way it works is you bill the local (eg, Anthem), they direct it to the correct payer, and it ultimately is covered. On the ERA there was no payment with the comment, "THIS CARE MAY BE COVERED BY ANOTHER PAYER PER COORDINATION OF BENEFITS."
  • The patient, in their mind, has no change in insurance. However, they actually had their ID # change. I would just see the rejected claim, look up their coverage period on the provider portal, and re-submit with the correct info.
  • Stupid mistakes (99213+99213, accidentally submit 2 claims on the same day, a mistake with the name on the claim, etc).
  • After seeing a patient who was inactive, billing new patient code (eg, 99204), having it rejected because it wasn't > 3 years. Correction by submitting new with 99214.
  • Claims denied because a patient's coverage terminated early.
If I'm up-to-date with my note writing/claim submission, I can catch things fairly quickly and resolve with the patient before things get too far alone. Since getting my credentialling squared away, I have yet to have had to call an insurance company about a claim.

My overhead is probably ≤ 2k/mo. The following excludes CME, quickbooks+turbotax, miscellaneous office supplies, gas/fuel, entertainment,

Yearly Recurrent Costs
AdvertisingPsychToday$360.00
SEAK$550.00
ACBA Vendor Guide$50.00
Web Services/SoftwareOffice Ally (+ Reminder Texts)$719.40
G Suite + Google domains + GVoice$450.00
Doximity Dialer and Fax, doxy.me$0.00
WorldPay Credit Card Processing$2,202.00
RentRent$8,388.00
Utilities$310.00
InsuranceMedMal Insure$3,700.00
Gen Business Insure$360.00
LicensingMed License$360.00
DEA$244.00
Exostar Token (2-factor auth for e-controlled rxs)$100.00
Total$17,693.40
/mo$1,474.45
 
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finalpsychyear

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I look at overhead only as how it compares to my gross. While I do have a slightly higher overhead this is mostly due to having a 20 hour ish staff and rent. My overhead still comes out to 10% of gross which is the most significant number imo as it relates to how successful the business is actually doing instead of focusing on just how low can the overhead be.
 
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randomdoc1

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I would not waste money on a billing company. Most of them do a terrible job of collections and often don’t understand the insurance any better than me. This is what I did:
  • I use icanotes ehr since it integrates with revenue cycle management systems like waystar and you can collect payment in there, you can send claims from there, send statements from there, and see aging reports in there of insurance and patient payments
  • With the integration all claims get sent out by me end of the day
  • Waystar allows me to check status of claims even though I have all sorts of payers but for complete claim status info I got logins at the various payer sites: United, umr, Medicare, Humana, Aetna, Cigna, blue cross, market place plans, etc.
  • With icanotes, I get the remits integrated
  • I signed up for efts
  • Icanotes also allowed me to integrate with Bill flash to send out bills
  • BUT even better, I PRE collect. So before patient comes for appointment, I calculate patient responsibility: deductible, copay, or coinsurance and I collect at time of service to reduce billing hassle.
  • Icanotes allows me to flag patient charts, so if someone calls and they owe, my staff know to collect when pts are on the phone.
  • My ehr allows me to generate an aging report. Most payers pay within 60 days. I found less than 2% of claims take longer or are not responded to. It’s collecting from patients that is the problem. Which is why I collect at time of service. Weeds out the ones that will stiff you pretty damn fast.
  • My collections have been awesome: over 420k was what I brought in last year. That was my take home PROFIT. My gross revenue was higher of course.


  • I highly recommend you check benefits and eligibility of each patient before each appointment. I found with standard billing procedures not only do most patients avoid paying you but they also conveniently will not tell you if they lost their insurance or their insurance changed. Easiest to sort this out before services are rendered. This experience I have with billing needless to say has left me with some negative countertransferance. Most people don’t seem to care if we get paid so we have to be our own advocates.


  • Did I also mention that the ehr sends text message reminders for appointments and has a patient portal? Pretty slick!
 
