4 Steps to Breaking Up with Managed Care

Breaking Up is Hard to Do

We've talked a lot recently about the benefits of switching from using a managed care system to a private pay model. It benefits your clients, it benefits you, and overall it just benefits your practice (click here for a post detailing the math and financial advantage of a self-pay model)! But how exactly do you do it? It's quite a change, so it can be difficult to know where to start. Here are 4 strategies to help you make the transition:

 1) Resign in Waves       

Instead of trying to go cold turkey by leaving your panels at once, pick one or two to begin. I suggest choosing the companies that cause you the most headaches, give you unreasonable hoops to jump through, are infamous for not paying on time, and have the lowest reimbursement rates (most therapists I've consulted have no problem identifying which ones these are). Make the transition by weaning off of managed care panels one at a time.

While you are doing this, you need to be ramping up your REST "marketing" process. This will help you attract full-fee clients. Do them simultaneously to secure future business for your practice.

2) Review Your Contract   

Carefully and meticulously read the details of your contract with the insurance companies. What is the length of time required before resignation? You don't want to get hit with fees or have your transition timeline thrown off because you didn't quite understand your contractual obligations, so do your research and give yourself plenty of time.

3) Write An Official Resignation Letter    

After you've determined the timetable you have, sit down and write your letter to officially resign from the insurance panel(s) you've chosen. Be clear, concise, and professional. No need to go into detail about your reasons for ending your business with a certain company. Firmly express your decision to resign. Also, it's a good idea to follow up to ensure that your letter was received.  

4) Prepare Your Clients

And finally, perhaps the most important step to take in making the transition to a private pay model is to let your clients know. Give them plenty of notice (three months minimum), and present them with a considerate and professional letter that clearly states the upcoming changes. Also, offer them options. If they are close to completing treatment, work with them to finish their sessions before you resign from that particular panel. If your clients desire to stay with you and will be transitioning to paying out of pocket, begin to decrease the length or frequency of their sessions if needs be. It's amazing how some people can turn on the motivation when they have to! You also can educate your clients and encourage them to explore out-of-network benefits. Or you might prepare to transfer clients to a trusted colleague.

When I made the change, my clients were exceptionally understanding. I believe part of this was that I informed them in a confident and considerate way, and I was open to feedback and helping clients process their emotions about it. I was also able to use this experience as a way to model self-care and making difficult decisions. Overall, this was remarkably successful, and the majority of my clients stayed with me!

Click here for access to the full webinar of all the ins and outs of Breaking Up With Managed Care.

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The Power of Online Presence: Blogger Dawn Friedman uses her Advanced SEO Skills to Rank High in Google

Discover how some very successful mental health professionals use blogging, social media, and other technologies as powerful tools for their therapy practices.

Dawn Friedman, MSEd LPC, is a clinical counselor specializing in issues surrounding family building, including infertility, adoption, pregnancy, and parenting. An early adopter of technology, Dawn started a blog that became the basis of her strong online presence and has helped her grow a thriving practice. Read about her story here:

When and how did you first start putting time and effort into maintaining a strong online presence?

Back in 2001, I started a personal blog that I continued for about ten years. In that time, blogging went from a fairly introverted way to journal to a massive (and competitive) industry. Because I had started early, I got to see the field of blogging really take off and learn it as it happened. So when I turned to blogging for a private practice I hadn't opened yet (about a year before I planned to launch), I already had a strong understanding of how blogging and other social media work. 

Starting my professional blog a year before my practice opened gave me time to play around with the design (in WordPress) and think about how to lay it all out. It also gave me the space to find my blogging voice. I wasn't sure how to switch from personal writing to more careful disclosure as a therapist, and it took some time and bumbling around to figure out how to be friendly, open, and myself without giving away so much information that it might overwhelm a potential client. I started out way too impersonal and over time let myself loosen up and have more fun with what I wrote. The advantage, too, of starting a year in advance is that having a living, breathing web site that was already getting some traffic made it much easier to start showing up in local searches once I was ready to launch. The blog was already going, and I just needed to focus on creating the pages that described my services, hosted my paperwork, etc.

Please describe what social platforms you currently use.

I used to do social media consulting on the side back in my personal blogging days. What I told clients was to go and claim your online real estate, which means grab the Twitter handles, the Instagram names, etc. Even if you're not going to use them, you don't want someone else to have them. So technically, I have most of the social platforms, but I don't use them all. Many of them you can keep alive passively (WordPress blogs will automatically post to Twitter, LinkedIn, Google Plus and Facebook if you're using JetPack). Once you have all your accounts lined up, you can figure out which ones make the most sense for you to put more work into.

