So you want to start a private practice: some thoughts

1
So you want to start a private practice some
thoughts

• Judy Ripsch, Ph.D., L.C.S.W.

2
Intro

• Intro Self (Who made me the expert?)
• Why are you here?
• What do you want to know?
• Need to assess market and assess self

3
Assess Self

• Attitude
• Knowledge
• Skills
• Both as a practicing clinician and as a business
  person
• Lets talk about the business person

4
Business Hat Exercise

• Write down all the words and phrases that you
  think of when you hear the word "business.
• Share

5
Business Hat Exercise

• Does the word business make you feel uneasy,
  tense?
• Do you think someone may be taking advantage of
  you?
• Do you feel that you lack business skills?

6
Business Hat Exercise (Cont.)

• Do you believe that business people are
  ruthless, money-hungry, without ethics,
  insensitive to others, a different breed from
  counselors and counselor educators, and from you?

7
Business Hat Exercise (Cont.)

• If your answer was "yes" to any of these
  questions, then you may have roadblocks that hold
  you back from deciding whether to start a private
  practice.
• Do you want to be a business person?

8
Attitude

• Your first step is to put on your business hat!
• The confidence it takes to put on this hat comes
  from your desire to not only help people, but
  also to make money.
• Can you bill? Can you collect? Are you worth
  your fee?

9
Attitude (Cont.)

• You must be comfortable with your need to make
  money and charge directly for your
  servicesremember, making a living is not
  unethical!

10
Attitude (Cont.)

• You must be willing to take some risks
  financially.
• It often takes at least two years to build a
  successful practice considerably more if it is
  planned and managed poorly.

11
Attitude (Cont.)

• (after 5 yrs IRS considers it a hobby!)
• You may lose money initially until a referral
  network and client base are established.

12
Knowledge

• You must become well acquainted with budgets,
  cash flows and business plans to evaluate the
  potential and ongoing viability of your
  independent practice.
• You must know about billing, coding, collecting.
• You must be prepared to market your skills to
  guarantee success.

13
Skills

• You must be able to attend to the minutiae of
  running an office as it is unlikely you will be
  able to afford to hire someone to do this
  initially.
• You must be able to perform in an ethical,
  competent, legal manner.

14
What do I need to start?

• License
• Malpractice Ins (1,000,000-3,000,000)
• Lawyer
• Incorporate? LLC?
• Accountant
• Taxes
• Business Plan
• Access to clients
• Access to payers

15
Business Plan

• A detailed and sound business plan plots your
  targets for your business and identifies how you
  will achieve them.
• Most business plans contain three standard
  elements
• Marketing plan.
• Operating plan.
• Financial plan.

16
Marketing Plan

• Your marketing plan should contain a detailed
  marketing analysis.
• How will you do this? (e.g. other professionals,
  customer/clients)
• Needs analysis.
• Whats needed in the area?
• What already exists?
• Wait lists?
• Other

17
Marketing Plan (Cont.)

• Analysis of your competitive strengths and
  weaknesses in ability to fill need.
• Identify the areas where you know you have an
  edge and those where you are less qualified.
• Finally, identify your sales strategythe means
  by which you will make your services known.

18
Operating Plan

• Good business planning also involves the creation
  of an operating planone that attends to the
  "mechanics" of running a business.
• You must specify
• The location (building and equipment).
• Management and staffing (as appropriate).
• Administrative or professional procedures that
  you expect to follow (hours of work, scheduled
  services). (PP manual)

19
Financial Plan

• Lastly, your business plan requires a financial
  plan component. Clearly identify startup costs,
  expected sources of funds, cash-flow forecasts,
  operating costs, and an initial profit/loss
  forecast.
• Your business plan must emphasize quantitative
  data to justify why your business will succeed.

20
Financial Plan (Cont.)

• Qualitative data can be used as well to help in
  identifying trends associated with the
  marketplace.
• Using quantitative and qualitative data to build
  your business demonstrates that you understand
  that the market truly requires your services.

21
Strategic Plan

• For most private practitioners, the business and
  strategic plan will be one and the same.
• Strategic questions to be considered are
• What are your long-term strategies to market
  the practice?
• What are your long-term client and revenue
  goals?