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finalpsychyear

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I would not waste money on a billing company. Most of them do a terrible job of collections and often don’t understand the insurance any better than me. This is what I did:
  • I use icanotes ehr since it integrates with revenue cycle management systems like waystar and you can collect payment in there, you can send claims from there, send statements from there, and see aging reports in there of insurance and patient payments
  • With the integration all claims get sent out by me end of the day
  • Waystar allows me to check status of claims even though I have all sorts of payers but for complete claim status info I got logins at the various payer sites: United, umr, Medicare, Humana, Aetna, Cigna, blue cross, market place plans, etc.
  • With icanotes, I get the remits integrated
  • I signed up for efts
  • Icanotes also allowed me to integrate with Bill flash to send out bills
  • BUT even better, I PRE collect. So before patient comes for appointment, I calculate patient responsibility: deductible, copay, or coinsurance and I collect at time of service to reduce billing hassle.
  • Icanotes allows me to flag patient charts, so if someone calls and they owe, my staff know to collect when pts are on the phone.
  • My ehr allows me to generate an aging report. Most payers pay within 60 days. I found less than 2% of claims take longer or are not responded to. It’s collecting from patients that is the problem. Which is why I collect at time of service. Weeds out the ones that will stiff you pretty damn fast.
  • My collections have been awesome: over 420k was what I brought in last year. That was my take home PROFIT. My gross revenue was higher of course.


  • I highly recommend you check benefits and eligibility of each patient before each appointment. I found with standard billing procedures not only do most patients avoid paying you but they also conveniently will not tell you if they lost their insurance or their insurance changed. Easiest to sort this out before services are rendered. This experience I have with billing needless to say has left me with some negative countertransferance. Most people don’t seem to care if we get paid so we have to be our own advocates.


  • Did I also mention that the ehr sends text message reminders for appointments and has a patient portal? Pretty slick!


I agree with your advice. I do think that for any private practice that is new except maybe all cash there is a learning curve and reality check.
It's a strange feeling to not get paid by patients who lie to staff and are never to be seen again. It is part of the growing pains of a new practice. I would hope it is sort of a like an initiation that everyone has to go through in the beginning when they are naive and ignorant as this is all new to the new bushy tailed big eye practitioner who has not experience this type of behavior in their career.

In some ways it is good. Better to get stiffed a few times early in your practice career when your slow and ignorant and that leaves an imprint to not have that happen much in the future. I would hope most peope figure that out. Its a crappy feeling but you can learn and improve.
 
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RomanticScience

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I would not waste money on a billing company. Most of them do a terrible job of collections and often don’t understand the insurance any better than me. This is what I did:
  • I use icanotes ehr since it integrates with revenue cycle management systems like waystar and you can collect payment in there, you can send claims from there, send statements from there, and see aging reports in there of insurance and patient payments
  • With the integration all claims get sent out by me end of the day
  • Waystar allows me to check status of claims even though I have all sorts of payers but for complete claim status info I got logins at the various payer sites: United, umr, Medicare, Humana, Aetna, Cigna, blue cross, market place plans, etc.
  • With icanotes, I get the remits integrated
  • I signed up for efts
  • Icanotes also allowed me to integrate with Bill flash to send out bills
  • BUT even better, I PRE collect. So before patient comes for appointment, I calculate patient responsibility: deductible, copay, or coinsurance and I collect at time of service to reduce billing hassle.
  • Icanotes allows me to flag patient charts, so if someone calls and they owe, my staff know to collect when pts are on the phone.
  • My ehr allows me to generate an aging report. Most payers pay within 60 days. I found less than 2% of claims take longer or are not responded to. It’s collecting from patients that is the problem. Which is why I collect at time of service. Weeds out the ones that will stiff you pretty damn fast.
  • My collections have been awesome: over 420k was what I brought in last year. That was my take home PROFIT. My gross revenue was higher of course.


  • I highly recommend you check benefits and eligibility of each patient before each appointment. I found with standard billing procedures not only do most patients avoid paying you but they also conveniently will not tell you if they lost their insurance or their insurance changed. Easiest to sort this out before services are rendered. This experience I have with billing needless to say has left me with some negative countertransferance. Most people don’t seem to care if we get paid so we have to be our own advocates.


