Why I Only Hire W-2 Therapists (W-2 vs. 1099 part 3)

I've noticed that private practice therapist tend to hire additional therapists as 1099 contract employees. Reasons frequently cited for choosing to hire therapists as 1099 employees is that they don't have to pay the therapists taxes. While it may be more "affordable" to hire therapists as contractors, in my experience, there are also "costs." (For an summary of the difference between W-2 and 1099 employees read part 1 in this series. To hear about my employment tax audit adventure read part 2.)

According to the IRS website, the general rule for classifying 1099 independent contractor is "if the payer has the right to control or direct only the result of the work and not what will be done and how it will be done" (italics added). It also states that an employee is not a contract employee if the services "can be controlled by an employer (what will be done and how it will be done)" and if "the employer has the legal right to control the details of how the services are performed."

In consulting with therapists around the U.S. I've heard about some of the "costs" of hiring 1099 employees. Some of the costs high turnover rates due to the part-time and often temporary nature of contract employee relationships. Some of those "costs" include lack of control over how and where therapy is done, inability to require specific paperwork, inability to require attendance at staff meetings or trainings, inability to request that therapists network and participate in community outreach to boost referrals.

Here are the four main reasons I only hire therapists as W-2 employees:

1) Overall Cohesiveness

My vision for Wasatch Family Therapy has always been to build a cohesive team with a shared long-term vision of providing excellent clinical services to clients across the lifespan from an attachment perspective, not just have a group of therapist doing any kind of therapy they choose.  Now that we have grown into a clinic of 18 therapists at 3 locations cohesiveness is even more crucial. When therapists are hired as 1099 contractors employers are not supposed to tell the contract worker how to do therapy, or make other specific requirements of the worker, such attendance at trainings.

2) Higher Level of Quality Control

If a therapist is going to work under my name and my practice name or "brand", I want to be able to have a say in how, where, and when they do the work.  I've spend over 10 years building trust, credibility, and presence in my region and I want to be able to be able provide mentoring, direction, and training in how my clinical team provides services.

3) Ability to Require Certain Activities

I want to be able to require certain activities from my team members that hiring them as 1099 workers does not allow me to do. We have streamlined forms for notes and documentation in our EHR system. I require each therapist to engage in at least one outreach or networking activity each month in order to create strong referral sources. I require attendance at two monthly staff meetings, and a certain level of professional appearance at the office.

4) Implication of Long-Term Relationship

I am not interested in hiring temporary therapists to provide services. Hiring 1099 workers generally implies a short-term relationship. I am interested in hiring therapists who have a shared vision and who I can invest in long-term, and who will invest in building the practice long-term. I want to build mutually beneficial relationships not just provide services. Hiring therapists as W-2 employees shows a greater long-term commitment to them to build their practice for the long haul. I also allows me to expect a greater commitment from them.

5 Steps To Resigning From Insurance Panels

One of the most common questions that private practice therapists ask me is "How do I get off of insurance panels?" This question just came up today in my Private Practice Toolbox Facebook Group so I thought it would be a great topic for a blog post. In previous posts I've written about why I broke up with managed care (part 1) & (part 2), but this post will focus on how to do it.

The thought of letting go of the comfort of being on insurance panels can create a lot of anxiety for private practice therapists. After all, if we don't have clients, we don't get paid. Find comfort in knowing this equation. You only need about half the number of clients in a self-pay practice to make the same income (or more) than you made in an insurance based practice. Once I realized this fact, I felt a lot more comfortable resigning from insurance panels. Let's do the math...

Insurance:

Say you are seeing 20 managed care clients per week and you are reimbursed an average of $70 per client.

20 clients x $70 session = $1,400

20 clients x $70 session x 4 weeks = $5,600 per month

(then subtract your time or money spent in billing and paperwork)

Fee-for-service:

2o clients x $125 = $2500/wk

20 clients x $125 session x 4 weeks = $10,000 per month

10 clients x $125 session x 4 weeks = $5,000 per month

(with NO extra paperwork, NO delay in payment, NO denied claims, NO required diagnosis...)

So often we focus on number of clients instead of the quality of clients and the amount collected per client.

5 Steps To Resigning From Health Insurance Panels

1) Rank the insurance companies

Make a list of insurance panels and rank them from your most favorite to least favorite based on:

• reimbursement rates
• paper work requirements
• how quickly you're paid
• number of clients you see from each panel
• the type of clients generally referred
• your general feeling working with each panel

2) Resign in waves starting with your least favorite

Generally, I recommend to my consulting clients to resign in waves over the course of a year. Resign first from the panels with the lowest ranking - the ones that pay the least and are the most difficult to work with.

