Does Medicare require a real brick-n-mortar office for your private psychotherapy practice address?

Does Medicare require you to have a physical office to see clients in your private psychotherapy practice?

I’ve seen this question posted several times in forums since the pandemic began. I get asked this question often, so here’s the long and short of it.

Short answer first: YES. CMS (https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance?redirect=/home/regsguidance.asp) makes the rules and regulations and they apply nationwide.

Here’s the long answer I recently wrote to someone (I’ve edited that response and added some minor details and links for this post):

Yes, and…

Regular Medicare requires us to have a brick-n-mortar practice address/office that is not your home address. You have to be able to see Medicare recipients in person and your home is not acceptable (and after the PHE ends, you will be required to see them in person periodically; how often will depend on how the rules change by then). These are CMS rules and regulations that apply nationwide. 

Your billing, correspondence, and notification addresses can be your home address.

If you decide not to get a real office in your telehealth-only practice and you decide to see Medicare recipients who can pay privately (no reimbursement from Medicare), you will need to “opt-out” of Medicare. With your license (LCSW), you are already an “eligible provider,” even if you have not “enrolled,” therefore, you are required to follow Medicare guidelines for Medicare recipients, unless you officially “opt-out.”  (https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/Manage-Your-Enrollment)

By the way, for seeing Medicare folks, following the guidelines includes charging only what Medicare will reimburse (and that is dependent on which jurisdiction you are in). (https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Downloads/contact_list.pdf)

The question I received recently also indicated the clinician might apply to commercial insurance panels. Here’s information related to that and Medicare:

Some commercial insurance companies require you to have a brick-n-mortar office, but it might be hard to figure out if the panel you are applying to requires it. 

I would call provider relations and ask before going through the hassle and/or cost of credentialing (but know that information from them can be inaccurate and also remember they can and do change their rules even after you are contracted). 

That commercial insurance you are interested in may even have a Medicare product, so without a brick-n-mortar, you’d either a) be excluded from their Medicare folks, or b) to be eligible to see their Medicare recipients,  you’d have to enroll with regular Medicare first.

More information:

I enrolled in Medicare and contracted with several insurance companies from the start of my practice, then this year took myself off all commercial panels.  

Medicare has been my bread-n-butter since the beginning (and my favorite population), however, if I ever reopen my practice (closed this summer due to family caregiving), I will opt-out of Medicare (much to my own surprise) because the risks have become personally unacceptable.  It is a personal and business model decision you should make with as much information as possible.

The person who asked me recently didn’t ask about private pay only, but here’s a tip:

You can make more money hourly with private pay only (don’t offer superbills for clients to get reimbursed). You can avoid the risk of audits and clawbacks which are very real, have less stress about several everyday things related to insurance contracts, reimbursement and documentation requirements, and have greater peace of mind in the short and long runs by offering private pay only (no insurance reimbursement to you or client).

You just have to understand how to find clients.

Offering “telehealth only” makes this doable since you can see clients across the state you are licensed in (and potentially more states with laws and regulations changing due to pandemic demands) making it a more open field to build a referral network for clients who can afford private pay. The biggest concerns are the clinical implications which I’ve written about in a recent thread on the NASW forum.

For anyone with questions, I’m happy to consult further regarding the pros and cons of insurance contracting and enrolling in Medicare. The cost is $90/hr whether it’s online video, phone, or detailed email responses after we’ve had the first consultation.

If you are looking to start your private psychotherapy practice, check out the guide I wrote. It’s guaranteed to answer a zillion questions (okay, not a zillion but lots).

The guide: The Guide renamed: The 14 Concrete (but not so hard!) Steps to Private Practice

Recommended Reading: Recovering the Self A Journal of Hope and Healing

Sometimes leaving your dream job is your best chance for recovering from Post-Traumatic Stress Disorder (PTSD) triggered by vicarious trauma (VT). Leaving the job that continues to trigger your symptoms can create a healthy opening for finding your way back to your sense of meaning, purpose, and an even truer self, a better version of the identity that was shattered.

Leaving that job does not mean you are a failure. I know this to be true because I lived through the harrowing experience of my brain being hijacked by PTSD and coming out the other side whole again.

An article I wrote The Turbulence of Vicarious Trauma Propels Success about my experience with PTSD triggered by the trauma of others was recently published in Recovering the Self: A Journal of Hope and Healing. If you are a clinician or know someone who is at risk for vicarious trauma, I invite you to read my article in the journal. Please read more about the journal and the timing of this publication below The Overview section.


The Turbulence of Vicarious Trauma Propels Success: The Overview (get the journal for the entire article)

In 2011, I was working at my dream job in a Level II Trauma Center as an on-call social worker. I experienced PTSD as a result of witnessing a family’s particularly tragic death of their child on a parental holiday. Some professionals call this Vicarious Trauma (VT) or Secondary Traumatic Stress (STS), but my doctor called it PTSD. My brain didn’t know the difference; it reacted as if it were my child that died. I took a five-week break, then went back to work. Although the intensity had decreased enough to return to work, I was still suffering from symptoms. I feared someone would decide I couldn’t do my job anymore. I wrestled with big questions: Who was I to suffer so much when it wasn’t my child that died? Why am I so weak when everyone around me is dealing with so much tragedy and they appear normal?

Two years later, I quit that dream job amidst confusing feelings of guilt, shame, fear, and beliefs that I was a failure for having experienced PTSD; I still felt like an imposter posing as a social worker. My social worker identity was still deeply wounded even though I’d successfully navigated the halls of the hospital for two years after the incident.

I was not happy at my job anymore. I didn’t feel “safe” in an environment that didn’t support social workers experiencing vicarious trauma. So when a new opportunity arose at a local hospice, I quit my dream job. During that time, I was plagued with more questions: Was I fleeing as a result of PTSD? And, if so, what did that say about me?

It took years and tears, and a lot of writing, talking, and “doing” to work through my questions and regain my confidence as a social worker. My successful private practice was an integral part of the process.

Read More

Publication and Validation

In December 2017, when my mom was dying of breast cancer, I wrote an article about my PTSD experience and submitted it to the editor of Recovering the Self: A Journal of Hope and Healing. My article titled The Turbulence of Vicarious Trauma Propels Success was not only accepted but set as the featured article in Vol. VII, No. 1 Focus on Work. What a happy shock that was! I was only in my first year of creative writing and my Healing through Writing and Creativity blog was less than a year old. I was writing to heal various wounds, not just from my hospital experience.

Four years after submission, the journal was published in April 2022. The truth of what happened is now “public.” It’s out in the world in a permanent space where critics and judgment abound. I invite you to read it.

This edition of the journal is offered as an e-book only, so it’s reasonably priced at $4.95. Here’s the link again: https://www.amazon.com/gp/product/B09YKZ7BD2

There are 26 articles, some are poetry, containing stories of challenges and recovery related to work life. Many of the articles are written by published authors and poets who are doctors, therapists, and other clinicians. I am honored to be among them as an unpublished (#futureauthor) writer!

I guarantee you will find inspirational and courageous stories of recovery.

Photo credit: Lisa Redfern at Redfern.biz


The Timing of Things – Closing My Private Practice

It is both ironic and serendipitous that the article I wrote about finding a better version of my social worker identity through starting my private psychotherapy practice was published during this time when I am closing that private practice for an undetermined period of time. Private practice has been the best. job. ever., however, life has brought new turbulence (unrelated to, but tagging onto the effects of the pandemic) coinciding with a strong desire to explore other meaningful avenues in life.

I no longer have the office described in the article (thank you pandemic for that most unwelcome turbulence!), though the furniture, art, and the spirit of the office reside throughout my home.

I also have a 70k-word vomit draft memoir manuscript of the longer story about my social work career being intertwined with, and often propelled by, my personal life.

Maybe someday I will get back to that manuscript and make another dream come true: a book-length memoir about being a social worker whose career has continually been propelled by death, loss, codependency, and other difficult realities of life.