For me, I put the greatest effort into my blog and website.  I've worked very hard on my search engine optimization (SEO) and am on the front page for most of the local searches that I've targeted. The second place where I put in effort is on my Facebook page. I have a professional page and a personal account. My personal account is on lockdown with the privacy settings but I assume anything posted on the internet could potentially show up on a client's screen, so I bear that in mind when I'm posting. That said, I've found that Facebook is the social media site that will drive the most traffic -- especially local traffic, which is what I want -- to my site. I have my blog automatically post new updates to my professional page, and then I share from my page to my personal account. Since doing this, I've seen an increase in traffic, and more people have liked my page. So overall, I do invest some time into Facebook, but I'd rather spend more energy on my blog. It's a very personal choice, and there's no right way for everybody.

About how much time do you devote to your online presence? How do you balance it with your other work responsibilities?

Back in my journaling days, I would blog daily. Now, if I can post six to eight times a month, I'm pretty happy. I'd like to post more because I really enjoy it, but I just get too busy. Other than putting out new content, I also spend a few hours each month updating my site, playing around with my theme, changing out my front page picture, and looking at my stats to see where I can consolidate pages or tighten up my menu. I keep an eye on the number of hits the different pages get. For example, I realized that the part of my site that people clicked the least amount was "Services," so I turned it into a menu header. This led to an increase in clicks directly to services people are interested in. I also am always tweaking and adding things that might help my search engine optimization, which I think is a lot of fun because it's like a game!

What kinds of things do you use to inspire your content creation; what do you write about?

I usually write about things that tend to come up a lot in sessions. For example, many of the children I see struggle with anxiety, and I get quite a few questions about that subject too, so I wrote a three-part series on child anxiety. I also write about books I've read -- counseling related or not -- share fun music videos, and highlight local events that my potential and current clients might be interested in.

I will add that sharing local resources helps me in several ways: It gives me a writing topic, it allows me to share good information with readers who will welcome it, it lets me to network to get that resource up on my blog, and it improves my local SEO. I mean, it's fun to get readers from all over the world but unless you live within driving distance to my office, you're unlikely to become a client or refer me to someone you know. Sharing local events makes it clear that I want to be a resource for my community here in town, and it's also much more likely to be shared by locals on Twitter or Facebook. Win/win!

Back when I did social media consulting, I'd tell people to share the kinds of things you might find yourself talking about at a dinner party. What interesting, fun anecdotes do you have? What thought provoking things have you come across? Even though things like SEO and header tags are important, sometimes you have to put aside the worry and just write. Find your voice first, and your blog will benefit you even if you don't do all that social media stuff "right." Trust me on this. If people like what you write, they will share it, and that will help your traffic. Also, people who click to you from a directory or a Google search will have the opportunity to get to know you, which will increase the chance that the people who call you will be a good fit for your practice.

Just write!

How do you best balance personal and professional in your online activities? Please give examples.

This was a tricky thing to figure out, and it's something that I still reflect on regularly since I think ethics demand that we always be thoughtful and aware about what we share and how that might impact our clients. I do know that I tend to be more comfortable with disclosure than some therapists, and I think that's a matter of personal style. On the other hand, I've seen therapists share way, way more than I'd be willing to do (And I say this having lots of published essays out there that will give any client with Google the opportunity to learn my kids' names, my political beliefs and my personal philosophies on a whole bunch of things). 

Generally, I've decided that I will share anything on my blog that I might share in a session. For example, I might write about a parenting challenge I've faced personally to illustrate a developmental phase presenting in a client's family because that's something we might talk about together in my office (Note: I always get my kids' permission before posting stories about them). When I want to write about something that might make a client even slightly worry that I'm talking about him/her, I'll write about a fictional character. In the series on anxiety, instead of using a fake Jane Doe, (which might lead a client to think I'm writing about his or her child) I wrote about Goldilocks. This allows me to illustrate ideas without threatening anyone's therapeutic relationship. I've written about Harriet the Spy and Ramona Quimby, too, to talk about kids. Other therapists might like using characters on television shows or movies. Using fictional characters not only protects clients from thinking they're seeing themselves in what you write, it's also a fun way to call out cultural touchstones that speak to you.

What is some tangible evidence that your online presence has grown your business?

