Getting Better at Private Practice: Q & A

1. Getting Better At Private Practice Q & A

2. What I Won’t Do…  Give legal advice  Give illegal advice  Give accounting advice  Give dating advice.

3. What I Could Do, But Not Today…  Discuss clinical interventions and evidence based practice issues  Clinical contracting and risk management  Practice tools, forms, and approaches  Give dating advice.

4. What I Will Do Is…  Discuss Answers and Ideas to your Submitted Questions  Give You Lots-o-Tools!!  Provide Plenty of Resources  With Gobs of Examples  And keep you awake! (I promise.)

5. Give you a lot of ideas to sample from

6. Then you can experiment

7. You can try on/try out…

8. …and see what works best for you and your practice.

9. Materials I used…

11. Warning: I may say some things that are scary

12. Getting Started…

13. Going Further…

14. Getting Better…

15. 1) How do we pay clinicians if fee splitting is not allowed? Most practices pay a percentage of what the clinician generates.  Fee-splitting is a part of the vague risk-laden netherworld of paying for referrals, giving kick-backs, violating the Stark Amendment, and giving an inducement for referrals.

17. Tips Tips: :  Establish a logical, defendable rate that you pay your consulting (1099) clinical staff.  You provide services to your clinical staff—office space/overhead, marketing collaterals (brochures, business business cards, etc.), administrative support, utilities, marketing, etc., and that accounts for some of the difference difference between what you gross and what you pay.  PS: Be super clear on all insurance billing as to who did what!! Easy area to unintentionally have a billing staff person get you in fraudulent hot water.  What’s done when there is a denial?  PPS: Great paper on this by Ardent Fox: Legal Issues to Consider When Creating a Health Care Business Model (http://www.nhpco.org/sites/default/files/public/palliat palliat ivecare/legal-issues-to-consider.pdf )

18. 2) What is the highest percentage a practice can go to and still stay viable? Depends on…  Your costs of doing business  Payer mix  Profit margin  How leveraged you are  Amount and age of A/R  The marketplace demand for clinical staff… Look at my chapter on pricing and cost structure (“How much should psychotherapy cost?”)

19. 3) 1099 vs. W-2  How many of you have a contract with your 1099s or W-2s?  What does your contract say?  FYI: You cannot employ a MD in Illinois, unless you are one, too, welcome to the Corporate Practice of Medicine Act.

20. https://www.irs.gov/businesses/small-businesses- self-employed/independent-contractor-self- employed-or-employee

21. Generally someone that “…performs services for you is your (W-2) employee if you can control what will be done and how it will be done. This is so even when you give the employee freedom of action. What matters is that you have the right to control the details of how the services are performed.” Generally you will hire clinical staff as independent contractors for a number of reasons, predominantly economic, as you are NOT obliged to pay payroll tax, cover malpractice insurance, travel costs, healthcare benefits, workers’ comp insurance, etc…

22. 4) What incentives can be offered to clinicians to earn more income?  Have them be more productive and work more  If you have a special population that they have a particular skill-set (e.g., neuropsych testing) that is in high demand you can negotiate a premium differential for those cases  Pay for making marketing collaterals, social media, outreach, public speaking….

23. 5a) Do most groups provide all the referrals or is the expectation that all contribute to the group?  What do you all do?  Why?  Results?

24. 5b) What ought to be the responsibility of members in a group to produce referrals to the practice? This can be tricky for 1099s, as it’s my bias that’s the job of the owner(s), either to make rain for the practice or hire someone (sales rep, not clinical) to do it. If your staff are W-2 you could make it part of their job description and performance metrics (e.g., number of workshops, not number of referrals resulting from it). There may be instances in which someone has a good skillset, for example, public speaking to families of children with learning disabilities. You could consider creating a weekend workshop for parents, and you’d cover the costs in conducting it and paying your consulting clinician’s time in presenting there.