  • Did I also mention that the ehr sends text message reminders for appointments and has a patient portal? Pretty slick!

What does the icanotes w/ add-ons+Waystar+Bill Flash combo cost?
 
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randomdoc1

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What does the icanotes w/ add-ons+Waystar+Bill Flash combo cost?

Icanotes: depends on number of accounts (and of those accounts which ones have esignature--which I only reserve for providers) and if you have the text message reminder feature. My office has me and 3 psychotherapists and we have the text message feature. It's about $500/month.
Waystar aka Zirmed: they bill separately. Depends on if you add features. My husband decided to include the claim denial management system, still trying to decide if it is worth the cost. The cost also depends on how many claims you process. My cost ranges $300-$600 a month.
Billflash: depends on how many bills you send out, paper or email bills, and if you use color or B&W ink. Now when I bill...I send bills out every week, sort of a gentle reminder that our office is serious about collecting. Fortunately I only need to send out 30-50 bills a week since we precollect (PRECOLLECTING is a godsend). But my cost is about $150 a month.
NOW, it sounds expensive, but then I look at billing companies who will take 4-6% of the revenue and you will likely lose more money in poor collections. (4% of 300k, and that is an underestimate of gross revenue is already 12,000 and assuming 100% collection rate). Yea, it worked out well for me.

Your costs will likely be lower if you are a 1-2 provider practice. What would I say are the essentials?
-and EHR that integrates with a clearinghouse/revenue cycle management system (waystar has been really straightforward especially since it works with so many payors and the customer service was really good)
-EFTs
-electronic remits integrating into the EHR
-text message reminders, saves you ALOT on missed appointments
-get logins at payer sites, it's free anyways
-billflash integration

Now that I made the list, that looks like everything. But at least it's what has worked well for me. My income last year, I worked 3.5 days a week. My collection rate is about 97%. Don't waste my f***ing time. We worked too hard for this. Not surprisingly, the most troublesome cases tend to be the poorest in terms of generating revenue.
 
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Sushirolls

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The other variable is staff time, not necessarily reflected in your calculations above. Randomdoc1 how much time are you or staff spending on billing tasks, benefits look up, mailings of bills, digging into denials, resubmits, or simply chart review to see what needs a little work? What's the hourly time/wages spent on that?

My pre-calculations so far reflect whether I do it in house in fashion you are describing with Luminello and my assistant, versus using a billing company and my assistant, pencils out to possibly be the same, at least for a snap shot of this years projections. Optimistically it might be less this year if I make the switch to full Luminello. Did you have an inflection point where it clearly is more cost saving to have it done internally?
 

randomdoc1

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The other variable is staff time, not necessarily reflected in your calculations above. Randomdoc1 how much time are you or staff spending on billing tasks, benefits look up, mailings of bills, digging into denials, resubmits, or simply chart review to see what needs a little work? What's the hourly time/wages spent on that?

My pre-calculations so far reflect whether I do it in house in fashion you are describing with Luminello and my assistant, versus using a billing company and my assistant, pencils out to possibly be the same, at least for a snap shot of this years projections. Optimistically it might be less this year if I make the switch to full Luminello. Did you have an inflection point where it clearly is more cost saving to have it done internally?

Wow, that's a great question! Admittedly, I have not crunched numbers prior to executing this as tightly as you are in the process of. I sort of looked at it at a much more approximated manner, how many hours am I working a week and what am I bringing home versus what other employers offer me. I work about 35 hours a week and have a nice income. Some of those hours are administrative duties. With help of the aging report, I suspect each week the time for billing tasks looks like the following:
Following up old claims ~1 hour
Following up unpaid balances of patients ~2 hours
Checking benefits and eligibility each week ~3 hours
-Icanotes has a nice export feature. Pulls up the patients for next week on an excel file with insurance plan, ID number, patient DOB. Then I sort the sheet by payor and go through all the sites and check 1)insurance still active and 2)what is patient responsibility. Doing this in bulk and by payor saves a LOT of time
Sending out bills ~2 hours
Denials and resubmits ~1hr A MONTH

I think 8 months in is when I could reliably see the pay off. Probably even before that. Anyways, definitely by the profit and loss report on quikbooks after my first year in, that's when I saw the over 420k profit I brought home and then you know it was the right move. Seeing patients 3.5 days a week and half day a week doing admin work.