For those here for my coaching, consulting, and mentoring help, I will continue coaching clinicians starting or struggling with aspects of private practice. The Guide is still offered here on my website as an electronic .pdf.

It is on sale again, despite advice by published authors to raise the price. My next goal with the Guide is to publish it as an e-book on Amazon. You can stay tuned by Subscribing below.

Feel free to contact me with your questions.

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Telehealth Video-Conferencing Platform Choices for Psychotherapists

As I spent time editing and updating the Telehealth chapter in the newest version of the guide, which by the way is now called 14 Concrete (but not so hard!) Steps to Private Practice, I realized there are so many more choices for telehealth video conferencing than there were just two years ago. No doubt the pandemic sparked big growth in the market.

If you are looking for telehealth online video options for your psychotherapy practice, check out the list below.

When making your decision, of course, you’ll consider cost, but you should also think about ease of use (does the client need an app or can they access from any device without an app?) and any systems like Microsoft Teams or Google Workspace that you can use for multiple purposes in your practice and that happen to include video-conferencing.

And don’t forget to choose a service that offers the Business Associate Agreement (BAA) that brings the service into HIPAA compliance. When you choose a platform, you might have to complete a few extra steps in order to get that BAA in place.

Telehealth-specific online video platforms that offer that crucial Business Associate Agreement (BAA):

I use these two platforms:

  • Doxy.me – https://doxy.me/ The free version includes the BAA. With a paid version you can modify your Waiting Room and have additional features like group participants and screenshare. You can see my waiting room here: www.doxy.me/bonniemckeeganlcsw One advantage of doxy.me is your waiting room URL (the link to see you) is always the same. Your clients can access it from anywhere without needing to click an appointment-specific link like with an EHR platform or another platform where a meeting is “scheduled” (like on Google Meet or Zoom).
  • Google Meet with Google Workspace Plan https://meet.google.com/ For $6/mo you get a whole ‘lotta goods along with that BAA. I recently upgraded to the $12/mo version of Google Workspace for more storage cuz hey, it’s a great place for my gazzillion photos and now I have the option of recording meetings. It also includes tons of other services I love to use (Google Drive, Spreadsheets, Forms, Docs, Calendar, etc.). Google Meet works nicely for group therapy or sessions with family members in different places.

Here’s the list of other options I’ve found:

Several on the list are through Electronic Health Record (EHR) platforms.

If you are thinking of starting an EHR (or switching) and looking for one that offers a telehealth platform, check out my blog post about Simple Practice. Get a discount for your first paid month ($100 if you start in November 2021 / $50 normally). If you use my link, I get the same credit you get.

I used Simple Practice’s telehealth option for a while. It worked for most clients, but two complications occurred:

1) It required an app on the client’s phone and two clients couldn’t add anything to their phones. I got tired of keeping track of who could use the Simple Practice appointment link and who needed to use my www.doxy.me/bonniemckeeganlcsw Waiting Room.

2) Like other EHRs, when you use the Simple Practice telehealth platform, you create a unique appointment link. The client is set up in the system as part of your Video Office. The system pulls that information onto the claim and labels the Place of Service (POS) as Telehealth (02). This is usually fine for commercial insurance companies who want you to use POS 02. However, most of my clients are Medicare (different POS requirements than commercial insurance) so I’d have to manually fix the claim (change the Place of Service to Office – 11) before submitting claims.

So, in the interest of saving time, avoiding confusion, and submitting accurate claims without an extra step (cuz efficiency gives me more time to take a bazillion more photos), I switched all of my clients over to Doxy.me. And as a bonus, this solution saved me the $10 per month fee for telehealth within Simple Practice.

With all of the options available, there really is no reason to use a video platform that does not offer the Business Associate Agreement (BAA) (which makes your use of online video for your psychotherapy clients HIPAA compliant).

This decision can be overwhelming. After trying different options, I have found what works best for my practice.

If you need help figuring out your best option, feel free to contact me.

If you feel inclined, drop a line in the comments and let us know your favorite telehealth platform. I am sure there are more out there I haven’t discovered yet!

Image by Alexandra_Koch from Pixabay

Simple Practice EHR Pros and Cons – link for $100 discount code

In this (updated February/March 2022) blog post, I share my experience with the Simple Practice Electronic Health Record (EHR).

The referral discount is $100 which is credited to you when you begin your monthly paid subscription after your initial free 30 days. If you find this review helpful and are interested in trying it out, scroll down to the referral discount code link I’ve provided.

I’ve been using Simple Practice EHR for documentation and billing since October 2019. Previously, call the Professional Plan, I continue to use the Essential Plan which is now $69 per month. I’ve found my way through some of the non-intuitive processes which can be annoying at times, and overall I still appreciate what this platform has to offer.

I highly recommend using an EHR over paper charts. Why stress out over not being caught up with notes or the quality of your notes when you can get it done more efficiently for less than (or equal to) the cost of one client session per month? With integrated billing and doing it myself, my expense for billing went from 9% of paid claims to .25cents per claim submitted using Simple Practice.

To give some perspective, here’s some math for you:

  • 25 sessions x $90 paid per claim: expense to a billing agency at 9% = $202.50
  • 25 sessions x .25¢ per claim: expense to Simple Practice = $6.25

Using an EHR is quite possibly (it is!) the best investment I’ve made in private practice.

What is your charting process? If you are using an EHR, which one are you using? Do you recommend it?

Simple Practice Review originally published October 2020 (edited January/February/March 2022)

I highly recommend simplifying your private practice by using an EHR as soon as you can afford it. If you or your clients get reimbursed for psychotherapy services, you almost can’t afford NOT to.

For the cost of perhaps one session’s reimbursement per month (depending on your fees), you can present your practice to clients professionally with an EHR Client Portal with all of its benefits including e-signature forms, signatures on treatment plans and other documents, and streamline your practice management to save significant time, money, and stress.

If you have a telehealth practice (like I do), an electronic health record (EHR) with e-signature and a truly “paperless” office is the only practical way to go. Don’t worry, you can still use paper for those clients without access or skills to access the internet and their Client Portal.

During the coronavirus pandemic, using the Simple Practice EHR with e-signature for clients to complete documents made it possible for me to quickly adapt to telehealth only. I didn’t miss a beat in terms of appointments and scheduling new clients when the shelter-in-place directives came down in California in March 2020.

My experience with Simple Practice comes from using it as a solo practitioner since Fall 2019 so I can’t speak to it’s benefits or downfalls for a group practice (the cost may be the biggest factor to consider).  It served me well in the office pre-pandemic and continues to be excellent for my telehealth practice. Despite some non-intuitive workflows and idiosyncrasies that take time to figure out (and honestly are annoying), I still recommend Simple Practice. 

Start your free first month of Simple Practice here and receive a $100 credit for your first paid month with my referral discount code – I get a $100 credit, too ;-).

Previous to Simple Practice, I used TherapyAppointment.com (TA) the Legacy system for charting and electronic claims submission integrated with Office Ally (OA). 

Switching to Simple Practice was a vast improvement over TA’s Legacy system in terms of charting, telehealth practice in general, and electronic submission to secondary insurances (which was not possible at the time I left TA.com). 

When I left TA, I had been waiting for over a year for the transition to the new TA 2.0. which would have been comparable to Simple Practice’s platform at the time. I got tired of waiting and I am so glad I made the transition to SP before the coronavirus pandemic turned everything upside down. 

Regarding Office Ally (OA). If you are looking for a billing-only option (using paper charts), check out OA. If I were to drop the use of an EHR, I’d go back to OA for billing. When I took over my billing to save money and serious aggravation but was still using paper charts, I used OA and I still recommend them.

I highly recommend using an EHR for time management (high on my list of priorities) and efficiency/accuracy of charting (also high on my priority list because, uuuuhhhhhmmmm, no, I do not want to give an insurance company any money back for insufficient documentation).  In addition, the ease of integrated electronic claim submission and client billing is a big time saver. Did I mention the money saved doing my own billing? 

