Okay, the title is a bit misleading. There is nothing especially easy about starting a private practice. But, there is definitely a "hard way" and "easier way" to go about it. The hard way involves stumbling through the process yourself, learning through mistakes. Lots of mistakes. Insurance companies don't provide a "Intro to Insurance for Dummies" (though they should!) If you haven't worked in an agency that bills to insurance (which I had not) the process of learning the lingo of insurance is like learning a foreign language without a textbook.
The following is a list of steps you'll need to go through to start your private practice. If you plan to bill insurance, you'll have to follow all the steps. If you don't, there will be some you can skip. While I tried to put the steps in order of needing to do them, some of the tasks have kind of a "chicken or the egg" quality to them. For instance, while it's logical to sign up for insurance before taking the step of securing a practice location, the process of applying for insurance requires a business address.
The process can get a bit overwhelming and you may wonder if it's worth the trouble to jump through all these hoops. I will say, once you're through the hoops, things get a lot easier. By the time you've been in private practice 6 months, you will feel much more confident.
*Note: two of the links below are affiliate links, most of the links are not. Regardless, all sites linked here are solid resources that I use myself.
Step 1: Be sure you're ready for private practice. If you've just finished your professional degree, I'd strongly suggest working in a mental health agency or, at the very least, a group practice. Working in solo practice is isolating. It's important to have colleagues with whom you can consult about cases. This is especially important in the early years of your career.
Step 2: Consider Increasing Your Malpractice Coverage. I assume that you have a malpractice policy that covered you during your training and your work at previous sites. If not, you definitely need to get malpractice insurance. The Trust is a solid company to choose. How much is enough coverage? Consider the assets that you may need to protect. If you're not sure, consult with a lawyer, with your own licensing board, with your professional organization or with your malpractice insurance company.
Step 3: Decide on a business structure. While it's possible to operate your private practice under your own name without creating a business structure, you risk more should you ever be sued for malpractice. Many solo therapists run their business as an LLC. Running your practice as an LLC can help protect you, should you be sued. Setting up an LLC is relatively easy. You can just set up your LLC through your state's business registry. Here is the link for the registry in my home state of Kansas. You may want a lawyer to set up your business structure for you. In my area, that process runs $700-$1000. It's especially important if you plan to open a partnership, since the documents drafted would protect you should your partnership dissolve. Partnerships and group practices also need to register as a PLLC (professional LLC) that limits your liability if one of your partners/colleagues/employees gets sued. These have to be registered with a state board. Some states require this of all professionals, some of just practices with more than one member. If you've never run a business before, you may feel really unsure about how to structure your business. There are some good online resources that can help, but nothing is more useful than consulting with a good accountant. Even if you decide to do your own taxes, it's really useful to have an accountant to talk to about business issues.
Step 4: Consider Applying for a Tax ID number. You need to decide what identification number you will use when paying your taxes on your private practice income. It may be possible to use your SSN if you are in solo practice and plan to have no employees. However, there are several situations in which having a EIN (employer identification number) is necessary or just convenient (it limits who has access to your SSN.) It's free to do through the IRS. Every insurance company you work with will ask for your tax ID. If you feel unsure about business structure or TIN choice, it's wise to consult with an accountant. A good accountant can help you understand the process of opening a small business and how you'll need to pay your taxes (hint: quarterly!)
Step 5: Choose office space. Are you planning on being full-time in private practice or part-time? Either way, it may make sense to start your practice by sharing office space with another therapist. This keeps your cost down while you're working to build up your practice. If you're sharing space, be sure to ask around to ensure that you're paying a fair amount for the space you're using. If you're renting, or buying, your own space, consider how much you can afford monthly. Ideally, you'll want to keep your overhead expenses at less than 10 percent of your income. Of course, if can be hard to know, in advance, how much you can expect to earn. It's a good idea to network with other therapists in your area who have your same credentials to ask them about issues like budgeting. Regardless of what you decide, having your business address is an important part of this process, as you will need a business address to move forward with the process of being credentialed by insurance agents. If you're planning on working 100% online, you may still need to secure an address for business reasons. If you don't have a business address, you will need to designate a registered agent (often an attorney) for your LLC. More information on this topic can be found here.