I've hired staff at ~$17-18 an hour. No benefits. Some day when I'm big enough, I will try to offer that. I train my staff to:
-do basic front desk phone work
-work on insurance aging and patient aging reports. It is broken in an alpha split. E.g. someone gets the first half of the alphabet by last name and other person gets the rest. That way they are incentivized to get the claims/balances paid or else their work will just keep piling up.
-I'm the one sending out the bills and checking benefits and eligibility.

I think a big trick is finding someone who is smart enough who can start to assume all these responsibilities so I won't have to do any of it eventually. But as an owner, it is good to know all of it, you will see where the money is made and lost. A smart, highly qualified, and motivated person has been hard to find so far. There's a lot of number crunching and there's a learning curve to understanding the insurance language AND persuading patients that yes, you need to pay for your care.

Another thing I learned, make sure you hire people that produce well for the clinic. It's in their best interest too. I've had employees who would drag their feet in scheduling new patients. I even caught some discouraging callers from scheduling, especially if the employee thinks you don't know. They just become dead weight that 1)costs you way more than the hourly wage you pay them and 2)poison the culture of the company because other people start to follow suit. I've worked hard to foster a culture of, let's all try to succeed together and when there is work to be done, let's be go getters and not "it's not my job". My new phone system, although I did not get it for this reason, allows me to see a call log. Incoming and outgoing. How long did the call last, missed calls, calls that went to voicemail, which number was called, which number did the call come from, etc. It was telling. I have found employees who when I'm not out there, purposely did not answer calls. I've learned that you try your best to promote growth in your employees but some don't care to change. Fire them. Try to make it an amicable break up but they have no business poisoning a practice you worked so hard for.

Also, harass those insurance companies. Keep negotiating fee schedule increases. They will do it! I got a 30% fee schedule increase with United. Cigna and some marketplace plans I was successful with too. Increasing revenue per unit of time is a super smart move and will allow you to really let that practice boom. And get this, some payors I persuaded them to pay me $207 for 99213+90833. Yea baby!!!
 
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AD04

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I think 8 months in is when I could reliably see the pay off. Probably even before that. Anyways, definitely by the profit and loss report on quikbooks after my first year in, that's when I saw the over 420k profit I brought home and then you know it was the right move. Seeing patients 3.5 days a week and half day a week doing admin work.

Assuming 8 hours a day of work, you're really slaying it!

I can see employees not picking up the phone when you're not there. But actively turning people away?? I'm shocked.

What is your strategy for negotiating with insurance companies? How do you get them to pay attention to you as a solo psychiatrist practice?

Any plans with taking on another psychiatrist and becoming a group practice? It seems you have the structure in place to do so.

How do you pay your therapist? Salary? Hourly? Per patient? Collection?
 

randomdoc1

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Assuming 8 hours a day of work, you're really slaying it!

I can see employees not picking up the phone when you're not there. But actively turning people away?? I'm shocked.

What is your strategy for negotiating with insurance companies? How do you get them to pay attention to you as a solo psychiatrist practice?

Any plans with taking on another psychiatrist and becoming a group practice? It seems you have the structure in place to do so.

How do you pay your therapist? Salary? Hourly? Per patient? Collection?
Yes, I think some people have steered away from scheduling new patients because 1)it's more work gathering all the info and 2)they know more traffic means more work for them. What I don't get is why some employee types feel so secure when the traffic is dead. When there's little work to do it means your job is not secure. But yea, it's a super bad idea to try to be sly if your boss is a psychiatrist. We are very well trained to call out bull.