Start your free first month of Simple Practice here and receive a $100 credit for your first paid month with my discount coupon code

Simple Practice Pros and Cons

This list is not exhaustive of all the pros and cons of Simple Practice. Some clinicians I know, really don’t like Simple Practice. Others love it, or have decided it’s the best they can find, so far. Changing EHRs is an exercise in mental patience and takes time, so be sure to look at reviews of other EHRs, then decide how you want to proceed.

These are a few notes, in no particular order, from my experience. I haven’t used all of the features, and in early 2022 the plans changed, so please look carefully at the package you choose.

CLIENT PORTAL

Pros: 

  • The Simple Practice Client Portal is great for getting documents electronically signed by clients, sharing .pdfs and pictures (to and from clients), secure text messaging with clients, sending invoices superbills and statesments to clients, and receiving payments from clients (Stripe is integrated for online payments – the fee is comparable to Square).
  • When a client shares an uploaded document with you or completes the documents you have sent to them, you get an email notification.
  • Clients can “sign” their name now rather than just click the e-signature box.
  • Clients can see their scheduled appointments, documents, and payments in the portal.

Cons:   

  • Regarding creating the documents you send to clients for review, e-signature, and filling out, there are two distinct processes you must learn. Learning the difference between the two and which forms are under each heading takes time. It’s not 100% intuitive.
  • Secure Messaging via the Client Portal can be inconvienent for the client to manage. The direct secure link is sent to the client by email when a clinician sends a message to the client. The link is time limited. If the time expires, the client has to figure out how to get into their client portal.  The system has been improved, but it is still a learning curve for the client.
  • There’s no client-facing app for their smartphone.  For the most part, my clients don’t use the secure messaging feature. It’s too inconvienent because it requires them to sign into the portal. If it was an app on their phone some of them would probably use it.

SCHEDULING

Pros: 

  • The schedule is relatively easy to manage and you can change view to day, week, or month. 
  • There is an option to allow clients to request appointments online via a booking widget. (I don’t use this so I can’t report on it)
  • You can create multiple offices (such as for in-office visits, home visits, telehealth, etc). You assign the proper office to each individual client so the Place of Service (10, 02, 11, etc) prepopulates on the calendar (then on the claim form).
  • You can change the office for each individual appointment on the calendar. So, if you usually see someone in the office (and have assigned this to their file), but you change to a telehealth appointment for that day, then you can easily change the Place of Service on the calendar just for that day.
  • You can schedule Repeat appointments (multiple repeating appointments like weekly or every 2 weeks) for a set period of time.
  • You can sync the calendar with your Google calendar (and possibly other calendars) but this service is now only included in the most expensive plan (the Plus Plan at $99 per month). (I don’t use this so I can’t report on it)

Cons: 

  • The appointments on the calendar are not easy to identify in terms of which office the client is scheduled for (in-office vs home visit or telehealth, etc). There is a color coding line on the edge of each appointment on the schedule but it is difficult to see. This means you need to memorize the color for each office type or open each appointment to see where the appointment is scheduled for. 
  • If you assign the Simple Practice Telehealth Office (for a secure appointment-specific link to the video platform) to your client or to a specific appointment on the calendar, it automatically assigns the Place Of Service (it was originally 02 but may have changed to 10 as of January 1st 2022) to claims. There is an icon indicating a video camera which is pretty much the only obvious office assignment. 
    • Here’s the catch: The automatic Place of Service with the Simple Practice Telehealth Office can be a problem. If you assign SP’s Telehealth Office so that you use SP’s video platform, but the client’s insurance requires a different POS for telehealth, (e.g., Medicare is different and remains 11 until March 2022), then you have to change the POS on each individual claim (too easily forgotten prior to submission and requires extra time/effort).

CREATING DOCUMENTS, INFORMED CONSENTS, ASSESSMENTS, TREATMENT PLANS, AND PROGRESS NOTES – this is one of the best parts of Simple Practice!

Pros: 

  • There is a large library of documents, assessments, progress notes, informed consents, etc., that are customizable (with Essential Plan) and/or you can start with a clean slate and create new documents from your own existing documents.
  • Looking up diagnosis codes is straightforward.
  • The Treatment Plan has been updated to make it easier to use (relatively speaking), including getting a signature from the client.
  • Treatment plan reminders give you a head’s up according to the schedule you preset.

Cons: 

  • There are two processes to learn to create documents.
  • Wiley Treatment Planner is now an extra $15 per month, if you chose the Essential Plan (as of the March 2022 change in plans). 😦 Big downer because integrated Wiley makes it so much easier to create a comprehensive treatment plan without having to type everything from scratch.
  • After you Sign the plan it is locked. You can’t edit it without unlocking it.
  • There is no built in process for updating the plan properly (in particular, adding progress for each intervention, objective, and goal). You have to unlock the signed plan and edit on each line item which is labor intensive and not intuitive to figure out, at all.
  • You have to unlock the plan to add goals, objectives, and interventions but dating is not flexible.
  • In other words, it’s not a “living” document that can be easily modified during each session.
  • Recently (as of late February) changes to the treatment plan workflow have created confusion for me (and I am persistent in figure this stuff out).
  • Treatment plan workflow needs serious updating. When you juxtapose that to the increase in cost by $15 to add Wiley, things are disappointing…

REMINDER MESSAGES (voice, text, email)

Pros: 

  • Included in the monthly price (not an add on like other EHRs). 
  • You can edit the email, text, and voice messages to include practice specific information. For example, I use doxy.me for telehealth rather than S.P. Telehealth platform.  I’ve included my doxy.me waiting room link in the reminder email and text messages for telehealth appointments.
  • You can type the exact words the Voice reminder will speak.
  • Appointment Confirmations are a new feature.
  • Using appointment reminders has reduced No Shows in my practice. 
  • You can set up individual clients to receive both a text and email reminder.

Cons – I can’t think of anything specific.

CLAIMS PROCESSING

Pros:

  • Claim processing is optional.
  • Inexpensive compared to paying a billing agency.
  • Once set up, it’s fast to submit.
  • You get to review the actual claim before submitting it.
  • Current cost choices (no more discount packages)
    • 25c per claim (first 10 are included in Essential Plan)
  • ERAs (Electronic Remittance Advice) are now available for download. This was a BIG improvement.
  • You can grant your biller access to deal with billing.

Cons:

  • The Medicare ERA (electronic remittance advice) doesn’t tell you if and where the claim was forwarded for secondary insurance processing (for comparison, Office Ally’s ERA includes all information so you can verify the secondary went to the right insurance company).
  • Clinicians/billers have no direct access to the clearinghouse that SP uses (Eligible, Inc).
  • Claims processed from Medicare don’t automatically adjust the Contractual Obligation (CO). You must do this manually for each Medicare claim. Claims processed from other insurance companies do generally automatically adjust the CO (but not the Medicare secondaries).
  • If there is an amount owed by the client after a claim comes through, deductible or coinsurance for example, there is no specific notification process to the clinician.  The information is there but it’s not obvious so you have to create your own practice management process look for it.
  • If a Medicare Electronic Remittance Advice (ERA) includes only claims that were assigned to the deductibles for each client (in other words a zero payment), then there is no Payment that shows up in the usual place (tabs = Billing; Insurance; Payments). You need to go through another heading to find the information then manually enter a Zero Payment and add the details for each client. This is time consuming and frustrating. There’s no logic to it from the clinician point of view.
  • The process to get set up with each insurance company for processing via SP’s clearinghouse is a bit labor-intensive.  By comparison, Office Ally and TherapyAppointment.com were much easier.
  • Medicare + Secondary claims:  If a client has a secondary insurance to Medicare, when the secondary ERA is processed, it is listed in SP (tabs = Billing; Insurance; Payments) as being from Medicare (you cannot correct this in the client’s account but you can correct it under the Payments list).  This is a serious issue with inaccurate information being reported to the clinician. Each payment from a secondary in this situation has to be verified elsewhere (from the paper check sent to you, the other insurance company website, your bank statement – ACH, etc.), then corrected in the Payments part of the SP system. 
  • Appointment Status feature is difficult to follow, often innaccurate in terms of Paid vs Unpaid appointment dates, nor is it easy to correct.
  • You have to pay extra to give your biller access.