22
Strategic Plan (Cont.)

• What are your minimal profit margins/client
  retention rates required to maintain the
  practice?
• What associations and networks are planned to
  promote practice growth?
• What contingency plans have been created for
  times of illness or slowness in the marketplace?

23
Strategic Plan (Cont.)

• While business and strategic plans are to be
  written, they are not carved in stone.
• Each is to be treated as a toola fluid
  documentthat you can adjust and reevaluate as
  necessary.
• Think Treatment Planning!

24
Budgeting

• Your budget will be a key feature of your
  business plan and is updated annually.
• A budget outlines expected sources of income and
  expenses and results in a projected income or
  loss for the year.

25
Budgeting (Cont.)

• Your budget for your first year of practice will
  include start-up costs in addition to ongoing
  expenses.
• When budgeting, it is useful to overestimate
  costs and underestimate projected income so as to
  increase the realistic nature of your
  expectations.

26
Budgeting (Cont.)

• Developing a "worst case" scenario will result in
  more careful planning of budget categories.
• Your budget and your financial statementproduced
  at the end of the fiscal yearpermit more
  accurate planning of your budget for your second
  and subsequent years of practice.

27
Budgeting (Cont.)

• A financial statement is the summary of actual
  income and costs incurred for the fiscal year and
  shows either a profit or a loss on the balance
  sheet.
• It uses the same categories as those used in your
  budget and includes various depreciation
  schedules.
• See Accountant!

28
Expense categories

• Expense categories in a budget can vary, but
  common ones might include
• Office spacerent, furniture, cleaning,
  upgrades and painting, utilities, parking.
• Telephonephone lines, computer access, fax
  line, long distance charges, cellular phone
  service, answering services.
• Machinecomputer, server, fax, copier, printer,
  answering machine

29
Expense categories (Cont.)

• Office supplies and materialsbasic office
  supplies, ink, paper, stationery, specialized
  supplies, test materials, reference materials,
  coffee.
• Postage.
• Bank chargesfor checks, accounts, deposits,
  NSF checks written by clients, credit card fees.
• Billing program/service (clearing house)
• Business program (Quicken?)

30
Expense categories (Cont.)

• interests on loans.
• Insuranceprofessional liability, general
  office liability, health care, disability, office
  expense (e.g. unemployment ins.) , accidental
  death and dismemberment.
• Salaries and benefits paid to staff (self).
• Retirement savings
• Pro Bono work

31
Expense categories (Cont.)

• Licensesprofessional licenses, business
  licenses, registration fees, listing fees.
• Income taxespayments are computed based on
  your income or loss for the year and are not a
  budget category per se. You will however, need to
  plan on accumulating enough cash to pay your
  taxes on a quarterly basis. (Double FICA)
• Business and other taxesas may be required
  locally.

32
Expense categories (Cont.)

• Bad debtsunpaid invoices that are written off.
• Bookkeeping and accounting fees.
• Legal fees.
• Outside professional servicescase consultants,
  supervision, holiday cover-off.
• Professional developmentconferences and
  workshops, supervision. (CEUs)
• Professional dues and membership fees.

33
Expense categories (Cont.)

• - Play therapy materialsstocking a play therapy
  room can be very costly. Depending on the
  complexity of the materials offered, costs can
  run to several thousand dollars.
• - Biofeedback materialsagain this specialized
  equipment can be very costly. Often a specialized
  room and chair for sessions will further add to
  cost.

34
Expense categories (Cont.)

• - Professional journals, reference materials and
  membershipsin order to keep current with
  emerging research findings regarding theory and
  clinical practice, it is convenient to subscribe
  to various professional journals and to buy
  essential reference materials.
• - Locked fireproof filing cabinets (At lease two
  locks between files and intruder)

35
Expense categories (Cont.)

• Sales promotionopen house, special mailings,
  phone book, internet presence.
• Vehicle and travel expensestravel logs of
  business and personal use, vehicle charges,
  mileage paid, airfares, metered parking
• Depreciation of furniture, business machines
  and any large purchases.
• Collection fees
• Software (client records)
• Others

36
Simple principles can guide early budgeting

• Be realistic and estimate costs carefully.
• Practice austerity and shop around.
• Balance cost, durability and quality of
  materials.
• Start basic.