Each insurance payor has a department for network management. They usually ask you to write a letter and/or fill a form. I include my proposed rates and of course ask for more than what I think they will give. Then give as much info as possible as to why the office deserves it:
  1. what specialty services do you offer?
    1. TMS? suboxone? MAOI or long acting injection experience?
  2. Any special certifications providers have?
  3. How do you save the insurances money?
    1. they like to see offices enrolled in EFT, ERA, using EMRs etc.
  4. Patient outcomes
    1. for example, United has the ACE program where you provide questionnaires to patients and if they see you reliably produce data showing that your care actually helps, they will be more receptive to paying you better
  5. Availability
    1. Insurances like to see offices that can get people in sooner
Also, when you negotiate a higher rate, please check your remits and make sure they are actually paying that. United dragged their feet for 6 months! They kept saying the matter was "resolved" and week after week, same old insurance rates. I had to call network management, call her boss, her boss's boss, and finally they started paying what they agreed to and gave us a back pay check. There are still a few old fee schedules slipping in here and there but 98% of it is up to date now. Follow up with those insurances companies tightly to make sure they got your application, they tend to conveniently lose letters like that. If you get denied a rate increase, try again in 6-12 months. Just keep trying.

Yup! I am actively recruiting for a new psychiatrist. Now that I know how to bill telemedicine, I can recruit one from anywhere in the country!

Therapists are based on production. Like an RVU model.

My next steps now are:
1)start having therapists in training here to do their practicum. This will help my current therapists generate more income and help them stay sharp on their skills and offer free recruiting.
2)I'll be supervising residents and looking to start a rotation here. For a variety of reasons but of course get the word out and get more docs on board ;).
 
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AD04

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Thanks. Your tips were super helpful. I have a feeling you'll grow even more and do spectacularly.
 
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I graduated residency last year, and started my own solo practice right out of the gate. I lurked SDN all through residency but only now registered to post.

I don't take insurance, and I use Payment Depot for credit card processing. I keep cards on file, and at the end of the day when I'm doing notes I will look at the daily schedule and then bill each of those patients thru the merchant website. It takes like 30 seconds and it's super easy. Rarely a card will get declined, and it's always one of those health savings plan cards.

Definitely try to avoid having to hire or pay someone to run your cash flow. Whatever I bill goes right into the business bank account. I'm paying like 1-2% in fees maybe, plus the monthly payment depot fee. The problem with cash or checks is that like 1/5th of patients will 'forget' to bring them to the visit. A lot of checks will bounce, etc. I've been CC only since day once and it's the way to go. I bill the full fee for no-shows as well. Good luck getting a no-show fee if you only take physical cash.

Try to streamline whatever your process is for billing. It's not worth the money if you are spending 1-2 hours a day tracking down invoices or calling insurance companies. Like I said, I spend like 30 seconds to a minute per day on actual 'billing' duties.
 
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Candidate2017

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I graduated residency last year, and started my own solo practice right out of the gate. I lurked SDN all through residency but only now registered to post.

I don't take insurance, and I use Payment Depot for credit card processing.

How frequently do most stable cash patients prefer to schedule follow ups?

My stable insurance patients in the residency clinic prefer 30 minute follow ups every 4-8 weeks (they appear evenly split between a preference for 4, 6 and 8 wks) for medications plus supportive. I wonder if this would be replicable in a cash practice. Or do cash patients prefer less visits if it's not primarily therapy?
 

randomdoc1

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Newsflash! It looks like you can even get software and customize your own algorithm to do the collecting for you. Basically you can send statements via mail, text, or email. You can make as many steps in the algorithm as you want(e.g. how the software reaches out to the patient who has an unpaid bills 30 days old versus 60 days, and how often it will reach out). You can set up chat bots too to answer questions on the bill and patients can pay via web, mail, or automated phone. This can greatly reduce staff work and hiring needs. Not to mention reliability of the work.
 
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How frequently do most stable cash patients prefer to schedule follow ups?

My stable insurance patients in the residency clinic prefer 30 minute follow ups every 4-8 weeks (they appear evenly split between a preference for 4, 6 and 8 wks) for medications plus supportive. I wonder if this would be replicable in a cash practice. Or do cash patients prefer less visits if it's not primarily therapy?