25. 5c) My purpose and intention in working with my clients is to care for the community, make a contribution that matters and assist people in healing, not just "fix" a problem. How do we as Owners / Directors transmit that to our team? Is it fair to expect that they carry the same mission? Well, such can become the ethos of the practice. It can be a draw for recruiting and retaining likeminded clinicians. It’s an ambitious and noble goal, but it may mean different things to different people. It could be helpful to articulate what this means and how it’s expressed. Also, use caution to not run afoul with confidentiality concerns. How to communicate it? Make it clear in interviewing candidates. Via mission statement? How do you start each meeting? Pay staff to go do pro bono (good-will and visibility, not referrals). • •

26. 6) Are consultations with the Practice Owner / Director considered supervision? What are the liability issues? It depends. What do you call such consultations? What does your contract (1099) or employment agreement (W-2) say? Do you have oversight of telling what the therapist to do and does she/he have to listen to you? What if he/she doesn’t? If supervision, then notes, dates, goals, etc. A business meeting covers goings-on in the practice, staff performance, management issues, etc… Concept of “Vicarious Liability” And just because you don’t “supervise” someone, it does not mean that you will not be held liable for an untoward event. Would your malpractice insurance cover you for such if there was a problem? Risk of the appearance of being a group—Risk management pitfall #1 Risk of the appearance of still being part of a group after you have left—Risk management pitfall #2

27. 7) What factors should be considered when planning for growth? • Not getting too far over your skis • Where are your markets for growth? Are they sustainable? • Space, staff, increased costs of doing business? • Locations? • Increased referrals • Ensuring your margins will remain healthy and viable

28. 8) What consultants are essential for healthy Practice Management? • Well…..

30. • Good attorney that’s experienced in practices, especially mental health with all of our quirky things concerning confidentiality, risk management, contracting with staff and payers, etc... Bonus points if they know HR or labor law. • A good CPA to maximize managing your expenses, taxes, and income.

31. 9) What is a reasonable percent for the Owner / Director to take as dividends vs. salary? It depends. • Would you want to profit share to help keep great staff or fund growth in the practice? • You can do both if you have enough profit. • Remember, it’s the entrepreneur/CEO/business owner that is a risk to suck it up when things are tough and still take care of your staff who do more work than you. When things are flush, take care of them and the practice first, and then treat yourself. Either way, feast or famine, you always come in second or last. •

32. 10) Hiring or Firing? https://www.linkedin.com/pulse/i-quit-you-signed-contract-dr- chris-stout?trk=mp-author-card

33. Hiring: Work on your employment or consultant agreement with a competent attorney. Understand every word of it. Explain it to friend/college who is not an attorney or HR professional. • Point about “non-competes.” • What is “compensation?” Firing: Uh-oh. Well, just like clinical notes, document, document, document. Get a third party to be present with you to do the termination. The termination should not be a surprise to the person, if he/she has done something wrong. There may be a liability and or ethical concern that you may need to address as well. Get professional consultation vis-à-vis the ethical aspect from your guild (e.g., IPA) and document that all to a T. If it is a layoff issue, again, keep their patients’ best interest in mind along with the clinician being let go.

34. 11) Is it necessary to hire a social media expert? It depends. Do you need one? Why or why not? Who is your target clientele? Do they select therapists via social media? If they hear about you and someone Googles you, what will they find? Do you have a personal and public facing FB page? Do you have a professional FB page? What social media is important to you and why? What do you use and why? What is your current “persona”? Any “bad” stuff out there? • • • • • • • •

35. Social Media Manager

36. 12) How to determine the amount of administrative staff needed? It depends. • How busy are you? • Do you have the skillset and time to do what’s needed? • Can you afford a person, service, or tech to off- load what you cannot do? • Who uses an admin assistant? Part-time? Full- time? Duties? Helpful…?

37. 13) Is a practice manager necessary, suggested? See above. If you are busy and can afford someone, you’re doing well and he/she will likely help you do even better.

38. 14) What is the future of healthcare? ACO's? MCO's? What do we need to know? A cautionary tail…

39. Moral: It’s hard to successfully do an ACO

40. 15) How do we prepare? What are the best practices doing to stay viable in this ever changing market? • It’s always good to be agile and adaptive. • What are the points-of-pain of payers? NeuroPsych example with BPD. • Good systems help any practice and are cost effective. • Join guilds, ListServs, groups like this, etc. • For psychologists, I recommend IPA, APA, Div 42, and ethics consults. • How about LCPCs and LCSWs…?

41. http://www.slideshare.net/drchrisstout1/how-to-afford-your- private-practice-ways-to-fund-starting-up-and-how-to-keep-it- going-strong

42. Productivity and organization are critical no matter what you’re doing. I’m kinda nuts about it.

43. https://www.pinterest.com/drchrisstout/productivity -tools/

44. Cool Tools DrChrisStout.com DrChrisStout@gmail.com