37
Simple principles can guide early budgeting
(Cont.)

• Underestimate income and overestimate costs.
• Accumulate operating capital prior to opening
  your office.
• Avoid large loans as you will need considerable
  income to service the debt.
• Expect some payment lag. (Depends a lot on
  payor)

38
Simple principles can guide early budgeting
(Cont.)

• Obtain partial guaranteed funding. (part time,
  consultant, services for hosp/court/etc.)
• Maintain a block of funds to cover at least six
  months of operating expenses in case of various
  emergencies.
• Review your budget regularly to gauge your
  financial performance.

39
Accounting and financial records

• As an independent practitioner and business
  person, you will need to keep accurate and
  detailed financial records.
• Not only does this allow you to track and manage
  your finances, but such records are necessary
  should you ever be audited by federal tax
  personnel.
• Consultation with a business accountant is
  essential in setting your accounting system and
  financial records.

40
Accounting and financial records (Cont.)

• Your accountant also may suggest a user-friendly
  accounting software package that enables you or
  your support staff to enter basic data and even
  produce a financial statement.
• You should consult a licensed accountant to
  determine the need for a formal audit or
  financial review of your business.
• If you incorporate you may require a formal
  audita statement that ensures accuracy and
  appropriateness of all expenses and income
  claimed by your business. Check with lawyer.

41
Accounting and financial records (Cont.)

• If you plan to depend on support staff to be
  responsible for record-keeping, ask detailed
  questions during their initial interviews about
  their experience with financial record-keeping,
  get references!!!
• Institute checks and balances.

42
Accounting and financial records (Cont.)

• Even so, it is very worth your while to be well
  aware of the income and costs in your business
  and review them regularly.
• You are ultimately responsible for the success or
  failure of your business and cannot make informed
  business decisions unless you are indeed
  informed.

43
What else?

• You are your own business manager/CEO.
• You may also be your own bookkeeper!

44
Basic necessary financial records include

• Receipts for all money received from direct,
  uninvoiced payment. (e.g. Co-Pay)
• Number these sequentially provide one copy to
  the client and keep one for your records.
• Invoices for services.
• Number these sequentially provide two copies
  to the clientone to be returned with payment,
  one to keepand keep one for your records.
• Open a separate account solely for your
  business, record all deposits/checks and balance
  all statements on a monthly basis.

45
Basic necessary financial records include

• Use of a separate bank account assists in the
  ongoing management of your finances and saves you
  time when preparing financial statements and tax
  returns
• Bank deposit slips. These are provided by your
  bank number them sequentially.
• Use sequentially numbered, personalized
  business checks.
• Record the name of the payee, the reason for the
  payment and the amount of the check on the check
  stubs.

46
Basic necessary financial records include

• For services invoiced to you, note the check
  number and the date paid on your copy of the
  invoice.
• Always check and balance statements of credit
  cards and checking accounts used for your
  business.
• Maintain a petty cash fund and accurate records
  (receipts) of expenses paid with these moneys.

47
Basic necessary financial records include

• Keep a log of all mileage driven for your
  business so that you can either claim mileage or
  a portion of your vehicle expenses.
• Consult your accountant on the best strategy.
• Keep a log of all pay telephone and parking
  meter cash payments for later claims
• My Accountant gave me a book!

48
Basic necessary financial records include

• Keep records of pay issued to people in your
  employ. If not contractual, you will need to
  make deductions for them and submit the Income
  Tax and FICA.
• Regular monthly remittances reduce penalties. You
  will also need to decide what pay schedule to use
  to pay employees (e.g., monthly, biweekly, etc.).
  
• You will need to pay them regularly and to pay
  them prior to paying your own salary if cash flow
  is low.

49
Basic necessary financial records include

• While these records are detailed and laborious to
  keep, they are worth the effort as every penny is
  accounted for and you can see clearly how your
  business is functioning and can then plan
  accordingly.
• As an independent practitioner, you will be
  responsible for paying and collecting various
  taxes. (e.g. Fed St. Income Tax, HICFA,
  Unemployment tax)
• Electronic billing/banking will make some of
  these suggestions archaic.

50
Office Space

• You will need to find or develop office space.
• One way is to contact existing practitioners in
  your area and sublet space from them.
• Most private practitioners have open times in
  their offices where, for a fee, you may be able
  to use the office when they do not.

51
Office Space (Cont.)

• The difficulty with this plan is that you are at
  the mercy of their schedules.
• Another creative way to obtain office space is by
  contacting your local pediatricians, general
  practitioners, gynecologists, or other doctors.