Once someone is doing well, I usually want them to follow-up at least every 3 months. 6 months for a select few. Usually the first few follow-ups are 3-6 weeks apart. I think my residency clinic was pretty similar to yours.

There are two small groups of patients I have noticed though:

One is generally disinterested in the treatment, always wants follow-ups to be farther away than I do. ("Doc, 6 weeks? Can't we do 6 months? I have uh.. a work trip coming up! I'll be out of town!") and will almost always call the week before an appointment to reschedule it out another month. I try to avoid taking these people as patients to begin with since they are usually the ones who are dismissive of medications or ambivalent about engaging in treatment. They're always hyperfocused on the financial aspect, asking how much and how long visits are at least a few times. But some slip through. These are usually the pts I end up firing due to poor compliance or no-shows.

Another group, which usually have some dependent personality traits, will want follow-ups to be a little closer than necessary each time. I try to therapeutically space the visits farther out (if warranted, depending on what we're doing with the meds) to get them to that 3 month mark. But these patients would definitely struggle with anything past 3 months out, since they treat my clinic like their safety blanket.

The vast majority of patients are fine with whatever the appropriate time is to schedule the next follow-up. Each usually has a specific day or time that work for them, but they don't complain or balk at all.

But to answer your question, cash patients are definitely not going to come in every 4-8 weeks if you're not actively making medication adjustments. But try to avoid taking people who are barely wanting to come in. I had one guy call and say "I'll make an initial appointment if you PROMISE me I won't have to follow-up more than twice a year", it was pretty funny. I wanted to tell him I'm a shrink not a fortune teller.

Also, I don't prescribe any controlled substances at all in my practice. If you did, that would probably change when you're scheduling follow-ups for some pts.
 
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finalpsychyear

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Once someone is doing well, I usually want them to follow-up at least every 3 months. 6 months for a select few. Usually the first few follow-ups are 3-6 weeks apart. I think my residency clinic was pretty similar to yours.

There are two small groups of patients I have noticed though:

One is generally disinterested in the treatment, always wants follow-ups to be farther away than I do. ("Doc, 6 weeks? Can't we do 6 months? I have uh.. a work trip coming up! I'll be out of town!") and will almost always call the week before an appointment to reschedule it out another month. I try to avoid taking these people as patients to begin with since they are usually the ones who are dismissive of medications or ambivalent about engaging in treatment. They're always hyperfocused on the financial aspect, asking how much and how long visits are at least a few times. But some slip through. These are usually the pts I end up firing due to poor compliance or no-shows.

Another group, which usually have some dependent personality traits, will want follow-ups to be a little closer than necessary each time. I try to therapeutically space the visits farther out (if warranted, depending on what we're doing with the meds) to get them to that 3 month mark. But these patients would definitely struggle with anything past 3 months out, since they treat my clinic like their safety blanket.

The vast majority of patients are fine with whatever the appropriate time is to schedule the next follow-up. Each usually has a specific day or time that work for them, but they don't complain or balk at all.

But to answer your question, cash patients are definitely not going to come in every 4-8 weeks if you're not actively making medication adjustments. But try to avoid taking people who are barely wanting to come in. I had one guy call and say "I'll make an initial appointment if you PROMISE me I won't have to follow-up more than twice a year", it was pretty funny. I wanted to tell him I'm a shrink not a fortune teller.

Also, I don't prescribe any controlled substances at all in my practice. If you did, that would probably change when you're scheduling follow-ups for some pts.

Providers in my area that do controlled substances r 4 wks no refills. Those patients almost always come. One of those guys said by not doing controls you elimate a large consistent base who r mostly simple until there not.
 
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Newsflash! It looks like you can even get software and customize your own algorithm to do the collecting for you. Basically you can send statements via mail, text, or email. You can make as many steps in the algorithm as you want(e.g. how the software reaches out to the patient who has an unpaid bills 30 days old versus 60 days, and how often it will reach out). You can set up chat bots too to answer questions on the bill and patients can pay via web, mail, or automated phone. This can greatly reduce staff work and hiring needs. Not to mention reliability of the work.