TELEHEALTH BY SIMPLE PRACTICE (I am not using it, currently)

Pros:

  • The telehealth platform gives you the ability to send reminder messages with secure appointment unique links to your client.  
  • You can share your screen during session and the features have been updated recently.
  • The format looks professional. 

Cons:

  • The Essential Plan which is currently $69 (previously known as the Professional plan which was $59) now automatically includes the SP Telehealth Platform. If you use another platform like I do, you are still stuck with paying for this feature with SP.
  • The Telehealth by Simple Practice client facing app must be downloaded by your client.  
  • Some clients are not able to download the app on their device for various reasons.  If the client is using their cell phone for video appointments and is not tech-savvy or unable to add apps to their phone for any reason, you’ll have to use another platform for online video conferencing. This is the main reason I switched back to using Doxy.me.  
  • You might have some clients on a different platform because they can’t get Telehealth by Simple Practice on their device (which means you need to remember what each client is using).
  • The client must click on the Appointment Unique Link to access each appointment. No using an old link anymore which increases security but can be a problem if the client can’t find the email or text reminder or is using a device without incoming email attached to it (you must remember to send the Reminder by Text if they are using a cellphone in this case).

CUSTOMER SERVICE

Pros:

  • Help is obtained primarily via chat and email. 
  • The Help system has tutorials and a Community Forum.
  • In the Community Forum you can ask questions and get information and answers from other SP users.
  • You can also make suggestions for improvements or vote on other customer suggestions.
  • Friendly Reps.
  • There is now an option to request a phone call in their Help request widget.

Cons:

  • If email and text chat hasn’t solved your problem, you might need/want to talk to someone. It can be difficult to get someone on the phone for customer support, but it is possible by communicating with the person you’ve been emailing and text chatting with. There is no phone number published but they will send it to you if you ask.
  • Online tutorials are not always updated to new workflows Simple Practice creates.

GENERAL 

Pros:

  • Couples and Minor Management recently upgraded (I haven’t used this feature).
  • Billing “Ask the Biller” blog series – one example: (https://www.simplepractice.com/whats-new/insurance-payments-ask-a-biller-4/)
  • Community listserv for asking questions and getting useful information from other users.
  • Earn credit for referring others (thank you for using my link!).
  • Appointment Status Reports are helpful for finding Medicare clients in particular whose manual write-offs you may have missed when updating Payments. CON: The report is inaccurate for other purposes unless you’ve manually done the CO (Contractual Obligations) write-offs ahead of time. 
  • Daily Agenda emails sent in the early AM and Evening Summary emails from the system are helpful. The Evening Summary email lets you double check in a matter of seconds that you’ve written your notes for the day.
  • They offer a website landing page for your practice much like Psychology Today. It’s called Monarch.
  • They update processes and features frequently (unlike Therapyapppointment.com whose updates are announced then drag on for years).

Cons:

  • You might have to upgrade to the most expensive plan in order to add Billers, Schedulers, Supervisors, and extra clinicians. The cost can be shocking.
  • Auto Pay has some significant glitches, according to complaints I’ve read. I don’t use it. I manually send invoices and statements after I’ve created and reviewed them. PRO: It only takes a minute or two per client.
  • With the least expensive (Basic) plan, you cannot customize your note templates. This is a huge disappointment because this is probably the most important part of using an EHR.
  • Learning the “back office” particulars such as how to process clients’ invoices and statements can be frustrating.  The set up is not ideal in terms of billing clients after insurance claims have been processed. You must create Invoices before creating the Statement.
  • Invoices and Statements don’t include the insurance payment information. This is confusing for client and practitioner.  Invoices and Statements lack information that should be there and is normally included from your medical providers. 
  • If a client makes a partial payment on an invoice owed, that partial payment doesn’t show up where it should (on an invoice or on your screen). Only payments in full show up and they are not listed on the invoice itself (only on the statement).  If the full amount of an invoice is received by the system, the invoice is magically stamped with a Paid stamp (the date, amount, and form of payment is not on the invoice).  This makes for major confusion for the client and the practitioner.  The second step (creating a statement) must then be performed in order to see the payment.
  • There is no documentation within the client’s chart regarding emails sent (you can find an email list in the practice Reports section but not the actual emails and doesn’t include the content of the words you typed in the notification emails you sent).
  • There is no way to directly email your client within the system (e.g. “We need to change your scheduled appointment.”). The system will send only specific notification emails such as appointment reminder messages, invite to access client portal, notification the clinician has shared document(s), notification of an invoice or statement, and notificatin of overdue invoice.  You can modify some of the email notification messages you initiate, but, again, the system doesn’t save it for you to look at later.
  • To document any emails sent and received outside the system, you need to copy and paste it into a Note (non-appointment Note) in the chart.
  • The system saves the secure text messaging you do with a client, but not inside their actual chart. So, you have to copy and paste them into a non-appointment chart note.
  • Some of the Reports are useless because the information is inaccurate.
  • Sometimes new features like Monarch appear to be higher priority and marketed heavily to us clinicians when fixing problems that have been longstanding should be more important.
  • Starting in early 2022, Simple Practice updated their plans. In doing so, the cost increased. Things like Monarch and the Telehealth by Simple Practice video platform are included on the plan that allows you to modify/customize your forms. You pay for them whether you use them or not. This has enraged many of us including me. I hope for a “grandfathering” in to soften the blow of increased cost.
  • Wiley Treatment Planners now cost an extra $15/month if you chose the Essential Plan.
  • You can’t carve out things you don’t need in order to save money on the Essential Plan.

ON-BOARDING

Pros:

  • Uploading a client’s records (in .pdf form) from another EHR system is fairly straightforward with the choice of uploading to individual client records or all client records as a whole. It’s tedious work no matter what platform you use, but it’s doable.
  • There are tutorials, videos, customer service, and a community forum to help you get through the set up and learning process.
  • There’s a Help chat service available during normal business hours.
  • Email requests for help are answered within a business day (my experience) and include detailed instructions with screenshots.

Cons:

  • The system for getting insurances set up for claim submission is clunky and time consuming (depending on the specific insurance e.g., Medicare or Medicaid).  Before you can set up a particular insurance for electronic claim submission, you have to enter a client with that insurance.  You can’t just get set up with all panels you are on ahead of time, which could mean a delay in submitting claims and receiving payment when you do get the first client with that insurance. Office Ally and TA’s systems were much easier. A work around could be to add all the panels you are on to the fake client in the system. That way when you get a real client with that insurance, you will have gone through the clearinghouse connection process and be ready to submit immediately after seeing your real client.
  • The tutorials for setting up your office need some updating.
  • Initial set up is not as intuitive or as guided as it could be.
  • No customer service phone number advertised. Waiting for email or chat help to get set up might be frustrating, but you can now ask to speak to someone in the Chat box.

MOBILE APP for General Purposes (for the clinician only)

Pros:

  • For in person visits you can securely take a photo, upload, and store your client’s insurance card directly from the SimplePractice mobile app (for the clinician only). There’s no need for a separate scanner, HIPAA-compliant software, or computer.
  • You can perform many every day practice tasks from the mobile app (scheduling, charting, secure messaging).

Cons:

  • There is no client-facing Simple Practice mobile app where the client can send secure messages, cancel/reschedule appointments, and view billing. Clients currently have to sign into their Client Portal via the website.  They often lose track of the link information. A push notification alerting the client there is a secure message or an invoice to pay via a client facing app would be a vast improvement rather than depending solely on emails.
  • You can’t deal with back office things like certain billing things via the clinician app.

BOTTOM LINE

If you are not already familiar with billing practices, Simple Practice might be somewhat confusing until you learn the idiosyncrasies of their system in relation to the billing process.

It has been totally worth the sometimes frustrating learning curve to switch over to Simple Practice for all that it offers for a price comparable to other EHRs. 