I've had many clients come to see me because of something they've read on my blog. Someone will share something I wrote on Facebook, and another person will see it, click through, and see that I'm a therapist and then call me. I've also had people go looking for a therapist and stop to read my blog first. Sometimes people tell me that they've read my blog for several weeks or months before making that leap. Having that updating, ongoing resource made it easier for them to feel safe making the call. Some clients say that they want to see me even though I don't take their insurance because they like what I said about a particular topic or feel like they would be comfortable with me. In other words, they want to see me, not just whatever therapist answers the phone first.

Also my blog and attention to SEO has kept me on the front page of local Google searches for my target market. That's huge and has definitely been a tremendous help in my practice building. It's not just potential clients, either. Referral sources use Google, too.

Besides attracting clients, what other ways has your strong online presence helped you?

My blog has helped me secure speaking and writing gigs. I've stepped way, way back on my professional writing since working on my practice, but both my personal blog and professional blog have brought editors to me. Networking is also easier when you have a great web site. It's fun to meet someone for coffee and have them say, "I already know this about you..." It makes starting those conversations easier.

What have been some of the biggest challenges you’ve encountered creating and maintaining your online presence?

There were some technical challenges I had when I first started my professional blog. I was using the URL I had used for my personal blog so that I wouldn't lose out on traffic. I had to change the URL and needed a 301 redirect to maintain that traffic. This is one of those things that sounds scary and complicated, but is actually pretty easy. There's a great explanation of how to do this on Wordpress if you're ever in need.

Beyond that, it's easy to become overwhelmed or to think you need to use every bell and whistle available. I tend to try out new things for a little while, then drop them if they're not useful. Part of this is that I just like learning this stuff, but I do have to watch my time constraints. It's way more fun to me to create a great, shareable image on Canva than it is to write up my case notes, so sometimes I reward myself with online tweaking when I'm all caught up on paperwork.

Also it's tempting to save things. Like save that great metaphor for my next talk, or save that terrific example for writing I might publish elsewhere. I've since learned that the more I give, the more I have to give. Memoirist Annie Dillard said:

"One of the things I know about writing is this: spend it all, shoot it, play it, lose it, all, right away, every time. Do not hoard what seems good for a later place in the book or for another book; give it, give it all, give it now. The impulse to save something good for a better place later is the signal to spend it now. Something more will arise for later, something better. Anything you do not give freely and abundantly becomes lost to you. You open your safe and find ashes."

It's true. The more you write, the more you share, the more you will create. To hold back is a little bit like never adding weights to your lifting routine because you want to save it for when you're stronger. It's the exact opposite really.

What tips or resources can you recommend to help therapists who are new to the online world of blogging, social media, SEO, etc.?

I really like Amy Lynn Andrews for her series on starting a blog. I send her information to people all of the time. It's clear, it's easy to implement, and it works. I also like her newsletter for staying up to date on different tools that might be useful. She's not specific to counseling, but I always learn something, and even though she's super beginner-friendly, she also points to other resources for when you're ready to dig deeper into social media and SEO.

Dawn Friedman MSEd LPC

Website: www.BuildingFamilyCounseling.com
Facebook: www.facebook.com/BuildingFamilyCounseling

4 Ways a Private Pay Practice Model Benefits Clients

The value of using a private pay model (instead of a managed care system) for your therapy practice is clear: less stress about additional paperwork requirements, greater autonomy to provide the services you deem are in the client's best interest, and immediate payment of your full fee are some of the main advantages. But some therapists are understandably hesitant about how to make the switch because of the potential impact this choice it might have on their clients. Some common fears are “Clients might stop getting the therapy they need because they can’t afford me” or “charging a higher fee is selfish and means I care more about money than helping people.” When I was considering making the switch, I too had thoughts like these cross my mind. But I discovered that the opposite was true; breaking up with managed care and embracing the new way of structuring my practice actually benefited clients who received services. Here are 4 ways that a private pay model benefits clients:

1) No Mandatory Diagnosis

Many managed care systems require that you diagnose a client's specific mental health condition condition prior to paying you for your services. In some cases, insurance companies will only pay for certain diagnoses. Often, relationship issues are not covered. However, this can turn in to serious ethical problems.

I remember years ago I was referred an urgent client - a child who was sexually assaulted. I determined that she had no clear-cut symptoms and didn't meet a diagnosis that her insurance benefits would cover. I was in a terrible dilemma: do I give an inaccurate diagnosis to satisfy the requirements of managed care, or do I get paid for the initial? No therapist should ever have to find him/herself in this kind of a situation, and no client should be subject to this either.