Very cool. Nice find!
What software have you come across that does this?
 

randomdoc1

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Very cool. Nice find!
What software have you come across that does this?
Collectly has that feature and they can integrate with EMRs. They are on the pricey side, but I'll see what I can work out. I'm sure there's a few ways around this and there will probably be other services like this propping up in the medical billing future.
 
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calvnandhobbs68

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Providers in my area that do controlled substances r 4 wks no refills. Those patients almost always come. One of those guys said by not doing controls you elimate a large consistent base who r mostly simple until there not.

Yeah I mean it cuts both ways with controlled substances. Patients are definitely incentivized to show up and you can almost always justify having them come back q4-8 weeks. Also most of them know that it’s difficult to find another doctor to accept them in the private practice world once they’re on benzos or stimulants (most people don’t want to inherit messes if they don’t need to). Although a decent amount of stable simple controlled substance patients can find PCPs who are fine prescribing stimulants etc.

I think a reasonable way to filter this would be to ask for list of meds and dosages prior to scheduling an intake appt. Then you can make an informed decision from there. On Lexapro and Adderall XR daily? Prob not a big deal and easy patient to regularly followup with. On Adderall IR BID, Ativan BID and Ambien? Yeahhh no.
 
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AD04

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How do you stay up to date with insurance requirements? For example, how do you learn about MIPS and make sure doing the proper things and not penalized?

@Basis

It’s cool you’re starting a cash practice right out the gates. What do you do for marketing and how do you determine your rates?
 

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Yeah I mean it cuts both ways with controlled substances. Patients are definitely incentivized to show up and you can almost always justify having them come back q4-8 weeks. Also most of them know that it’s difficult to find another doctor to accept them in the private practice world once they’re on benzos or stimulants (most people don’t want to inherit messes if they don’t need to). Although a decent amount of stable simple controlled substance patients can find PCPs who are fine prescribing stimulants etc.

I think a reasonable way to filter this would be to ask for list of meds and dosages prior to scheduling an intake appt. Then you can make an informed decision from there. On Lexapro and Adderall XR daily? Prob not a big deal and easy patient to regularly followup with. On Adderall IR BID, Ativan BID and Ambien? Yeahhh no.

For real, my CMHC days always go much smoother on the days where I see one of my few folks who are employed full time and could definitely afford a fancier practice but don't really want to jump through the hoops necessary to get someone to keep writing their Adderall XR (or as reflected on these forums sometimes, finding a psychiatrist who doesn't simply refuse to engage with the idea that adults might have ADHD without a decade of report cards).
 

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How do you stay up to date with insurance requirements? For example, how do you learn about MIPS and make sure doing the proper things and not penalized?
MIPS pertains only to medicare. It has cut offs for how much you bill that determines if MIPs applies to you or not. I think its like 30K to medicare? This means don't bill/see more than that dollar value as one thought process. Or another thought is just take the financial hit if you do. The old adage *just see one more patient and it'll work out in the end* could apply.

MIPs is basically another waste of bureaucratic hoop for larger entities to jump thru for the lie of 'quality metrics' and 'meaningful use.' I've used Epic EMR and Luminello and others. Luminello is more meaningful then any of the others, but it is not on the cool kids list of MIPs satisfying EMRs.

Ultimately Medicare comes with too much issues, that I hope by the end of the year to disenroll and be an Opt Out doctor.

Play the MIPs game if you want to capture that 1% or whatever it happens to be, but for most small psych offices, its not worth the hassle, but your large health system, 1% means millions of dollars and thus their reason to double down on forcing mips metrics with every one of their doctors to the zeal intensity of a JCHAO official finding a coffee cup a the nursing station.
 
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AD04

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MIPS pertains only to medicare. It has cut offs for how much you bill that determines if MIPs applies to you or not. I think its like 30K to medicare? This means don't bill/see more than that dollar value as one thought process. Or another thought is just take the financial hit if you do. The old adage *just see one more patient and it'll work out in the end* could apply.

MIPs is basically another waste of bureaucratic hoop for larger entities to jump thru for the lie of 'quality metrics' and 'meaningful use.' I've used Epic EMR and Luminello and others. Luminello is more meaningful then any of the others, but it is not on the cool kids list of MIPs satisfying EMRs.