Simple Practice far exceeds TherapyAppointment.com’s Legacy system in terms of options and basic operations.  TherapyAppointment’s 2.0 system looks comparable to Simple Practice, but TA’s website still has a lot of old information related to their Legacy system, so it’s not clear where they are at with the rollout of their new system.

TherapyNotes is also highly rated by clinicians but you will need to investigate this closely to compare cost and options.

Office Ally’s EHR 24/7 is another option to look at. I haven’t used it though, so, like TherapyNotes, I can’t comment on specifics.

Start your Simple Practice free month here and receive a $100 off your first paid month with my discount code – I get a $100 credit, too. 😉

Go to Simple Practice website to see their current plans. If this review was helpful, don’t forget to come back here for my link to start your free 30 days.

Featured Image by Luis Ricardo Rivera from Pixabay Modified.

Are You Considering Private Psychotherapy Practice? Here’s What it Gives Me: Control

Listen to post via Soundcloud (spend 8 minutes out of your chair) or read below:

Listen to blog post via Soundcloud

Do you need control over your work schedule and environment? Private practice might be the answer. It was for me.

Why I Started Private Practice Years Ahead of Schedule

In late 2013, I took a break from work. I quit my new job, of only four months, at a local non-profit hospice for multiple personal reasons. After a year of considering my options alongside the reasons I needed that break, I started my private practice in my birth month (seems apropos now!), November 2014. The primary reason for pivoting away from employer-based social work is why private practice is still ideal. Control.

Because life is complex and flexibility matters a great deal to me, control over my schedule was a primary factor in pursuing private practice. That seems fairly simple, right? We all want control over when and how much we work. As you might’ve already guessed, it goes deeper than that. Much deeper.

The decision to quit hospice was difficult to make because that job had been on my career bucket list for years. At California State University, Sacramento (CSUS MSW ‘98), I’d put hospice on the list of job experiences I intended to obtain. I’d go to work for a hospice agency near the end of my hospital career, then pivot to private practice when I was a gray-haired social worker, with a nice retirement package, ready to rest my feet in a comfortable therapist chair. In 2002, after my brother died on hospice service, I modified my goal to include the hospice agency that had taken care of him. 

It turned out that after several years at the hospital, my feet got tired long before I had planned (a story for another time), and genetics graced me with a shocking amount of gray hair early on. 

Seriously, thank you, unknown ancestor! For making me get the question of dying my hair vs. going a-la-naturale out of the way permanently while my kids were still young! 

Plus, I was sick of the commute. I wanted to work locally and move on with my career.

In May 2013, I applied to the hospice agency on my bucket list. Boom! They hired me on the day of my interview. Check! A career on track. Do you recognize that feeling?

The two main events that led to quitting my on-call hospice position years before my original plan were personal. Complex, but simple and perhaps familiar to you depending on where you are in life.

Main Event #1 At the end of my month-long training period, my mother was diagnosed with metastatic breast cancer. It was the “sooner or later you will die from it” type. I knew she’d eventually be on the rolls of the agency I was working for. 

Two things happened in my mind: a) I wanted to be able to help when needed without jeopardizing my employment and b) I wondered how effective I’d be as a hospice social worker over the coming months, years, whatever time we had while she endured traditional treatment trying to buy more time with us. And, I really didn’t know how I’d be able to work while losing my mind over my mother’s death and seeing her name AT work when the time came. Then, there was the patient who was dying of breast cancer… 

Main Event #2 During my third and four months with hospice, my husband’s job started taking him out of town for weeks at a time. From the beginning of parenting, we’d agreed that he was the primary breadwinner. I was uber happy to be a stay-at-home-mom working per-diem on the weekends. For several years, our twins had great fun with their dad with no hovering mama, and I got to be a social worker interacting with adults at the hospital.  It had been perfect. The hospice job schedule was weekends only, too.

Because of his job change and unpredictability, our weekend plan wouldn’t work anymore. Our kids were not old enough to be left alone, day or night. Childcare was a problem, especially at a moment’s notice with my on-call status.

With all of life’s happenings (not in my plans!), I needed 100% control over my schedule. And for my health, I needed to have more control of my caseload while finding a way for maximum compassion satisfaction.

Why Private Practice Still Works

Private practice was and still is the answer. My mom passed away three years ago (February 2018) and because I had flexibility and control, I was able to take the time off I needed to help her and be with her.

I still need control over my schedule for other family reasons. I need time for professional development to maximize efficacy with my clients e.g., grow skills while managing things that can lead to burnout (yes, the risk exists in private practice) and compassion fatigue (yep, that too).

I have control over my schedule which means I have a better chance of keeping life in balance. Well, the things I have control over anyway. I’m sure you know what I mean.

Through private practice, I’ve found a highly satisfying way of achieving one of my primary purposes in life: to help ease suffering. I get to help clients from the seat of my burgundy wingback chair with my coffee cup in hand. Feet resting and grounded. Whether in person or via telehealth, I can adjust according to life’s planned and unplanned events (and the random pandemic).

Are You Wondering How to Start Private Practice?

If this sounds like something you’d like to pursue, but you are unsure what the steps are for starting private practice, take a look at the table of contents in A Quick Guide to Starting Private Practice.  This is how I did it. 

How I achieved a full practice far ahead of schedule is in the details.

The Guide includes much of what I’ve learned along the way related to the steps. It doesn’t include every last piece of minutia though, because to be honest, that book would be too long and you’d give up the idea before even starting. I couldn’t even write it. Besides that, I learn something new every time I turn around. That’s part of what keeps me on my toes and is a natural part of private practice.

Private practice is one way you can gain control of your work life and experience deep compassion satisfaction at the same time. Can’t see yourself as a business owner? I can relate. I started with the goal of five clients. Within months, I’d achieved that goal and was ready for more. Being a business owner is just a matter of a learning curve. Like everything else you’ve learned along the way.

If you need help, I am here. Get the Guide (read more about it at the link) first, though. It will answer a ton of questions along the way. You might not even need me. That’s my goal: to help you as efficiently as possible and work myself out of a job. 

That’s why I wrote it. For you and for me.

Thank you for joining me today and don’t forget to follow my blog for the occasional post about private practice.

Get A Quick Guide to Starting Private PracticeConcise Steps with Helpful Tips for Starting a Sole Practitioner Private Psychotherapy Practice – Over 100 pages designed to get you started quickly!

Choosing a HIPAA Compliant Email for Your Psychotherapy Practice

I was recently asked about setting up a private practice email with HIPAA compliance in mind. The first two things to remember:

  • Your email is not technically HIPAA compliant unless you have a Business Associate Agreement (BAA) with the email provider
  • AND you use it properly.

In other words, there are limits to what you should send in an email message, even when set up with a BAA.

The following is from the newest edition of the Guide (in annual revision February 2021 and will replace the current edition). I use Google Workspace with a BAA, so you will see more details below regarding this option.

Here’s the info in the upcoming revision of the Guide.

Choosing Your Psychotherapy Practice Email

Figuring out which email service to use will take some time and consideration for cost and convenience. Your decision might be influenced by services you are already using.  

Both of those services offer additional features you will appreciate sooner or later.

Some Electronic Health Records (EHR) have integrated email in addition to Secure Messaging.

Secure Messaging within the EHR is the safest way to communicate electronically with your client because HIPAA Compliance is built into the EHR.  The client must sign in on their end to see the content of the message within their Client Portal.

While EHRs use email to send things like invoices, statements, superbills, reminder messages, informed consents, intake questionnaires, documents, and .pdfs, not all of them allow you to free type a general communication email. For example, you want to send the client resource information, but you’ll need to use an email system outside of the EHR.

I know, confusing…

Remember: Any email communication is a legal part of a client’s record, whether it is sent within an EHR or outside of it.

Emails to and from your client are considered e-PHI (electronic Protected Health Information). 

Remember: The email service must offer a BAA (and you need to find out how to obtain it after you sign up – some services require a phone call, others require flipping through a zillion web pages of instructions to find it).

It is generally recommended the only information you should communicate via email is regarding scheduling.