52
Office Space (Cont.)

• You might offer a service to them in exchange
  for space in their office when they are not using
  it.
• You could offer to do parenting groups, marriage
  enrichment groups, weight loss help, divorce
  recovery, or stress management, all in exchange
  for office space.

53
Office Space (Cont.)

• The idea here is that even a busy doctor's office
  has times where it is not in use.
• Also, a pediatrician may relish the thought of
  having a licensed mental health professional in
  the office, available to see his/her patients.

54
Office Space (Cont.)

• There are many options with which to negotiate.
  If the doctor or the office manager seems
  interested, but suggests some payment for office
  space, and if the cost is reasonable, you may ask
  to have your name put on the door with the other
  professionals.

55
Office Space (Cont.)

• The cost of using the office is offset by the
  invaluable publicity, creditability and access to
  clients.
• If you follow this plan, it is best to target a
  doctor's office that fits your niche.
  (CA/Pediatrician, Womens groups/gynecologist,
  etc.)

56
Office Space (Cont.)

• If this seems to difficult to do, remember that
  you are a business person and that the worst
  thing that they could say in answer to your offer
  is no.

57
Office Space (Cont.)

• Sharing office space holds down cost. Another
  mental health professional, a friend, may be
  interested in opening an office and all expenses
  would be shared.
• Finally, there's always the possibility of
  finding a small office in your target area that
  may fit your budget.

58
Office Space (Cont.)

• Be sure the office is accessible, clean, private,
  confidential, professional, has a waiting area,
  has accessible bathroom, etc.
• Depending on your area/nitch/comfort level, you
  may choose to provide home visits. (Not N.H. in
  IL as yet.)
• Be creative!

59
Forms

• Forms
• Clinical records (notes, plan, soc. Hx, diag.)
• Consent to treat , Confidentiality/HIPPA
  Statement
• Consent to bill
• Demographics, referral source
• Complete, organized and proper clinical records
  enhance service provision and also serve to
  protect the practitioner in the event of a
  malpractice allegation or later subpoena to
  court.

60
Core contents of clinical files

• Identifying data name, birth date, address,
  phone numbers, gender, responsible payor.
• Intake form identifying presenting problems.
• Record of appointments, no-shows,
  cancellations.

61
Core contents of clinical files (Cont.)

• Any assessments undertaken and interventions
  recommended, formulation and treatment goals.
• Description of the types and dates of the
  services provided, record of cancellations and
  no-shows.
• Periodic description of client progress.
  (Justify continuing service.)
• Copies of any formal service agreements.

62
Core contents of clinical files (Cont.)

• Copies of signed releases of information and of
  the information released. (Make note on release.)
• (Needed info is based on State Law. May include
  the names of any persons you expect to be
  contacting, the reason for the contact and the
  kind of information you will be discussing,
  purpose, expiration date of consent, signature,
  witness, etc.Check your state law!)

63
Core contents of clinical files (Cont.)

• Copies of any release forms for taping,
  training, etc.
• Copies of any written correspondence and record
  of phone calls.

64
Key elements to be addressed in effective
clinical record-keeping include

• Date all reports only on the day they are
  completed.
• Reports are to be signed by the practitioner
  providing service. (Name, License)
• Notes must be accurate and specificthese are
  vital to help follow the progress of a client.
• Include a mechanism for regular file review.

65
Security of information

• All records, regardless of whether they are on
  paper or electronic, must be kept securely.
• Must use appropriate firewalls if using
  electronic submissions.
• Choose fireproof cabinets and locations away from
  general traffic areas.

66
Security of information (Cont.)

• Keep files and records under lock and key at
  all timessecured from public access.
• Keep public areas of the practiceparticularly
  the reception areafree of personal or financial
  information. (e.g. Dont call client by name!)
• Shred all recordings or client documents that
  are no longer needed.
• Minimum of two locks between file and access..

67
Fees

• How do you set a fee schedule?
• (Find out usual and customary in area, may
  check insurance or Medicare payment schedule,
  consider your experience and skill level)
• The issue of payments is very important.