Ultimately Medicare comes with too much issues, that I hope by the end of the year to disenroll and be an Opt Out doctor.

Play the MIPs game if you want to capture that 1% or whatever it happens to be, but for most small psych offices, its not worth the hassle, but your large health system, 1% means millions of dollars and thus their reason to double down on forcing mips metrics with every one of their doctors to the zeal intensity of a JCHAO official finding a coffee cup a the nursing station.

You're right. I was talking to my friend who is currently the most successful among my residency class and he doesn't participate in MIPS. For him, instead of trying to jump through hoops to capture the few extra percentages from Medicare, he focused on big wins and got all the insurances he accepts to pay as much or more than Medicare.
 
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@Basis

It’s cool you’re starting a cash practice right out the gates. What do you do for marketing and how do you determine your rates?

For marketing, the best things are: Psychology Today, Google Maps, having your own small website, and mailing letters to all the PCPs in the area just letting them know you are open for business, a little about yourself, rates, and a few business cards. Not too many cards or the letter will need more than one stamp as I learned. 3-5 will be okay. Almost all of my new patients are from psychology today, because that is almost always the first actual google result if you type "(city) psychiatrist." And you can list yourself in 2 other cities/zip codes in addition to where your physical office is, so that helps. It takes a number of months for your google maps entry to really rise above all the other doctor offices, and for your website to show up in the first page of google results. But over time I get more and more patients who heard about my office from their PCP.

I did a lot of soul searching regarding rates when I started. I decided to set my follow-up visit cost at what I truly wanted it to be even in the future, instead of having it low and raising it over time or something. I thought about locking in a rate for an existing patient 'for life' and then possibly having a higher rate for newer patients... but then I'd have to keep track of it and it's too much bother. I have, however, played around a lot with the cost for the initial evaluation and found a kind of sweet spot. Most of your money is going to be generated from follow-ups over the long term, because the patient only pays the initial visit fee once. So my follow-ups are $160, 20 minutes -> $480 an hour. Sometimes I had the initial visit at $400 or $500, and sometimes I had it as low as $200. I have ended up keeping it around $325 for the last 4-5 months and it's worked out really well. When it was in the 200s I got more drug-seeking and borderline patients that I didn't take. Since I worked with a lawyer to word everything correctly according to state law and medical board policies, the first visit is basically a consultation and not a promise to take them as a pt. When I don't take someone as a pt, I have usually been refunding 100% of the visit cost. Do I want to get paid for my time? Yeah. But it is totally worth it to have a clean 'break' and it keeps them happy. I have no bad reviews on any rating website or google and I think it's because of this. This only happens like once a month at this point. They usually are like 'yeah yeah' on the phone when I tell them I don't do controlled substances and then they show up talking about how bad their focus is.

You can try to look up all the docs in your area before you start your practice to get an idea for the regional rates... but almost nobody has it on their website I found. Just think about how many hours you want to work a week long-term, and what kind of income you want, and what's reasonable for out of pocket fees, and you'll find a number you like.
 
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liquidshadow22

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Any advice on how to start a cash practice and actually attract patients? Give your card to primary care offices?
 

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Here's how I'm able to do my own billing without staff using office ally.

1) Complete note in the EMR module, designate ICD and CPT codes.
2) Sign note and "create visit"
3) Go to the "visit" and "create claim;" claims are automatically submitted to the clearinghouse.
4) Payments from insurance companies directed deposited to my bank accounts.
5) Later, electronic ERAs are received in the EMR and can be posted to pt's accounts/visits automatically.
6) If there's a remaining balance, update it so pt can pay through the patient portal using a credit card.
7) Apply the remaining patient payment.
8) From time to time, look through "visits" to see if there are "outstanding balances"
I'm diving into the integrated Luminello billing feature that uses the ApexEDI clearing house. End goal will be to have a work flow the same as RS above. Starting with a slow roll out of test cases with different insurance. I'm excited and optimistic to stream line the billing and overhead with this.
 
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