Step 6: Get a Business Credit Card. You'll have a lot of little, and big, expenses as you start up your private practice and into the future. Using your personal credit card, or cash, is an option. However, by getting a business credit card, one that you use only for your deductible business expenses, you'll find it easier to account for your deductions come tax time. I use a Capital One Spark card* because it gives you cash back that you can use to pay of charges, get as a refund or even pay for purchases on Amazon or through PayPal.
Step 7: Decide about taking insurance. If you search on the internet, you'll get the idea that "good therapists" don't take insurance. I've also heard "I'm a specialty therapist. I don't take insurance." In my view, it's not about whether or not you're highly skilled or a specialist. Your choice will be impacted by your practice location, your values and beliefs, and your target clinical population. In terms of location, therapists in affluent areas can more easily get away with not taking insurance by catering to privileged clientele. In many parts of the country, there are too few people who are affluent enough to private pay. The other consideration is ethics. As a specialty psychologist myself, I don't feel like it would be ethical of me not to accept insurance because my specialty population is new parents. Parents who are pregnant, postpartum or who have lost a baby have likely paid thousands of dollars in medical care and have met their insurance deductible. I would not feel good about asking them to pay me privately on top of all their other expenses.
But, in the end, the choice is up to you. If you don't accept insurance, you have the freedom of not needing to formally diagnose your clients. You can set your own fees or even run a sliding scale. You don't need to feel worried that the insurance company might question or limit the amount of sessions you're providing. There are definitely benefits to it. If you're not going to take insurance, go ahead and skip to Step 11.
If you do want to bill to insurance, take heart. It's easier than it's ever been before. Using an Electronic Health Record (EHR)* makes the process seamless (once you get it set up!)
Step 8: Obtain your National Provider Identification (NPI) number. Your NPI number is your ID number as a therapist. You'll need it all the time when interacting with insurance companies. You apply for it here. The application asks for your business address.
Step 9: Fill out the CAQH. The CAQH (which stands for Council for Affordable Quality Healthcare) is an organization that collects and maintains all the information that you need to be credentialed by insurance companies. It's a beast of a form. Gather up all your college transcripts, information on your training sites, your licensure information and malpractice insurance policy (a digital copy will need to be uploaded.) You even need things like the physical address of the universities that you attended. So, grab yourself some snacks and a hot beverage. It's going to be a while before you're done with it. After you're finished, you'll have to reattest your CAQH every quarter. That seems burdensome, but you may find that you catch small changes that you've made (e.g. a new phone number.) Fortunately, CAQH e-mails you a reminder about the need to reattest.
Step 10: Get Credentialed. The process of being accepted as an in-network provider on insurance panels is called credentialing. It can be a tedious process that involves applying to each insurance company and retyping much of the information that you already put on the CAQH. Knowing that the insurance companies have access to your CAQH will, undoubtedly, make you puzzled about why you have to retype this information into yet another form. Don't let this raise your blood pressure. Just get more snacks and another hot drink. Take some deep breaths and tell yourself: this too shall pass. Or, easier yet, hire a billing professional to handle your credentialing for you. Billing professionals used to be a nearly essential part of running a practice. However, with newer, electronic claim filing, many therapists are doing their own billing. However, if you plan to take multiple insurance plans, hiring a billing professional can make your life much easier, especially during the credentialing process. You can find ones that bill a flat monthly fee. Most that I've heard of bill per claim. I've heard amounts from 5-9% mentioned by colleagues who use them.