3) Check your contract for resignation requirements

Review your contract to check on the resignation process that you agreed to. Look at the time frame required. Do you need to give them 30, 60, or 90 days notice? Do you need to send in a written letter?

4) Beef up your web presence

As part of your plan to resign from insurance panels, it critical to invest in creating other referral sources. The most important being your web presence. Google is my #1 referral source. The majority of our clients who come to my clinic Wasatch Family Therapy find us online. The benefit of clients finding you online is that they've already read about you, your services, and your philosophy on your website and have chosen to contact you. This increases the likelihood that they will be willing to pay your full fee.

• Website - If you don't have a website, make that a top priority. If you have a website, make sure it's effective. Here are some common website mistakes and how to fix them.
• Blog - If you don't have a blog on your site, add one and start blogging weekly.
• Therapist finder sites - join PsychologyToday.com, GoodTherapy.org, and your professional organization's "find a therapist" site to help potential clients find you.

5) Know the benefits of self-pay and be prepared to educate clients

There are benefits to the client for paying out of pocket, instead of going through their insurance company, that they may not be aware of. As you make the transition away from managed care to a fee-for-service practice it's important to familiarize yourself with these benefits so you can educate your clients. A few of those benefits are: control over which provider you choose to work with, the course of treatment decided on by client and therapist instead of insurance company, and no diagnosis requirement.

Here's an example of how a provider educates her patients on the benefits of self-pay. Utah Psychiatrist Kelli Hyland, MD my colleague and consultation client, shares her philosophy in this blog post "Why Self-pay?"

(c) Can Stock Photo

6 Ways To Put Your Practice On Autopilot

Whether you like it or not, when you're in private practice you are a business person. A common complaint I hear from new private practitioners is "I had no idea how much time (and money) it takes to run a business!" I nod my head in agreement.

With no business background, I ventured into private practice nearly 10 years ago. Starting out as a solo practitioner, I have learned how to maximize my time. Over the years I learned the importance of automating as many business systems as possible in order to decreases stress, and free up mental and emotional energy for the things I'd rather be doing...like therapy.

Here are 6 suggestions for automating your business systems in private practice:

1) Automate social media posts

While actual human conversation is the point of social media, I do automate some of my posts, tweets and status updates. The two social media management platforms I use are Hootsuite and Socialoomph. I use both because they have different strengths. Hootsuite allows me to manage multiple social media accounts from it's dashboard and respond to them in one place. SocialOomph is great for posting recurring tweets and updates because you can set the frequency of the recurrence and alter the text slightly.

I also use SocialOomph to set up auto-responders to thank new Twitter followers. SocialOomph also sends me daily digest email of keywords I've chosen to follow on Twitter so I can see who's tweeting about relevant topics and I can find new and interesting people to follow.

2) Switch to electronic health records

This year my clinic switched to online health records. One of the benefits has been that clients can log in, fill out initial paperwork and submit it online. Best of all they can print their own statements to send in to their health insurance company to seek reimbursement, which saves my office a lot of time and money.

3) Try an online scheduler

While I don't use an online scheduler, I know that many therapists do. Clients can book, cancel, reschedule their sessions online. Many programs also send automated appointment reminder emails to clients so they don't forget about their therapy appointment.

4) Schedule blog posts

If you have a blog on your practice website (which I certainly hope you do by now), set aside some time each week, or each month to crank out several posts and have them waiting in the queue. In the Wordpress platform that I use I can schedule the exact date and time that the post will publish. I have a least one post scheduled per week for the next four months on my practice website.

Another helpful tool is to set an editorial calendar for your blog so you know what topics you want to cover each week throughout the year. You may want to schedule them around certain holidays or national mental health awareness days. With your calendar set you can plan ahead for your topics and get them in the queue and off your mind. (This post was scheduled ahead of time.)

5) Automate your newsletter

Several months ago I switched e-newsletter services to Aweber. One main reason is that you can set up automated newsletters based on your blog posts. Basically, I set up the template, set the number of blog posts I want sent in each newsletter, and when it gets to that number of new blog posts, it automatically sends an e-newsletter to subscribers with blog post summaries!

Another cool automation feature is that I have set it to automatically send it out on Twitter and post on Facebook, too. It has saved me and my office manager several hours per month formatting the monthly newsletter. If you sign up for my Private Practice Toolbox newsletter below you'll see first hand what I'm talking about.

