[ALISON]:
You’re listening to the Grow a Group Practice podcast. Whether you’re thinking of starting a group practice, are in the beginning stages of a group practice, or want to learn how to scale up your already existing group practice, we have lots of great content for you.

Welcome to the Grow a Group Practice podcast. I’m Alison Pidgeon, your host. I’m so glad you’re here. Hopefully you checked out the previous episode, which is part one of this episode. I gave a talk at Killin’It Camp which just finished up this week, about how to scale up your group practice while also reducing your work hours. And so if you missed part one, definitely go back and listen to that first before you listen to part two, which is the episode for today. And also make sure you check out the slides in the show notes because there’s a lot of visuals, especially in this section, I have some diagrams about how my group practice has been structured over the past couple years that will be really helpful to look at so you understand what I’m talking about in the talk. And you might hear Sam, our chief marketing officer, ask some questions from the audience. She was the moderator for the talk, so if you hear somebody else’s voice that’s who that is. And I would love to hear your feedback about the talk and the content. If you want to send me a message my email is [email protected]. And yeah, enjoy part two of the talk of how to scale up your group practice while also reducing your work hours.

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[ALISON]:
So here’s the reason why practice owners don’t delegate. So again, with my work with consulting clients, these are things I’ve heard over and over and over again. And when I tell like, you know, I told my consulting client who ran the million dollar practice, like, well, you need to find somebody to answer the phone for you, you know, I hear all of these excuses, right? So the first one is, is that they think that no one else can do it as well as they can. That may or may not be true, but again, not the best use of your time to be cleaning the office or answering the phone. And when you find the right person and train them well, they might do better than you do. My assistant, my office manager, she answers the phone and schedules clients way better than I used to. So don’t always assume you’re never gonna find anybody who can’t do it better than you.

The next one is they can’t imagine finding someone to trust to get it done. Again, that sort of goes along with, like, how is anybody going to do it as well as I can? Or how am I going to know it got done? Or what if they do it eighty percent of the time, but the other twenty percent they don’t do it? Your business feels like your baby, and you wouldn’t just leave your baby with anybody; you want to make sure you trust that person.

The third one is they don’t know how to set up a system to ensure it gets done without being a micromanager. So this is the other thing I see all the time is that people, they’ll hire an assistant, but they’ll still be meddling – and I’m speaking from experience – because when I went on maternity leave, I put somebody in charge of the practice while I was gone. And I probably decided to stop working about maybe like a week or two before I was actually set to deliver. So um, I was just basically like ten months pregnant and miserable. And I was like, I’m just gonna stop working a little early because I was just… I was over it at that point. So then I’m like, at home, like, nothing to do and like, emailing the woman I put in charge, like, what about this? Did you think about this? Did you get this taken care of? Because again, it’s my baby and I wanted to make sure it was being taken care of. And I thought that I was being helpful, you know, reaching out to her just to make sure she knew everything and didn’t have any questions, but I was meddling. I didn’t need to meddle. She’d been working for me for a long time, she was totally trustworthy, and I was just annoying her at that point. So there’s definitely a way that you can set it up so that you can at a glance, make sure things are getting done, but you’re not gonna be like, in your staff’s business – I call it ‘too many cooks in the kitchen’. Because that definitely, you’re not helping yourself at that point. And someone commented about, yeah, they’re laughing about how I said I meddled, yeah, because they can see themselves doing the same thing.

And then the last one is, they don’t want to spend the money, Oh, I can’t afford to hire an assistant. Or I can’t afford to hire an accountant to do my taxes for me, or whatever it is. And I think this is one of the really hard parts about becoming a business owner that we don’t learn in school is that you’re making strategic investments with your money to grow your business that’s ultimately going to be a return on investment, right? So I always give people the example of like, if I am paying my cell phone bill, I get to use my cell phone, that’s what I’m paying for but it’s not necessarily, like, making me money; it’s just money going out the door. But if I invest money into growing my business, it is going to make me money. I like to tell people that when I started my practice, my solo practice, I spent $3300 of my own money to get things started. That’s the only money I’ve ever spent of my own in the business. Everything else that we’ve taken to grow the business has been reinvesting the profits. And this year, we will get very close to probably grossing about a million dollars. So if I said, hey, give me $3300 of your money and in five years you’ll have a million dollars, you would probably do it, right? That would be a really great investment. So just remember that when you think about, oh, well, this costs money, and I don’t know, and dah, dah, dah, dah. If it’s something that is going to make you money in the long run, it’s absolutely worth it. Any questions, Sam?