Step 11: Learn the Billing Lingo. In graduate school, you learned the clinical lingo of diagnosis, but if you haven't billed to insurance, you have more to learn. In order to file a claim with insurance, you will need more than an ICD-10 diagnosis (your EHR, if you use one, will have the DSM-5 and ICD-10 diagnosis codes integrated into the notes program.) You will also need to use a CPT code. CPT stands for "Current Procedural Terminology." A CPT code indicates the type of service that you are providing related to a given diagnosis. For instance, if you do an intake interview, it is a CPT code 90791. Most CPT codes for therapists are tied to the length of service, such as the common 60-minute Psychotherapy code 90837 or 45-minute Psychotherapy code 90834. You can get a list of common CPT codes here. The diagnosis and CPT code, along with the date of service, your NPI number, practice information and the client's name, address, date of birth and insurance information all go onto a visually complex looking form called the CMS-1500. The CMS stands for "Centers for Medicare and Medicaid Services" The 1500 stands for the number of sections on the form. Just kidding. It only feels like there are 1500 sections. Just looking at the CMS-1500 makes my heart glad that my Electronic Health Record (EHR) fills out this form for me, with just a few clicks. How does it do that? You enter all your practice information into your EHR when you sign up. When you get a new client, they enter all their personal and insurance information into your program (at least, that's how it works on my EHR.) After intake, you enter the diagnosis and service code. A few clicks later, the CMS-1500 is complete and sent off to the client's insurance company. After each session, you will send off another CMS-1500 to the insurance company specifying the service you delivered that session.
One caution on diagnoses: insurance only covers diagnoses that are thought to be health conditions, not life transitions. So, you can't bill for something like "Bereavement" or for "Parent-Child Relational Problem." You must justify that you a providing a service that is medically necessary. If the symptoms of a life transition are sufficiently disruptive, you may be able to bill the client as an Adjustment Disorder, a diagnosis which is accepted by insurance. Before agreeing to bill to insurance, you will need to let you clients know that not every condition is covered by insurance. For instance, couples counseling for normal relationship discord is not covered. However, conjoint counseling may be covered if you are treating a disorder in one partner and the other partner is there to help in that treatment process.
Step 12: Learn the Rules of Billing Insurance (aka Avoid Committing Insurance Fraud.) When you contract with an insurance company, you agree that you are not charging them any more than you are charging anyone else. They want to know that they have your best rate. So, this means that you cannot slide your fees for other clients without insurance. However, just because you charge the same rate to everyone, insurance companies don't all pay the same rate. One company may pay you 100% of your rate, another might pay 70%. It's okay for you to accept a lower rate than you charge from an insurance company, as long as you charged the same rate as you charge everyone. Unfortunately, you cannot charge a private pay client any less than you'd charge the insurance company. Nor can you ever "waive" a copay or other patient responsibility in billing. That would be considered insurance fraud.
What do I do about this? I set my rates just a few dollars higher than the best paying insurance company gives. That means, at the very least, that I'm not charging private pay clients significantly more than I'm charging insurance. Charging a few dollars more than they have been paying allows you to see any changes in the allowable rate by your highest paying company.
What can you do for clients who are struggling financially? While you cannot slide your fees for clients, you can offer payment plans. Be sure to be fair to the client AND to yourself. Be sure you're getting a fair amount of payment for each session, even if you're willing to allow part of the balanced to be paid at a later date. What I would not suggest doing: Do not just tell people "oh, pay me when you can." Therapy charges can add up quickly. A large, unpaid balance can become an issue in the therapeutic relationship.
What to do if someone doesn't pay their bill? You can use a collections agency. That's not something that I have chosen to do in my practice, but some practices do use collections agencies. While you must charge everyone the same and you must make a real effort to collect your fees from your clients, you are not forced to use a collections agency. If, after a period of time, you feel you have made a good faith effort to collect the balance, you are able to forgive the remaining balance. By forgiving the balance, you "write it off" on your books, but you cannot use this lost income as a "write off" on taxes. (Note: this is my read on the contracts that I have signed. Be sure to check your contracts to review the policies regarding non-payment before your forgive co-pays or other patient responsibilities.)