68
Fees (Cont.)

• Be sure the client (AND YOU) understand that
  payment is made at the time of the appointment,
  and that any insurance consideration will be
  worked out in advance.
• Deductables/copays, EOBs

69
Fees (Cont.)

• Accepting payment for your services may make you
  uncomfortable at first. Do not be. You are a
  valuable professional who is licensed, and
  remember you are solid, knowledgeable, and
  effective.

70
Fees (Cont.)

• If you consider sliding fee, be fair to yourself.
  Remember It is also a reflection of your
  vision, your self-worth and education. Many
  clients will see your fees as a gauge of your
  value as a professional.
• Pro-Bono

71
Marketing

• Provide good service. No network can compare to
  the one you create through the excellence of your
  work. Referrals from satisfied clients may not
  generate immediate referrals, but over time
  increase your client base. (After 30 years in
  Pontiac, I am seeing 3rd generation, presently
  WOM and EAP are my client base!)

72
Building a Client Base

• Provide personal contact and immediate
  responses to inquiries from both referral sources
  and potential clients to demonstrate your
  interest in meeting their needs.
• Maintain goodwill with potential referral
  sources and other professionals in the community.

73
Building a Client Base

• Realize that various other professionals besides
  psychologists may be valuable referral sources,
  including medical professionals, educators,
  social workers, general counselors, employee
  assistance programs, lawyers and social service
  personnel, to list a few.

74
Building a Client Base (Cont.)

• NETWORK, NETWORK, NETWORK
• Refer clients elsewhere if you do not have the
  specific skills they require, or provide an
  option of an alternate referral if your waiting
  list is very long. Maintain a referral list of
  other professionals whose work you respect.

75
Building a Client Base (Cont.)

• Distribute your business cards freely. Make
  them easy to read, attractive and professional.
  Include your name, degrees, license,
  certificates, address, and phone/fax/e-mail
  numbers. (e.g. mine)
• Send a thank you letter to the referral source
  once you have seen a client and received their
  written consent to do so.

76
Building a Client Base (Cont.)

• Send an announcement mailing when you first
  establish your practice, or add another
  practitioner to your practice. Realize that this
  may result in very few referrals, but will still
  make your availability known.
• Contact local business reporter to do a piece on
  something special you are offering. (Horse riding
  therapy)

77
Building a Client Base (Cont.)

• Hold an open-house to make your availability
  known, thank the people who have supported you,
  to establish a practice, and generally establish
  goodwill.
• Join the local Chamber of Commerce.

78
Building a Client Base (Cont.)

• Place your name and perhaps an advertisement in
  the Yellow Pages. Some people look there first.
• Realize, however, that some people may not
  select a psychologist through the Yellow Pages.
  Know that having your name there indicates that
  you are a bona fide practitioner and provides
  phone numbers and addresses to facilitate contact
  with you.

79
Building a Client Base (Cont.)

• Be willing to accept interviews from the media on
  general topics in psychology.
• Have your name placed on a list for speakers'
  bureaus indicating your willingness to give
  presentations and workshops. This makes your name
  known.
• Volunteer to speak at service clubs, church
  groups, womens groups, etc.

80
Building a Client Base (Cont.)

• Give your practice a name and a logo. Again,
  this makes your name stand out and is likely to
  be most useful if you are in a joint practice
  with several other practitioners.
• Serve on various community boards for either
  profit or non-profit societies.
• Become adjunct faculty for universities,
  community colleges, etc.

81
EAPs

• Employee Assistance Programs (EAPs) are employee
  benefit programs offered by many employers,
  typically in conjunction with a health insurance
  plan.
• EAPs are intended to help employees deal with
  personal problems that might adversely impact
  their work performance, health, and well-being.
• EAPs generally include assessment, short-term
  counseling and referral services for employees
  and their household members.

82
EAPs (Cont.)

• Employees and their household members may use
  EAPs to help manage issues that could adversely
  impact their work and personal lives.
• EAP counselors typically provide assessment,
  support, and if needed, referrals to additional
  resources.

83
The issues for which EAPs provide support vary,
but examples include

• substance abuse
• safe working environment
• emotional distress
• major life events, including births, accidents
  and deaths
• health care concerns
• financial or legal concerns

84
The issues for which EAPs provide support vary,
but examples include (Cont.)

• family/personal relationship issues
• Partner relationship issues
• work relationship issues
• concerns about aging parents
• An EAP's services are usually free to the
  employee or household member, having been
  pre-paid by the employer

85
/- of working with EAP

• PLUSES
• Easy to collect from Contractor
• Less paperwork
• Source of referrals
• No deductibles/co-pays to collect (no
  out-of-pocket for client)
• Does not require major (reimbursable) diagnosis

86
/- of working with EAP (Cont.)