[SAM]:
Yes, we have a few. The first one is would you help a 10-99 get credentialed?

[ALISON]:
I always did because, you know, that’s one of the reasons people want to come work for you is because they don’t want to deal with all of that stuff. And so we always did that for people just, you know, to make it easier for them.

[SAM]:
Awesome. And then did you use a VA forty hours a week for answering the phone? Or did they have another responsibility?

[ALISON]:
In the beginning, and this is something too I’ll show you, like, as things have changed over the years with the business, like, I started out with a part-time person and then eventually, we worked up to a full-time person. So I would say when we were small – like four or five clinicians – I maybe only needed somebody to answer the phone, like five hours a week. And now it’s grown to the point where I have two full-time administrative assistants, so that’s eighty hours a week. So yeah, so I think you definitely don’t need to start out with a full-time person, unless you’re already really big. You can definitely grow into that.

[SAM]:
And how do you monitor what people are doing without micromanaging?

[ALISON]:
Yeah, that’s a great question. We’re actually going to talk about that in another slide. So I’ll talk about that when we get there.

[SAM]:
Okay. Yeah, there is another one – I struggle with how to delegate to a VA and with what?

[ALISON]:
Yeah, so I would say, yeah, so this is an exercise that you could do, where you write down a list of absolutely everything that you do in your practice, and then you mark the things that could be done by somebody else, and then you also mark down the things that you are really good at, are a strength of yours, something that’s just sort of neutral, and then something that’s a weakness. And I would say that the very first things you should be delegating are the things that are a weakness. There is no reason why I should be managing the finances of a million dollar business, like, I needed to hire out an accountant. And so that was immediately like, yep, this is a good chunk of change every month, but it’s absolutely worth it because this is a weakness of mine. So that might be a good way to start. And then I think you’ll see as you start delegating, and it just sort of frees you up and helps you to feel less stressed out, then you’ll just be, like, yeah, let’s delegate everything. And then the more you have trust in your staff, and you can see what they can do, you just… I kept just giving them more and more tasks to do. So I didn’t dump everything on their lap, like, the first week they were there. It was a process of, you know, giving them tasks, seeing if I could trust them. You know, like, one of my office managers, I have now started, you know, kind of saw how she did the first ninety days and like, didn’t let her like handle any money. But then after ninety days, and I could see she was trustworthy, then I let her start handling some money, and she has the debit card for the practice and stuff to buy supplies and that kind of thing. And again, we have a check and balance system in place. So it’s not just like she’s using the debit card and I don’t know what’s going on. But at the same time, you know, it was a process to get to that point where I would trust her with those things.

[SAM]:
Cool. Last two. Do you use someone for credentialing?

[ALISON]:
I don’t. We’ve actually always done that ourselves because I am stubborn, and I heard not so great things from other colleagues about credentialing companies. So we just figured out how to do it ourselves. And now that we know how to do it, we just do it. We only take private insurances, though. I would say if you want to take Medicare or Medicaid, I would definitely hire a credentialing company. But you know, I was able to train my staff to do it, so they do it.

[SAM]:
And then last one, do you have the VA sign a confidentiality form?

[ALISON]:
Yeah, I mean, if you are going to hire a VA from a company, yeah, you would want them to sign what’s called a BAA – a business associate agreement. But if you are hiring your own in-house person, that is typically in the job description, or in your policy procedure manual, or in the contract, or however you have that set up. So you don’t need to have them sign a BAA if they’re actually going to be like your staff or your employee, if that makes sense.

[SAM]:
Awesome. That’s all for now.

[ALISON]:
Okay, great. Okay, so this is what I was kind of alluding to the past few slides that I was talking about. So how do you scale up the right way? So like I said, you don’t want to just, like, hire a bunch of people and give them a zillion things to do and just be like, good luck, see you later. So this is what I’ve learned about scaling up the right way. So the first thing I would recommend to you is be picky about who you hire. Just like we talk about having a really clear niche for clients, we also as group practice owners, want to have a really clear niche of what type of staff is going to be a good fit for our practice. And I will actually write down the values, and the mission, and the vision of the practice and give it to them in the interview process and ask them what they think about it. Does this resonate with you? Do you relate to it or not? And I find that the more clear I am about who is a good fit, the more I’m attracting the right people and repelling the wrong people. So yeah, so that’s number one.