Step 12.5: Other Billing Issues to Remember (Billing FAQ) I sometimes get questions from therapists new to private practice who have read this article. One recent question was about billing to insurance when you know the co-pay in advance. Specifically, the question was if you should charge the insurance company your full amount, or the amount minus the co-pay. It reminded me that I had this same question when I first started. The answer is, you bill the full amount of the session charge. The insurance company is expecting you to charge them your full fee. What the insurance company will pay you is whwat you bill them minus the co-pay. Imagine you have a client with a $25 co-pay and your fee is $150. You need to bill insurance $150 and they will pay you $125 and you will collect $25 from the client. If you were to bill the insurance company just $125, they would pay you $100. So, always charge your full fee, and always charge the same fee to each client and payer for any given CPT code.
An additional question was about when to collect the co-pay/co-insurance. You can collect the co-pay at the time of the session or after the claim has processed through insurance. Just know, if the client has a 20% co-insurance, that is not 20% of your fee, it is 20% of the insurance company's allowable charge for that service. So, you may wait and see what the insurance company allows before charging co-insurance for those who pay a percentage of the cost.
Step 13: Choose How to Keep Records. While it's now required that you submit your insurance claims electronically you can still keep your records in any format that you wish (paper, Word document, electronic health record.) Most people are choosing to use an Electronic Health Recorder (EHR.) EHRs enable you to work online, so you can work from home or your office. They use bank-level encryption to protect your records. They let you bill directly from the EHR, often with just one click. Other features may include allowing client's to self-schedule, sending e-invoices, and receiving payment online. There are several options on the market and surely will be more to come. I'd recommend narrowing it down to two or three and looking at each in detail. Most have a free trial period that lets you check out the features in advance of committing. Some well-known ones are Therapy Notes and Therapy Appointment. My personal preference is for Simple Practice*. Newer than the others, and lower cost, Simple Practice provides a wide range of services including sending out intake questionnaires and consent forms prior to the first appointment, integrated one-click billing and invoicing, and an easy to use patient and payment portal. It even has an "autopay" setting where you can, with your client's consent, set the program to bill your client's credit card (or Health Savings Card) after each session. These tools help you collect your payments promptly, which you'll find is an important part of surviving in private practice. Simple Practice also tracks your payments as they come back in, helping you see when you're paid, both by insurance and by your clients. I love the ease of Simple Practice. I know other therapists who swear by their own EHR. I would just say to choose carefully. While it's possible to switch your records from one system to another, it's a hassle. Most likely, you'll want to stick with one program.
Step 14: Develop Your Practice Documents When setting up your EHR, you'll need to create the documents that will help your clients understand the process of therapy, the limits of confidentiality, your billing practices, and other policies. You'll also need templates for record keeping. Fortunately, EHRs like Simple Practice provide some of these templates for you so you can customize them to your needs. Listed below are some guidelines & examples for you to consider when you're making your practice documents. These suggestions may not fit with your profession or your state's legal guidelines, so always consult with local authorities before finalizing your practice documents. Consent Forms & Practice PoliciesYou'll need an informed consent for psychotherapy that explains the type(s) of therapy you do, the risks and benefits, and your expectations for your clients participation in the process. You'll also want a basic Practice Policies document that describes issues related to session length, billing, insurance, policies for legal testimony and more. Here's a PDF of my own practice policies, which I wrote in an informal tone, in the hopes that this would make clients more likely to read through to the end. If you're offering telehealth, you'll need a separate Telehealth Consent document. You might also create a special consent form for other forms of therapy, such as a couples, or family therapy, consent form. EHRs allow you to customize which forms are sent to each new client you take on. Record Templates Every insurance company you contract with will have a list of essential elements that they will be looking for should they audit your records. Whether or not you decide to submit to insurance, keeping your records in a tidy, timely and thorough way will protect you and help you better serve your clients. At minimum, your records should include: the stop and start times of the session and session length; information on mental status, mood, affect, social and cognitive functioning; symptoms; progress since the last session; therapeutic interventions provided, any updates to the diagnosis or treatment plan; changes to medication; and your follow-up plan. If you're keeping a paper file, you should sign your note. If you're using an EHR, you need to "lock" the note to prevent editing as a way of "signing."