• MINUSES
• May be required to share clients info with
  employer (with clients permission)
• Can not charge a no show fee
• May not be able to self refer
• Eap company is Keeper of the Records
• Must be able to function in brief model
• Some EAP companies have questionable fee
  arrangements

87
Insurance

• Some insurances require that you be on their
  panel
• Some will pay at lesser rate if you are out of
  network, some not at all.
• Can often apply through web site (look for
  provider relations)
• Find out who insures most people in your area
• BC/BS is usually big

88
Insurance

• May check with other providers (hospital?) to see
  whom they bill
• Will need copies of current license, malpractice,
  certifications (e.g. CADC)
• Medicare is special insurance with own process
  see on line, all electronic billing (central
  management service)

89
/-

• PLUSES
• Some referrals if persons covered are seeking
  someone in network
• Can be reliable source of income
• You maintain your own records
• Many accept multiple billing methods

90
/-

• MINUSES
• May have to get preapproval
• Deal with deductibles each year and copays
• May pay reduced rates to covered therapists

91
Coding Info Needed for Billing

• The CPT is a uniform coding system consisting of
  descriptive terms and identifying codes that are
  used primarily to identify medical services and
  procedures furnished by physicians and other
  health care professionals.

92
Coding Info Needed for Billing (Cont.)

• These health care professionals use the CPT to
  identify services and procedures for which they
  bill public or private health insurance programs.
• Decisions regarding the addition, deletion, or
  revision of CPT codes are made by the AMA.
• The CPT codes are republished and updated
  annually by the AMA.

93
Coding Info Needed for Billing (Cont.)

• Because these particular codes mean so much
  income for the AMA, it is difficult to find lists
  of them that are accessible to the public. In
  fact, groups that have tried to make them public
  have been cited for violations and fines by the
  AMA and have been forced to remove them from the
  Internet. Many groups license the lists of codes
  from the AMA, however, and then publish them
  online or in books. They are allowed to charge
  for access since they are also paying that
  licensing fee.

94
CPT (Current Procedural Terminology)

• Billing service may have them
• May buy a book from AMA
• May pay for list on line
• Most common 90801-intake, 90806-45 to 50 minute
  session.(90804, 90808)
• Helpful to have the resource for parameters of
  what's included
• New Health and Behavior codes presently can be
  used by Psychologists

95
Health and Behavior

• CPT Code
• (15 min 1 unit)(1 hr 4 units)
• 96150 Assessment initial
• 96151 Re-assessment
• 96152 Intervention Individual
• 96153 Intervention group
• 96154 Intervention family w/ patient
• 96155 Intervention family w/o patient

96
ICD-09

• What Do the Numbers Mean? ICD-09, ICD-10 and
  Others?
• ICD codes were first developed in 1893 in France
  by a physician, Jacques Bertillion. They were
  called the Bertillon Classification of Causes of
  Death. In 1898, they were adopted in the United
  States, and were considered, in effect, ICD-1
  because that was the first version of code
  numbers.

97
ICD-09 (Cont.)

• Since then, as medical science has progressed and
  new diagnoses have been developed, named and
  described, the code lists have been updated. The
  number designation changes when the updates are
  so extensive that a wholesale change needs to be
  made. There may be annual updates, too, but those
  are considered to be relatively minor, and the
  basic code set doesn't change.
• For example, the upgrade in 1949, ICD-6, was the
  first time mental disorders were added to the
  code set.

98
ICD-09 (Cont.)

• Most of the codes we see in the United States
  today are version 9, called ICD-9-CM codes. With
  few exceptions, the paperwork we receive when we
  leave a doctors office will contain both CPT
  codes (Current Procedural Terminology) to
  describe the service that was rendered for
  billing purposes, and ICD-9-CM codes to describe
  why that service was provided. Further, most
  death certificates filed since 1977 will have an
  ICD-9 code on them.