One of the best parts of employing a private pay model is that there is obviously no such requirement. Diagnosis can be used as a tool, but you are not obligated to provide one. By eliminating the need to diagnosis a condition that may or may not fully exist, you can ensure that your clients receive ethical, honest, and accurate care.

2) Higher Quality of Service

Back when I used a managed care system, I was receiving approximately 40-70% of my stated fee. This meant I was in survival mode, seeing more and more clients just to try to get by and meet my own financial needs. And all the while, I still had the stressful task of running the business side of things. It’s not surprising then that I wasn’t able to give as much to my clients. As much as I tried, unfortunately the standard of care I could provide was compromised. That was unfair to me and unfair to the people who were paying me to help them.

By changing to a private pay model, I was able to see fewer clients and, which reduced my stress, which allowed me to be more present for my clients. I also no longer spending hours per week on phone calls and paperwork that came with using a managed care system, which freed up my energy to give to those I served.

3) Better Therapist/Client Match

A private pay model also lends itself to a better fit between the therapist and the client. If you have fewer clients, you can be selective about the ones you see. The opposite is also true; if someone is willing to pay more for professional therapy, it’s likely that he/ she has done his/ her research and sought you out because of your specialty and the expertise you provide. To put it simply, you want them, and they want you.

I’ve found that using this financial model attracts highly-motivated clients. Although they are required to pay more, they place high value on therapy and budget accordingly.

4) More Clients Reached

A private pay therapy model allows you to have a greater outreach and help more clients. This may initially seem counter-intuitive; how does seeing less clients serve more people? The answer is that if you have a surplus of potential clients or have people come to you with needs that are different that the expertise of your practice, you can refer them to trusted outside resources. You’re helping other therapists while simultaneously ensuring that clients receive the best care specifically for them.

The other thing I have found is that the income stability provided by a private pay model allows my colleagues and me to do more pro bono work. Paradoxically, because we earn more, we can provide more volunteer service when we choose.

All in all, switching to a private pay model was one of the best business decisions I made to benefit not only myself, not only my practice, but the clients and the community we serve. Charging a higher fee does not mean you are inconsiderate or selfish; it means you are valuing yourself and providing the best quality care to your clients.

*If you find that finances are legitimately a concern for some of your clients, you may decide to provide alternative choices, such as reduced fee sessions with Masters’ student interns. My practice Wasatch Family Therapy does this, and it works well for those looking for a more affordable option.

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Top 10 Best Books for Building Your Practice

I asked members of my Private Practice Toolbox Facebook Group what books have helped them succeed in Private Practice and added them to the list of my favorites. Some of the following are specific to the mental health profession, while others offer insight that applies to the business world in general, but all of them can teach you valuable tips and strategies to use for your practice. 1) "Building Your Ideal Private Practice" by Lynn Grodzki

This groundbreaking book is first on the list for a reason. Dr. Grodzski leads the way in offering time-tested strategies to grow and improve your therapy practice (read here).

2) "Be a Wealthy Therapist" by Casey Truffo

This one shows you strategies to be a great clinician and earn a robust living. You worked hard to be a therapist, and you should likewise be compensated well (read here).

3) "Book Yourself Solid" by Michael Port

Port lays out in detail how to obtain more and more clients. A great resource for those just starting out (read here).

4) "Million Dollar Private Practice" by David Steele

This book guides you in how to channel your expertise to create additional income streams and reach a bigger audience (read here).

5) "Earning a Living Outside of Managed Care: 50 Ways to Expand Your Practice" by Steve Walfish

Walfish gives you strategies for ditching managed care and instead embracing a fee-for-service model. He also includes examples of counselors who found success by carving out a niche for themselves in different areas of therapy (read here).

6) "Never Eat Alone: And Other Secrets to Success, One Relationship at a Time" by Keith Ferrazzi

This classic teaches the ins-and-outs of successfully forging networks and relationships in a way that is authentic and can help you reach your career goals (read here).

7) "Launch" by Jeff Walker

An internet millionaire gives you the inside scoop on how to leverage your business online to reach massive success (read here).

8) "Platform: Get Noticed in a Busy World" by Michael Hyatt

You may already have a great service, but Hyatt teaches you how to utilize your platform to get your message out there. As a well-sought after speaker and blogger, he shows you the power of social media to expand your outreach (read here).  