Do know, if you are accepting insurance that they may audit you and request to see you treatment notes. I would encourage you to keep your notes as brief as possible while fulfilling the basic requirements of what the insurance company will be looking for. Ideally, your EHR will allow you to keep separate "psychotherapy notes" which allows you to put in more personal details about your client that you would not want shared with insurance. I don't know about the other EHRs, but Simple Practice provides this feature. If your records are requested, you can simply download only the session notes, leaving the psychotherapy notes private.
Step 15: Shape Your Online Presence. In today's world, people expect you to have a website. Personally, I love using my website as a way to store handouts and other resources that I would have needed to print out in the past. Making a website can be a fun and rewarding process. If you're feeling tech-phobic about it, just know that it's now as easy as creating a Power Point presentation. I There are multiple web tools that allow you to create your website content. My personal preference is for Weebly. It allows you to choose a template and get started quickly. You can create a free website that will have a "weebly.com" address. Once you ready to commit, you can buy a domain name (i.e. yourpracticename.com) and connect your Weebly site to that domain. There are many web registrars who sell domain names (e.g. GoDaddy, Google, Register.com.) Be wary of any that want to charge you more than $12/year. Google domains is a solid choice. Once you've registered your website, you can also create any number of e-mail addresses based on your website name (i.e. yourname@yourpracticename.com.) You could even have separate address for billing (i.e. billing@yourpracticename.com.) This is a fun step. It helps you feel like your practice is a really coming together.
Outside of just your website, you'll want to be sure you're properly listed on all the search engines. You might also consider listing with one of the therapist referral websites. Personally, I didn't make that choice but many people do. If I were going to, I think I'd start with goodtherapy.org. Being enrolled with them allows you to access continuing education, unlimited, included in the price of your listing. There are lots of other options. Just search for "find a therapist" and see what pops up.
Step 16: Design your Printed Materials. For me, one of the most fun parts of setting up my practice was making business cards and other printed materials. I've found that you can get really amazing deals through Vistaprint. The cards may not feel like the highest quality but they are very affordable. Zazzle also has affordable materials with more stylish options. Search for coupon codes, as both of these websites regularly offer discounts. Be wary of both Vistaprint and Zazzle's metallic or glitter options (Wait, what? It is just me who wants sparkly cards?) They aren't actually metallic or sparkly, but just the appearance of such (i.e. like a photo of metal would appear.) If you'd like some really high-end, printed materials, consider getting a sample pack from one of the companies that specializes in really unique printed goods like Print Peppermint. Print Peppermint, and other stores like it, offer real metallic printing on diverse materials, including things like cork and wood. You can get a little carried away with all the options. Maybe that's just me, but I found it to be the fun part of this process.
Step 17: Consider a Giving Presentations to Referral Sources. One of your best marketing tools is simply developing a presentation on a topic and offering it to potential referral sources. Perhaps you excel at stress management. If so, maybe you could check with your local hospital to see if they'd like to learn about how their cardiac patients could learn how to relax. Or maybe you love working with eating disorders. You could consider giving a presentation at your nearest college counseling center. To get started, make a list of the type of clients that you most enjoy working with. Use that list to shape the professional identity that you want to market to others.
Okay, so there are some of the major steps you'll need to set up a private practice. If you have questions, corrections or suggestions, just e-mail me a drwesch@drsarahwesch.com. Good luck!