99
ICD-09 (Cont.)

• The most current list of codes in use is ICD-10.
  This list was first used in the United States in
  2007. Minor revisions added to ICD-10 codes were
  made available in early 2009 by the NCHS.
  Globally, most other countries in the world have
  implemented the ICD-10 codes. There are some
  major differences between the two code sets, the
  transition is very expensive, and most American
  providers have not yet upgraded to the ICD-10
  system.

100
But I use DSM-IV-TR to diagnose!

• Covered Diagnoses Crosswalk of DSMIV
• The crosswalk is a document designed to help you
  determine which ICD-9-CM diagnosis code (1977)
  corresponds to a particular DSM-IV-TR diagnosis
  code.

101
Do I need to use it?

• YES!
• Under the Health Insurance Portability and
  Accessibility Act (HIPAA), insurance companies
  who accept and process insurance claims
  electronically are only required to accept
  ICD-9-CM diagnosis codes.

102
Do I need to use it?

• Because there is no HIPAA requirement that
  insurance companies also accept DSM-IV-TR codes,
  insurance companies are likely to only accept
  electronic claims that use ICD-9-CM diagnosis
  codes, and which will require psychologists who
  are only familiar with DSM-IV-TR to convert their
  DSM-IVTR diagnosis codes into ICD-9-CM diagnosis
  codes.

103
Where do I find it?

• http//www.apapractice.org/apo/insider/practice/pr
  acmanage/practice_management/dsm-9.
• GenericArticle.Single.articleLink.GenericArticle.S
  ingle.file.tmp/Download_the_Covered_Diagnoses__Cr
  osswalk20of_DSM-IV_Codes_to_ICD-9-CM_Codes_chart.
  pdf
• Or Google Covered Diagnoses Crosswalk of
  DSMIV Codes to ICD-9-CM Codes

104
Mentor/supervision

• If you decide to start a business one of the most
  important components is finding a trustworthy
  reliable mentor/supervisor who is successful.
• Can supply needed expertise in business and
  psychotherapy.
• Can provide needed supervision.

105
Mentor/supervision (Cont.)

• Can provide access to assessing the current
  professional standard of care.
• It is also helpful to networking with other
  entrepreneurs/therapists, join in-person and
  virtual entrepreneur/therapist support groups,
  take classes and workshops.

106
Ways to start

• In the beginning opt for full-time work in an
  agency or institution, but take on a few clients
  privately.
• This augments income and helps determine if there
  is a market for your skills.
• This provides guaranteed income and benefits.

107
Ways to start (Cont.)

• Spend time learning the policies and procedures
  of the entity, including billing.
• Note you must be careful to avoid any conflict
  of interest, perhaps best achieved through
  completely different referral sources from those
  of the agency. It is also important not to use
  agency time to build your practice.

108
Ways to start (Cont.)

• Another alternative is to join a functioning
  professional practice as an associate to gain
  awareness and experience prior to establishing an
  independent practice.
• This also provides a safety net of sorts.
• Exercise the same care regarding conflict of
  interest as you would if working in an agency or
  institution.

109
Ways to start (Cont.)

• Opt for a clearly delineated part-time
  roleworking half-time at an agency and half-time
  in your own practice.
• This is advantageous, as you have some guaranteed
  income, but can have more energy available to
  devote to building your referral network. Again,
  take care to avoid any conflict of interest.

110
Ways to start (Cont.)

• Opt for full-time practice, while understanding
  the financial risks involved.
• Perhaps the best way to ensure viability is to
  ensure that you have some guaranteed funding,
  such as obtaining a contract for a block of
  service provision, or a part-time teaching
  position.

111
Ways to start (Cont.)

• Guaranteed funding ensures that bills will be
  paid during the time that you are building your
  referral network and a steady client base.
• Be creative in developing an option that best
  suits your skills, strengths, energy, need for
  security and present circumstances.
• Have a clear idea of anticipated costs and
  potential income.

112
My Advice

• Dont quit your day job!!!
• A new business can take up to 5 years to turn a
  good profit!

113
My Advice

• Expect to spend a great deal of time developing
  and running a private practiceboth in serving
  clients and in marketing and running the
  business.
• Careful planning and preparation is crucial and
  takes time.
• Have financial resources available to your
  business.

114
My Advice

• Be prepared to work hard at getting started,
  getting known and encouraging referrals.
• As your practice enlarges, decrease your other
  commitments.
• GO FOR IT! YOU CAN SUCCEED!!!!!
• Q/A