6) Set up auto bill pay

Finally, instead of writing checks for rent, water cooler service, cleaning service, web hosting, or any other recurring expense, set up automatic bill pay so you can mentally take those expenses off of your "to do" list.

What have you done to automate business systems in your private practice? I'd love to hear your tips!

photo credit: williamcho

The Gift Of Resentment

An interesting theme emerged in my private practice consultation group last week. It may seem like an odd theme for a business group -  resentment. As I shared a few of my own experiences in private practice it became very clear that I had used my feelings of resentment as a guide to lead me to my ideal private practice.

I view resentment as an amazing gift to let me know when I need to make a change or to set better boundaries. Here are a few examples that I share:

• After being in a group practice for a short time, I realized that I resented the inefficiency of how decisions were made in the group. So, I decided to go out on my own.
• After having my third child and moving to a new area years ago, I remember feeling increasingly resentful of my commute to my therapy office. That prompted me to move to an office closer to my new home.
• After I realized that I resented spending more time doing paperwork and making phone calls trying to get reimbursed from managed care companies than I was spending actually doing therapy, I started resigning from all panels.
• When I started resenting seeing clients after 5:00p.m. I stopped seeing clients in the evenings.

So, my fellow private practitioners, what are you resenting in your practice?

How can you use resentment as a gift to make needed changes and bring you closer to your your ideal practice?  

Why I 'Broke Up' With Managed Care (Part 2)

Several months ago I wrote a post titled, "Why I Broke Up With Managed Care" that stirred up some passionate discussion! While I understand that it's not the route for every private practitioner, I have continued to build a private practice free of managed care and recently hired my 12th therapist.

While we don't bill insurance directly, we do give a superbill to clients so they can seek reimbursement from their health insurance so they can still use their benefits. As I've continued to write this blog, I've come across several therapists who have also "broke up" with managed care and asked them why they decided to build a fee-for-service therapy practice. Here's what they had to say:

Increased Reimbursement Rate

I've been in private practice for over 15 years. So, I experienced the first major transition of health care to "managed" care. I had friends and colleagues who began working in the managed care industry, and it quickly became clear to me that despite all the rhetoric about the necessity for evidenced-based care (which can be a very useful model of care), managed mental health care was really about making corporate the work of individual psychotherapists.

I also did the math. The last time I checked, insurance reimbursement was the average rate charged by psychotherapists in the 1980s. Today, I can afford to have two additional office hours available for new clients, by taking just one fee-for-service patient. This also allows me more discretion in seeing clients who are needing a low fee. Will Courtenay, PhD, LCSW "The Men's Doc"

Control Over Therapeutic Work

I wanted the freedom to determine, along with parents, the course and length of treatment and felt managed care would impede on that. Pam Dyson, LPC, RPT

My training is in social work, which is the source of the old adage "start where the client is at." That's my barometer for treatment, not where an insurance company believes my client and I should start or end our work. Will Courtenay, PhD, LCSW "The Men's Doc"

Increased Client Commitment to Therapeutic Process

Being a Christian counselor, by law I cannot bill insurance, even if I could I think private pay gives each person responsibility in the therapeutic efforts. When people  have to pay it makes them take their  therapy more seriously. Natalie Davis

No Diagnosis Required

My services are specialized in that I will work with children as young as three, something many therapists in my area will not do. The problems child clients present with are often not clinical but rooted in the parent-child relationship. I feel strongly that young children do not need a diagnosis on their permanent health record. Pam Dyson, LPC, RPT

More Time With Clients (Less Time Doing Paperwork)

I had worked in a managed care setting in the past, and I decided that in my practice that I want to avoid the incredible amount of paperwork, defending sessions, and over-diagnosing.  I also think it provides clients with more privacy. Sara Levitsky, LMSW, Birmingham Counseling For Women

Paperwork was the other major decision (in building a fee-for-service practice). I put a great deal of time and energy into my work with clients outside of our scheduled hours, including receiving professional consultation on a consistent basis. I have no time or patience for administrative busywork. Will Courtenay, PhD, LCSW "The Men's Doc"

More Flexibility To Offer Reduced Fees

Like Dr. Courtenay mentioned earlier in this article, when his practice is doing well financially, he has more (not less) time to devote to seeing clients at a reduced fee. I have found the same to be true. As my practice grows I am able to offer more free community workshops and do more pro bono work.

Do you run a fee-for-service mental health therapy practice? What led to your decision?