Before you communicate via email with a client, you must provide Informed Consent for email communication.  Here are a few examples (a simple Google search will provide many examples):

A disclaimer in your Email Signature is important as well.  Here’s an email disclaimer example:

The information transmitted is intended only for the person or entity to which it is addressed and may contain confidential and/or privileged material.  Any review, retransmission, dissemination or other use of, or taking of any action in reliance upon, this information by persons or entities other than the intended recipient is prohibited. If you received this in error, please delete the material from any computer. Please note that gmail/email communication is not considered HIPPA Compliant for Protected Health Information.  By emailing or texting to (clinician name) you understand and accept the risk of email or text potentially not being secure.  Do not send Protected Health Information via email or text.

TIP

A client cannot “waive HIPAA” nor can they waive your responsibility to protect their Protected Health Information (PHI).  They can, however, consent to use of email and texting for specific information such as Appointment Reminder Messages (Informed Consent you require them to review and sign).

Read:

https://www.goodtherapy.org/for-professionals/software-technology/hipaa-security/article/hipaa-compliant-email-tips-for-therapists

Consider Encryption (an extra layer of protection), but don’t stress too much about it: https://telehealth.org/hipaa-compliant-email/

Three HIPAA Compliant Email examples to check out (then do your own Google Search):

Hint: name.com is the URL so theoretically an email for this domain could be YourName@name.com.

Here’s mine: bonniemckeeganlcsw @ bonniemckeeganlcsw.net (spaces intentional to avoid spam bot crawlers). It’s too long, but I didn’t know what I was doing when I set it up. Learn from my mistake, make your name part shorter ;-). bonniemckeeganlcsw.net is another website URL (domain) I own.

TIP

Regarding that URL domain you may need for your new email (or you may be thinking about for a website address), you can purchase the URL domain for your future website without ever creating an actual website.

Assignment: Choose Your New Professional HIPAA Compliant Email

What HIPAA Compliant Email service are you using? Would you mind sharing with readers what you like or dislike about it?

Don’t forget to Follow Navigator News by Email so you don’t miss anything!

Original Image by Clker-Free-Vector-Images from Pixabay

Marketing: Writing Your Private Psychotherapy Practice Bio – An Exercise in Brevity & Specifics

This week I was asked if I could help with developing a bio for a new psychotherapy practice and deciding where to spend energy developing referral sources.  

This post is about the first half of the question: Your professional bio. After you’ve completed this exercise, then, where to spend energy (and time) developing referral sources will become more clear. The second half depends on your bio and your ideal client. I’ll post on possible places to spend energy developing referral sources next time.

Here’s the marketing exercise:

Write a letter of introduction. This is an exercise in brevity and specifics.  After you have a written your letter, then you can modify it according to the audience (the agency or person you are sending it to) and use it for the foundation for online sites like Psychology Today and Helppro.com.

It will also help you when you talk to people about your practice (they don’t want the long story – just the bullet list, the elevator speech).

Keep in mind your “ideal” client. For example, mine is an older adult on Medicare dealing with issues of aging. There is a multitude of issues older people are dealing with, making this is a broad enough net, but specific enough that it helps guide where I market myself (and how I screen out clients I don’t resonate with).

The following is a basic structure (use letterhead) you are free to copy. You can modify however makes sense to you, but keep it succinct. Your reader will skim and you may only have their attention for about 9 seconds. No joke, but probably you have a sense of how short our attention spans are.

Dear (so and so), 

I am writing to introduce myself and my new private psychotherapy practice in (location). 

I provide treatment via (HIPAA Secure online video conferencing and telephone, in-office, assisted living, home) to (adults, minors).

I offer (individual, group, couples, family sessions,…).

My special interests are (eating disorders, issues in aging, LGBTQ, attachment disorders in kids, domestic violence, relationships, caregiver stress,…). (If you use the word ‘trauma’ be specific because it is too broad and you probably don’t love to work with ALL types of trauma)

My experience includes (relevant types of places you’ve worked – but keep it brief e.g. county mental health, trauma medical center, residential substance abuse treatment – OR you can use names of agencies,…).

I have special training in (EMDR, hypnosis, CB,…).  (Remember that special training is great and looks good on paper, however, it is not the key to success in treatment or growing your referral base – the relationship is the most important part, so essentially you are selling your unique style, not that you have mastered a specific treatment.)

I accept (list insurance panels you are on, Medicare/Medicaid, cash pay, etc.). (I handle the billing so the client can get the help they need without the stress of reimbursement issues.)

(something that makes you stand out, if it is relevant – when you were licensed, grad school you attended, years of experience doing psychotherapy, insurance panels you are pending a contract with)

I am looking forward to connecting with you about any questions or referrals you have.

  • Respectfully,
  • Name
  • Phone number
  • email
  • website
  • (include a number of business cards according to how you see them distributed by the referral source – don’t send too many. Include a few flyers if you have one, but, again, don’t send too many and don’t worry if you don’t have one.)

While I don’t consider myself a marketing expert, I do know what worked for me and my colleagues who all have full practices. Like me, they turn away referrals consistently.

Writing this letter will help clarify things in our own mind and that will help with every piece of marketing you do.

I hope this helps as you figure things out. Follow my blog by Email so you don’t miss the next post.

I offer a free Q&A Hour to anyone who purchases the A Quick Guide to Starting Private Practice.

Photo by Anna Tarazevich from Pexels

Common Private Psychotherapy Practice Forms

One of the challenges of starting a private practice is developing your practice policies and the forms that go with them. There are tons of forms… just figuring out what you need can be daunting. Be patient as you work through the process and keep in mind you will need to edit them as your practice evolves (hint: don’t print too many copies at once).

I started my practice in fall of 2014. I am still modifying forms and policies, as things change and new informed consents and policies are added to the ridiculously long list of forms private practice requires.

This is one reason I switched to electronic health record (EHR) and chose Simple Practice. Charting and editing forms is so much easier. Still, the seemingly endless forms are required whether you are using paper or using an EHR with e-sign for a “paperless” chart.

You will need to develop and/or review and understand most of these forms, depending on your practice model:

  • Registration/Intake Form
  • Diagnostic Evaluation / Biopsychosocial Assessment
  • Client Payment Record / Appointment & Activity Log
  • Informed Consent for Psychotherapy
  • Introductory Letter for marketing
  • Practice Policies
  • Confidential Psychotherapy Notes
  • Receipt for Payment / Superbill
  • Sliding Scale Payment Agreement
  • Treatment Plan
  • Sublet Rental Agreement (if you sublet your office)
  • Group Therapy Note
  • Group Therapy Informed Consent
  • Progress Note
  • Progress Note with Treatment Plan
  • CMS1500 Claim Form
  • Telehealth Informed Consent
  • HIPAA Notice of Privacy Practices (NPP)
  • Receipt and Acknowledgment of HIPAA NPP
  • Consent for Release of Information (SUD requires a different consent)
  • Consent to Charge Credit Card
  • Informed Consent for Reminder Messages
  • EAP: Assessment, Referral, Progress Notes & Informed Consent
  • Social Media Policy
  • Diagnostic and Objective Measurement tools like the PHQ9, GAD7, and PCL5
  • Informed Consent for In-office Appointments for Vaccinated
  • Informed Consent for In-office Appointments for Unvaccinated Clients
  • Good Faith Estimate (added into law as of January 1st, 2022!)

This list is not an all-inclusive list of the forms you could possibly need, but these are common. Several of these forms you can find online for free, such as the HIPAA Notice of Privacy Practices, Patient Health Questionnaire 9 (PHQ-9), and the Generalized Anxiety Disorder 7 (GAD-7).

For a Social Media Policy, I recommend checking out Dr. Keely Kolmes at https://drkkolmes.com/2010/02/01/updated-private-practice-social-media-policy/#.XyzbRijYo2w. This is her free version that you can modify and she has an updated version for a fee.

For additional forms, I recommended doing an online search plus, looking at the list of forms provided in The Paper Office. The Paper Office includes a disc with all the forms in editable format and tons of great information every clinician needs.