Number two would be clearly explaining the job duties and the outcome of the task. So a lot of times we say like, you know, especially with an administrative assistant, like, there’s a bazillion things and all this detailed stuff that they have to keep track of and remember and do. And so you may, in that beginning training period, really need to be very clear with them about like, what is your priority every day. I had an assistant once who had not a clue what the priority was, which was answering the phone, so she’d be like, scanning documents into the computer, which is not a time sensitive task at all and, like, wouldn’t answer the phone. And so I had to be very clear about, your priority is to answer the phone and keep people’s schedules full. If you’re doing anything else other than that and the phone is ringing, you need to stop and answer the phone. And some people that you hire will get that and other people need that explained to them in a very concrete way. So make sure you explain to them what the outcome is that you expect.

And then what I was alluding to before was you want to set up kind of a checks and balances system so you can make sure things are running smoothly. So what I hear from practice owners a lot of times is they don’t have these check and balance systems in place. And then a small problem becomes a huge problem because they just weren’t aware, or they weren’t keeping track of the data in the practice on a regular basis. And then all of a sudden, you know, they had $100,000 worth of unpaid claims from insurance because they weren’t keeping tabs on if insurance claims were getting paid.

So I’ll give you some examples of what is this check and balance system. So a lot of these things, fortunately, for us, are built into our EHR. So we can run reports. So I can run a report that shows do any of the therapists have missing progress notes. So we do that once a month, for the previous month. If anything is missing, we email them and say, hey, these are missing – it’s usually just human error – but you need to get these done in the next couple days. And we make sure then to follow up with, you know, do they get done. Something else would be an aging report. So an aging report is, again, something I can run in our EHR that shows me like, are there any balances, either from insurance or from clients, that are like thirty days past due? If it’s thirty days past due, that’s usually an indication there’s a problem. And so every week or two, my office manager goes in there runs the aging report, figures out, okay, what happened? Do we need to resubmit to insurance? Did we collect the wrong copay? And she keeps up on those. And so we typically only have about one percent or less of our money goes uncollected per year. So, like last year, we made over $600,000, and less than $5,000 for the whole year went uncollected because she is so on top of making sure we collect everything that we need to collect. So I think a one percent balance for uncollected payments is excellent. It’s much better than what it was when I was working in that community mental health system.

And so those are… I mean, we could probably have a whole presentation on like tracking data – I actually do have a whole training on that for people. But that’s just an example of some of the things that we look at. So one of the things too that I put in place with my office manager specifically, is like if she uses the debit card to buy something, like buy supplies, or we buy birthday gifts for the therapists and things like that, she just sends me an email that says, spent $25 on Amazon for so and so’s birthday. So that way I know what that was used for because I’m always looking at the bank account. That’s another thing that I look at quite often – several times a week, I’m looking just to make sure the transactions all look normal. So then I know, oh, okay, she used the card for that purpose. And then I know there wasn’t like a fraudulent charge or anything. And that also helps to keep her accountable, because she knows I’m keeping tabs on those things so she won’t use it for something that’s not appropriate.

And so then the last thing that I learned the hard way – and I love sharing mistakes that I make with people, so that you don’t make the same mistakes – is that I would not give one person all of the administrative managerial tasks. I would give those tasks to different people because if that one person leaves, you’re pretty screwed up. And also, if that one person understands how to run the whole business, they could just go and start their own business and they know exactly how you do everything in your business and how it runs. And so that is another reason why you’d want it kind of spread out among various people, and we’re going to talk about what that looks like in a second. Any more questions before we move on?

[SAM]:
Yeah, we’ve got a few. So someone’s requesting that you please have a class on your credentialing process.

[ALISON]:
Okay.

[SAM]:
There’s another question asking if there’s a standard BAA?

[ALISON]:
Is there a standard? I mean, I think all of them are pretty similar. I have one in my paperwork package so if someone’s looking for one I’m happy to send it to you.

[SAM]:
We could also include it in the ecourse that we put together of these recordings. And then, do you audit their note if you expect Medicaid to make sure they are addressing medical necessity, etc?

[ALISON]:
Yeah, we don’t take Medicaid, and I know that really varies by state. So I’m not really sure I can answer that.

[SAM]:
Okay. So the last one, what are some perks you give your employees to help with retention?