 9) "The Private Practice Field Guide" by Daniel Franz

Written by someone who took the leap from working for a company to starting his own practice, this book addresses the concerns of therapists looking to do the same. Franz gives strategies and tips on such topics as marketing, streamlining business practices, and working with insurance panels (read here).  

10) "The Portable Lawyer for Mental Health Professionals: An A-Z Guide to Protecting Your Clients, Your Practice, and Yourself" by Thomas Hartsell

This book will answer some of the tough legal/ ethical dilemmas we might encounter. The author is an attorney and private practice mediator from Dallas, so he definitely knows his stuff (read here)!

Phew, that's a lot of great reading material!

What other books can you suggest that have helped you?

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Tough Love: How to Be Firm About Finances

When you decided to go into the field of professional psychotherapy, it's likely that your reasons had little to do with money. Even as you first started, you probably didn't have dollars on the brain all the time (payments, insurance, fees, collections, etc.). Billing specialists deal with that stuff, not us, right? But those of us in private practice quickly discover how important it is to acknowledge and successfully navigate the financial aspect of our businesses. And resigning from managed care panels and switching to a fee-for-service model means that the responsibility to collect fees relies on the individual therapy practice; now, it's our job.

I certainly understand that it can be awkward. People get weird about money. I used to be uncomfortable asking clients for payment after they'd born their souls to me. But thankfully, there's a way to conquer money anxiety, serve your clients, and still meet the needs of your practice and of yourself. Here are some strategies I've discovered about how to be firm about finances and present your stated fees to clients with confidence:

(Re)Consider the Purpose of Money

Your own personal history may lead to your feeling anxiety about money. It may help to rethink the role it plays and the reason why we even have it in the first place: you are offering your time, energy, and skills to therapy, and in return, the client is offering you the resource of money. It's an energy exchange that can be emotionally neutral. It doesn't mean you are greedy or uncaring; not at all!

Value Yourself and Your Services

When I first started, I had a hard time seeing myself as a professional, which meant that I wasn't as confident or assertive about asking for money. But my supervisor helped me understand the training, skills, education, and experience I could offer. Remember what you're worth: you can provide valuable insight to those who are struggling, and you deserve to be compensated for your work. Keeping this in mind will help make it easier to accept payments and communicate about money issues.

Charge Before the Session

It works best to ask for payment at the beginning of the session before attempting to conquer tough emotional issues. This gets it out of the way right away and avoids the potentially awkward exchange at the end. There's no surprise, no uncomfortable conversation about fees owed. There's also something about being paid up front that is gratifying and enforcing for the therapist.

Use a "Money Script"

When possible, it's best to keep a separation between the therapist and the finances because it helps the client not associate his/her counselor with money. Use a planned and rehearsed script to communicate about payments. It may go something like this:

How would you like to pay for your session today?"

When potential clients ask, "Do you work with my insurance company?" I respond, "While we don't bill insurance directly, I'm happy to provide you with a receipt to submit for reimbursement from your insurance company. You may want to check with them and ask if you have out-of-network mental health benefits."

Have a Clearly Stated Payment Policy and Stick to It

Don't skimp on this. Take the time to develop and implement a carefully thought-out policy concerning payments, no-shows, cancellations, etc. By setting clear expectations, you can pave the way for an efficiently run practice with clients who attend sessions and take therapy seriously. Your actions and attitudes about finances will set the tone: if you feel anxious discussing money, your client likely will as well. But if you're professional, positive, and confident, a client will feel at ease.

My clinic policy is that if you are one session behind in payment your therapy is on hold until your account is up to date. Also, we charge full fee for no-shows and late cancellations, even on initial sessions, unless there is an emergency (read here for more about how to get paid for no-shows) . Therapist Leland Clipperton of Counseling & Mediation has a system in place where a client can actually receive a discount by pre-paying for 4 sessions in advance. Do some research, ask around, and get creative and innovative in developing a policy payment or tweaking your existing one.

You may find it helpful to have a system to notify your clients about their upcoming sessions. Making phone calls or using your EHR to send automated text messages or emails a day or two beforehand can serve as important reminders and reinforce the value of therapy. So if they're making the financial investment, we might consider making an extra effort to encourage them to be there.

In my 12 years in private practice, I've gotten extremely comfortable talking about financial issues with clients. With time, experience, and the use of these strategies, I am confident that the same can be true of you.

 How are YOU firm about finances?

What money tips and strategies that have benefitted your practice can you share?

Click here to access my webinar "How to Break Up With Managed Care" and learn more about how to improve your therapy practice.

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