If you are considering your forms, then congratulations are well on your way! You are deep in the process of starting your private practice!

This part of the process can feel overwhelming. Like the old adage, one day at a time, think of this process as One Form at a Time.

Consider an EHR with e-signature so that modifying forms is easier. And above all, don’t give up. It is totally doable, I promise.

Featured Image by Lorraine Mays from Pixabay

Psychotherapy: To Home Visit or Not to Home Visit

Welcome to Bonnie’s Navigator News blog!

From time to time, I’ll post information relevant to private psychotherapy practice. When I learn new stuff related to private practice, I like to share it with colleagues! I hope this proves helpful to you. I promise not to spam your inbox. Rest assured, I don’t have time for that ;-).

In this post you will find an excerpt from the Home Visiting chapter in A Quick Guide to Starting Private Practice:

  • Pros and cons of home visiting
  • Considering your previous home visiting experience
  • Things to think about: environment, safety, complexity, time management, confidentiality, client ability to meaningfully participate in psychotherapy
  • Definition of “homebound”
  • Medicare and home visits
  • Policies and procedures to consider
  • Case scenario

Consider the Pros and Cons of Home Visits  

Home visits in the role of a case manager, such as with an agency like hospice, home health, or a chronic care coordination program are great experience.  If you’ve had this opportunity, think about those visits for a moment.  

  • What type of clients did you visit?  
  • What were their needs?  
  • What type of environments did your clients live in?

When you are visiting for the purposes of psychotherapy you’ll need to consider several issues. There are pros for sure:  

  • Observing and interacting with a client in their home environment can provide oodles of valuable clinical information. 
  • Home visits can provide services to a population that otherwise may not have the opportunity for psychotherapy services.
  • When you have limited office sublet time, you can do home visits to keep money flowing while you build up your in-office clientele.
  • When the word gets out that you do home visits, you might fill your practice sooner than you expect!

My experience with home visits for psychotherapy is that the client’s overall needs are often complex requiring case management, and sometimes there are issues of safety, confidentiality, and questionable appropriateness for psychotherapy.

Medicare pays for home visits for psychotherapy if the client is considered “homebound” (see definition below) and these are the folks I’ve visited in private practice. You can imagine that if this is the case the needs are likely complex.  They might have a need for case management to help with caregiving, transportation, housing, access to care, and other basic needs.  If the issues are complex, dealing with them can interfere with psychotherapy.

More Things to Think About in Terms of Home Visits

  • Assess your tolerance for environments: If you have a health condition with certain triggers, like animal dander, cigarette or marijuana odor, dust, mold, animal urine or feces, litter box odors, etc then you will need to be more selective about home visits. If you have back problems, trouble with stairs, or a need for a controlled environment in some way, then home visits may not work well for you.

 

  • Time Management: If you decide to do home visits then you’ll need to plan for extra assessment time over the phone, then again during your first visit, before the person becomes your client. Plan for the possibility that you may spend more time in consultation with other providers involved in the case or searching for additional resources than with the average client. Think about the perimeter of your service area.   Determine time and distance factors from your office and home.  Obviously, home visits require more time, gas, and mileage on your vehicle.

 

  • Assessing for safety: Suicidality, dogs, guns, and other home environmental issues.

 

  • Assessing for confidentiality: Who is likely to be in the home during your visits? Spouse/family/caregivers?  Is the person living in an Assisted Living or Independent Senior Living complex? Confidentiality is bound to be blown eventually as other residents and staff notice your presence. Are you required to sign in to the facility?

 

  • Assessing for the appropriateness of psychotherapy. Can the person participate meaningfully? Are the needs more of a case management situation? Who was the referral from and what is the referral source hoping for from your involvement? If the case management type needs are met would they then be appropriate for psychotherapy?

Offering home visits can be a real boost to your practice because so few therapists offer them. Medicare pays the same amount for a home visit to a “homebound” client as it does for an office visit (in my experience).

Policies & Procedures to Consider for Home Visits

Should you decide to offer home visits, you will need to develop additional policies and procedures for

  • Assessment – how much on the phone before the first visit?
  • Region and clientele served
  • Safety
  • Informed consents specific to the issues of safety, confidentiality, and the therapist’s determination of the appropriateness of home visits for psychotherapy
  • Smoking
  • Releases of information
  • Maintaining confidentiality
  • Determining homebound status
  • Where in the home psychotherapy will take place

Regarding Releases of information: You should consider a policy that requests the client sign Release(s) of Information to the referral source, primary physician, primary caregiver, and other involved agencies or the facility where they live, when appropriate.

Being part of a multidisciplinary team is a helpful approach with complex cases. If the client refuses for certain people, a thorough understanding of why is important. Of course, you would not be planning to discuss certain things with a primary caregiver, but you may need to discuss scheduling or other issues related to caregiving during your presence.

Regarding homebound status: You should also consider a policy that includes requiring a statement from the client’s medical provider regarding their homebound status. If ever you were to be audited by Medicare, this could be a crucial component.

Regarding smoking: Will you sit with a client on their porch while they smoke? Are you willing to visit a house where people smoke inside?

Regarding where in the home psychotherapy will take place: Consider your policy regarding the location in the house where therapy will occur. Many clients who are homebound are not physically bedbound, but they’ve “taken themselves to bed” and conduct nearly all of their life stuff from bed. Are you willing to conduct therapy at the bedside?

Think About This Home Visit Scenario

You receive a referral from Adult Protective Services or another agency for an elderly client on oxygen who smokes, meets the definition of homebound according to Medicare, and is on high doses of opiates for chronic pain and COPD.

Believe it or not, this is a fairly common situation. The case continues:

The client’s family member lives with her who is apparently a caregiver of sorts but the boundaries are unclear and the client complains about him. He moves out and now the client lives alone, again. She is a high fall risk and still drives locally though she’s been told not to by her doctor.  When you express concern regarding safety issues related to living alone (fall risk and medical issues) and attempt to address caregiver problem-solving, she reassures you she is safe by pulling out her loaded handgun that is in a drawer at her bedside. It is the same gun she accidentally shot herself with in a few years prior; she shows you her scar in the same motion as showing you the gun. She prides herself on feeling safe because of the gun. She also insists that lying propped up in her bed is the most comfortable place for her because of her pain. She has a significant history of trauma and is grieving the death of her spouse.

What are your policies and procedures for dealing with this client?

Medicare’s Definition of “Homebound” 

Medicare considers you homebound if:

  • You need the help of another person or medical equipment such as crutches, a walker, or a wheelchair to leave your home, or your doctor believes that your health or illness could get worse if you leave your home
  • And, it is difficult for you to leave your home and you typically cannot do so

Your doctor should decide if you are homebound based on their evaluation of your condition. If you qualify for Medicare’s home health benefit, your plan of care will also certify that you are homebound. 

From: https://www.medicareinteractive.org/get-answers/medicare-covered-services/home-health-services/the-homebound-requirement


This is an excerpt from a chapter in A Quick Guide to Starting Private Practice. If you are still considering offering home visits for psychotherapy, there are more things to know such as rules around Place of Service on claims, hospice status, skilled nursing facilities, and Medicare Advantage Plans.


For more info about the Private Practice Coaching Services I offer, you can check out my website www.privatepracticenavigator.coach. Navigator News is part of the website and my endeavor to make official that which I have been doing unofficially for a while now – helping others navigate the startup of their private psychotherapy practices.  If you like what you see please consider sharing with your colleagues and on your social media platforms. Thank you!


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Should You Become a Network Provider? Plus Resource Review: Navigating the Insurance Maze

Welcome to Bonnie’s Navigator News blog! From time to time, I’ll post information relevant to private psychotherapy practice. When I learn new stuff related to private practice, I like to share it with colleagues! I hope this proves helpful to you. I promise not to spam your inbox. Rest assured, I don’t have time for that ;-).


In this post you will find:


Insurance Reimbursement is a Big Topic in Private Practice (and hard to address briefly)

As a newbie (and as a continuing option) in private practice, one of the most important questions you will be confronted with is: Should I become a network provider on insurance panels or only accept Private Pay?