[ALISON]:
Yeah, so there’s a great book about that called The Best Place to Work, and he talks about the research related to why people stay in their jobs, and I will give you the very short Cliff’s Notes version, that people like to have more frequent smaller rewards than just one less frequent, big reward. So what I do for my staff is we have snacks and drinks in the office – when we used to be in the office – that were for free, that they could take while they were working, and I buy them a birthday gift. If somebody has some major life event, we recognize that somehow, like I had somebody buy their first house, or like, I sent her a card and a gift card to Lowe’s, and just said, congratulations, you bought your first house, you know, that kind of stuff. So just demonstrating to them that you care about them and, obviously, you kind of know what’s going on in their life as far as much as they want to share about that. But I think that helps them to feel like you value them and you care about them.

[SAM]:
That’s all for now.

[ALISON]:
All right, well, let’s move on because I think this is gonna be interesting and there might be a lot of questions about this. So I wanted to kind of show you snapshots in time of what my practice has looked like over several years. And this is not something that… there’s not just one right way to do it; there’s probably like, twelve right ways to do it. And I just wanted to give you a real world example of what my practices looked like in terms of structure and how I’ve delegated things, just so you have an idea of what that looks like. But this is by no means the only way to do it, or the right way to do it. So you have to forgive me for my rudimentary drawings, because this is the only way I knew how to make these organizational charts. So if you’re familiar at all with organizational charts, it’s basically showing like what’s the hierarchy in a workplace in terms of, you know, like administration, and that kind of thing. So this is what this is about.

So let’s move to the next slide. Okay, so hopefully everybody can see this. So you see, CEO at the top, and T with a circle around it means ‘therapist’, and then the administrative assistant is on the bottom, is ‘AA’. So I’m at the top, the therapists in the middle, the administrative assistants down at the bottom, supporting the therapists. So when I had six therapists, this is basically what it looked like, you know, we were talking about you doing all the things, wearing all the hats, cleaning the office, answering… I wasn’t answering the phone, but doing lots more things that I shouldn’t have been doing, this is what the organizational structure looked like.

Then, a couple years later, when I got to the point where I was sort of pulling myself out of the practice, and I was pregnant and knew I was going to be on maternity leave, I came up with this structure. So here’s where there’s twelve therapists now in the practice, and I’m still at the top, the CEO, but I put that red circle in there because that stands for the clinical director. So when I was on maternity leave, she just popped right into that circle. So that’s what the structure looked like when I was there and then when I was out, that’s what the structure looked like. And then at the bottom, you can’t totally see it but it says full-time administrative assistant. So by the time we got to be twelve therapists, we needed somebody full-time. So that’s what that looked like. So I would say, this is like a year ago, this is what my practice looked like.

Okay, so now this is what it looks like today. So I’m still at the top, the CEO, but now I have two managers over each of the two main locations. And then below that, I have the therapists. And then below that, now I have two full-time administrative assistants, because that’s how much admin time we need to support everybody. So you see the little red X’s, that stands for additional responsibilities. So the managers support those therapists in those offices more like from a clinical standpoint. And then the therapists have interviewed and taken on additional responsibilities, if they want them, that they do in addition to seeing clients. And so we’re going to talk about what those things are in a second. So does this make sense? Are there any questions about the chart, Sam?

[SAM]:
Someone’s asking how do you compensate the managers differently?

[ALISON]:
Yeah. So right now, how we have it worked out is that they have a billable rate to see a client, and they have an admin rate to do other stuff. And so right now they’re just getting paid the admin rate to be the manager. But that’s something that, you know, depending on how their role evolves, they may end up getting paid a little bit more to be the manager.

[SAM]:
And will you do drawings for other businesses, like the Practice of the Practice org chart? That’s from Joe.

[ALISON]:
That’s Joe’s job, so I don’t know. So anyway, let me talk a little bit more in detail about that. And then the direction that we’re going right now is, so in between the managers and me is now going to be a COO – so a chief operating officer – who’s going to take over a lot of the day to day stuff that I’m doing right now that I don’t want to do anymore. So that’s going to free up even more of my time. So if you think about there being one more layer in there of administration, that’s kind of the direction that I’m going in. So people typically ask, well, what are these additional responsibilities that therapists are doing? So I have a new clinician trainer, so any of the new clinicians that come into the practice get trained by this person. A special projects coordinator, so we’re implementing a new software right now to use with our clients and I have somebody who’s helping with that. I have a marketing lead. I have, like I showed in the picture, a clinical manager of each location, and I have a clinical supervisor. So we do like, they have to attend one hour of supervision a month as W-2 employees. And so I have somebody who sort of facilitates those meetings, even though they’re just, you know, sort of like peer consultation.