The Truth

Dealing with insurance companies can be intimidating and frustrating. Even after five years of private practice, I still get kinda irritable and nervous when things go haywire on the insurance end of things – thankfully that doesn’t happen very often.

The process of becoming a provider on insurance panels is daunting. Applying is a multi-step process. It takes attention to detail, time, and uber patience.

Learning how to submit claims and deal with payments is another learning curve. You have choices about how to handle this part. You can do it all yourself (with or without paid services) or pay for billing services so you don’t have to deal with the claim submission process.

Dealing with certain technicalities, e.g. finding the address to submit claims, authorizations, and denials can be annoying and time-consuming. Learning the basics from the start will help you be efficient and reduce denials. Again thankfully, I rarely get a denial. Some things are out of our control, for example, when an insurance company pays the claim incorrectly. Knowing what to do is easy to learn. Maintaining patience through the process might be the hardest part.

I am on a number of insurance panels. For me, the pay off has been totally worth the time and effort to get on those panels and deal with the occasional complications that have arisen. While the details are confusing, none of it is rocket science. Really. You too can learn this stuff.

I decided from the start to become a network provider on several commercial insurance panels, Medicare, and Medi-Cal (California Medicaid).  The benefits have paid off:  

  • I get referrals regularly from several insurance companies – in fact, my practice has been full for a long time. As soon as there is an opening, the space gets filled up quickly.
  • I feel good offering a service the client is/has paid for through their insurance plan
  • I feel good about serving lower-income clients who are on a Managed Care Medi-Cal (Medicaid) Plan or have Medicare/Medi-Cal.
  • I don’t have to “sell” myself in terms of payment. The only payment the client is responsible for under commercial insurance and Medicare are the Deductibles, Copays, and Coinsurance portions.
  • My clients don’t usually quit due to the cost of therapy (there have been exceptions like when they have a large copay or haven’t met their deductible and it’s still all out of pocket)
  • The unexpected benefit of receiving news, clinical guidelines, and general information from insurance company newsletters. Some offer free trainings.

“But, Bonnie,” you ask, “If I am going to be a Private Pay Only therapist, do I still have to learn insurance mumbo-jumbo? Can’t I just skip all that head-spinning stuff?” The short answers: YES, you do need to learn a few things about insurance anyway, and NO, you really shouldn’t skip it – you could commit insurance fraud, risk your license, and not even know it.

The long reply to the “Yes” answer above – 

If you decide to accept Private Pay only, at the very least you will need to have a clear understanding of:

  • how to prepare your Private Pay Agreement
  • what CPT codes are and how to use them on your Superbill/Invoice
  • how to answer questions when clients ask you about reimbursement from their insurance company
  • how to prepare a Superbill/Invoice so the client can submit for possible partial reimbursement from their insurance company
  • your status (or non-status) as a “Medicare-eligible provider” (clinical social workers and clinical psychologists with the correct licensing in their state)
    • your choices regarding Participation, Non-participation, and Opting Out of Medicare and how it affects the client and your fees. If you have the correct licensing for your state, you are already considered a “non-participating provider” by virtue of your licensing, even if you don’t “Opt-Out.”
    • I highly recommend you read the following if you ever plan to accept a client with Medicare: Medicare Part B 101 Manual: Assignment of Benefits   Assignment means you must accept the assigned amount as payment in full and you cannot balance bill the client for any difference between your fee and the assigned amount.

Here’s an excerpt:                                                                                        

“Mandatory AssignmentIn certain situations, a provider, regardless of his/her participating status, must submit an assigned claim to Medicare. The following are instances when an assigned claim is mandatory.

  • The patient is eligible for Medicare and Medicaid.

Submit the claim to Medicare. Medicare will automatically forward payment information directly to Medicaid if the claim has been properly completed.

  • Participating physician/supplier (this would be you if you “enroll” to become a “participating provider”)
  • Services provided by the following non-physician practitioners:” Clinical social workers and clinical psychologists are listed amongst Mandatory Assignment providers (see the link above for the full list and the rest of the information)

Deciding if you should or shouldn’t apply to become a paneled provider on commercial insurance panels, EAPs, and Medicare and Medicaid (if eligible) is an important decision, and possibly one of the biggest decisions you’ll make in private practice.


Something to Consider When Deciding Whether or Not to Become a Network Provider

Many people cannot afford to pay out of pocket upfront, then wait for reimbursement after the hassle of submitting a Superbill or after waiting for the non-paneled therapist to submit claims to the insurance as a courtesy.  When someone is in need of therapy, dealing with Superbills and waiting for possible insurance partial reimbursement can be too much of a strain and a barrier to getting help.

Some people are, however, willing and able to pay upfront. If you decide to go this route- Private Pay only-you’ll be spending more time and possibly more money marketing and advertising.

If you decide to get on a few panels, you can still leave room in your practice for clients on panels you are not on. They can pay you upfront and you can offer them a Superbill for reimbursement. That way you could get your full fee for a few clients rather than the contracted amount you’d otherwise receive if you were on that panel.


A Bit More on Medicare

Being an LCSW* gave me the option of enrolling in Medicare as a participating provider OR Opting Out and charging my full fee to Medicare clients and not billing Medicare (nor could the client receive reimbursement from Medicare).

I chose to enroll.  The reimbursement rate is decent, as far as I am concerned, and better than commercial contracted rates.  Medicare pays in two weeks from the time I submit claims and has generally been a straight-forward process.

The majority of my clients are Medicare age (65 and older) or on Medicare due to disability. There are more people on Medicare in need of therapy than there are therapists able to serve them in some areas. As the boomer population continues to age, the gap between need and available providers may continue to grow.

*check your state for social work or clinical psychologist licensure level requirement to be a Medicare provider – in California for Social Workers it is “LCSW” but in other states the letters are different.


Insurance Resource Review – 5 ***** for this one!

I recently discovered Barbara Griswold, LMFT.  She has a website full of information, offers insurance coaching and webinars, and has published a great book full of insurance information every private practice therapist should have.

Whether you’ve decided on the insurance question or not, I highly recommend you visit Barbara’s website and consider getting her detailed book Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance – And Whether You Should.  

I wish I had this book when I started out five years ago. This 154 page, 19 chapter book is chock-full of information that appears spot on from what I’ve learned these past five years. Here are some of the topics covered:

  • helping you decide if becoming paneled on insurance plans is a good idea for your practice or not
  • how to complete and submit the cms1500 (the insurance claim form)
  • a sample Private Pay Agreement
  • terminology such as copays, coinsurance, managed care, etc
  • Employee Assistance Programs (EAP)
  • getting paid and understanding the Explanation of Benefits (EOB)
  • appealing denials
  • what it’s like to be a network provider
  • and one section I am excited to dig into and put into action called: Getting A Raise (from insurance panels)
  • and more!

The book is nicely organized, concise, and the information is often presented in a Question & Answer format. As a new private practice therapist, this book will give you much of the language and understanding you need to get started.

This book is focused on commercial insurances.

What you won’t find in this book is references to or details about Medicare, Medicaid/Medi-Cal, VA & Military benefits, or Crime Victim programs. As a Medicare and Tricare West (military/veteran) provider, it was a little disappointing not to see at least an overview but, I do understand why these are not included. These programs are a different breed and could be the focus of another book.

Overall, Navigating the Insurance Maze is a wise investment for the new therapist and as well as the one who’s been around a while ;-).

An added bonus about this book: California LMFTs, LCSWs, LPCCs, and LEPs can earn 7 CEUs by purchasing the CEU quiz for the book.

That’s it for now! Lemme know if you’ve found this information helpful and any suggestions for future blog posts you’d like to see.

If you’ve learned anything here, consider Following by Email so you don’t miss the next Navigator News article.

Bonnie

For more info about the Private Practice Coaching Services I offer, you can check out my website www.privatepracticenavigator.coach. Navigator News is part of the website and my endeavor to make official that which I have been doing unofficially for a while now – helping others navigate the startup of their private psychotherapy practices.