So the other thing I didn’t include in these organizational charts is that there are other people that I utilize in the practice. A Tax CPA, an accountant, I use Green Oak Accounting – Julie is speaking later this afternoon, she has been so helpful. I use a lawyer, I have a freelance social media person, and a ghost writer. All of these things, like, you could have potentially some of these things in your practice. Like, you could have one of the staff people write blogs for you, but I just found somebody really good who does that for me. So these are kind of other vendors I use that you didn’t see in the organizational charts. Okay, so I know we’re running out of time so what other questions do we have, Sam?

[SAM]:
Cool. So what specific questions would you ask a therapist you’re interviewing?

[ALISON]:
Yeah. So I would say, I put out kind of descriptions of what each of the roles were. And then I had them apply, and then when I interviewed them, I asked them, like, well, what makes you feel like you’re well suited to do this kind of role? And it was interesting because some of the therapists had skills or past experiences that I didn’t realize when I had hired them. Like, the one woman who does all the training now for us was like, oh, yeah, I used to do this at my old job and I didn’t realize she used to do that at her old job. And so it was just like, oh, yeah, that makes total sense to give you this role because you already have experience doing that.

[SAM]:
And then, do you hire associate therapists?

[ALISON]:
I did not up until very recently, I’m hiring an unlicensed person.

[SAM]:
Sorry, it looks like to the previous question, they’re saying not the bonus jobs, just normal clinician jobs.

[ALISON]:
Oh, what kind of questions do I ask them?

[SAM]:
Yes.

[ALISON]:
Okay. So I’ll give you very, like, this is a very short answer. We could probably have a whole ‘nother hour-long conversation about this. But I ask them about clinical skills, I ask them about boundaries with clients, and I ask them about organizational skills, and I ask them about interpersonal skills, like, how well they’re going to get along with their co-workers.

[SAM]:
Okay, we have a bunch of questions coming through. I’m not sure we’ll get to all of them, but is the one hour requirement supervision for the therapist individual supervision, or is it a group or case consultation?

[ALISON]:
Yeah, it’s like a small group case consultation. It’s like three to four clinicians.

[SAM]:
Okay, cool. And then, what interview questions do you use when you hire an AA, but I think it’s meant to be a VA?

[ALISON]:
Oh, yeah. Like an administrative assistant or virtual assistant?

[SAM]:
Yeah.

[ALISON]:
Yeah, we look for people who have past healthcare experience. If not that, even better, past mental health experience. If they’ve had any experience working in an outpatient healthcare facility, they probably will do pretty well. And we also ask them, you know, how detail-oriented they are and also about if they can handle, like, people being upset on the phone because that happens.

[SAM]:
What compensation formula for 10-99s worked best for you when you started the group practice?

[ALISON]:
So we started out doing 60/40, so the therapists got sixty percent and the practice got forty.

[SAM]:
When you had 10-99s, did they do their own billing? Or did a company do it for them?

[ALISON]:
Yeah, they actually do all their own billing. So they just literally after they’re done with all their stuff, all their documentation, it’s just like, click, click, click, and it sends the claim. They still do their own billing.

[SAM]:
What do you pay clinicians for their other work?

[ALISON]:
Yeah, so it’s about half what they would get for a billable hour.

[SAM]:
Screaming through these questions. How is an associate therapist paid if they can’t get paneled?

[ALISON]:
Yeah, so we’re charging much less for clients to see them and then we’re paying the therapist less, which she was okay with because she just really wanted to get the experience.

[SAM]:
And what do you charge for a billable hour?

[ALISON]:
Yeah, we charge $115 – that’s our self pay rate – but our average kind of insurance reimbursement is about $92.

[SAM]:
Awesome. And those of you who are asking about the charts, if there’s a way to go back to them, so we will be giving you access to all of these recordings probably in a month or so. And you’ll be able to watch the recordings and see the slides again, so don’t worry about that. Great, so with a minute to spare, thanks so much, Alison. That was super informative, and I know everyone gained a lot of value from it.

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[ALISON]:
Grow a Group Practice is part of the Practice of the Practice Podcast Network, a network of podcasts seeking to help you grow your group practice. To hear other podcasts like the Imperfect Thriving podcast, Bomb Mom podcast, Beta Male Revolution, or Empowered and Unapologetic, go to practiceofthepractice.com/network. If you love this podcast, will you please rate and review on iTunes or your favorite podcast player.

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