[ALISON PIDGEON]
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You are listening to the Grow a Group Practice podcast. Whether you were thinking about starting a group practice or in the beginning stages, or want to learn how to scale up your already existing group practice, you are in the right place. I’m Alison Pidgeon, your host, a serial entrepreneur with four businesses, one of which is a large group practice that I started in 2015. Each week, I feature a guest or topic that is relevant to group practice owners. Let’s get started.

Hi and welcome. I’m Alison Pidgeon your host. Today, I am doing a solo episode. We’re talking all about money leaks that can happen in your group practice, but before we get started with that, let me tell you a little bit about our membership community Group Practice Boss. So every month in our community, we do weekly webinars. We have a different theme for the month. So our theme for this past May was all about money management. So I did a webinar all about how money can leak out of your group practice. So what that means essentially is that if your systems or your processes aren’t really buttoned up and running smoothly, you could be leaving money on the table because it goes uncollected or you don’t have a good way of making sure that you are getting paid for everything you should be getting paid for.

So we’re going to go through those. I just wanted to let as well that the Group Practice Boss community is kind of a rolling membership community. If at some point you want to join, you don’t have to wait for a particular date. You can just jump on in. So if you want to check it out, it’s www.practiceofthepractice.com/grouppracticeboss. The monthly membership is 1 49 a month, and you have to be an established group practice owner to be in that group. And Whitney Owens and I, my counterpart at Practice of the Practice, we run it together. We have a lot of fun. It’s been so great getting to know the members of the group. We have over a hundred members now. And like I said, we do different topics every month. So whether it’s hiring or how to be a better boss or managing your money, we cover everything a group practice owner needs help with.

So with all that being said, let’s kind of dive into our topic today. So this is a list of money leaks that I have come up with over the years of working with different consulting clients and I will go through the list. The first several are really just in general that can be applied to any practice and then the last few we’re going to talk about are specific to either an insurance-based practice or a self-pay practice. So I’ll remind you of that when we get there. So the first money leak that I want to talk about is paying staff too much compared to the average reimbursement rate. So I have learned from Green Oak Accounting that if you have W2 employees in your practice, you should not be paying them any more than about 50% of your average reimbursement rate.

This means that if you make a hundred dollars an hour for therapy, you shouldn’t be paying them any more than $50. If you have a contractor, you probably can’t pay them much better than a 60/40 split meaning they’re getting 60% because that doesn’t leave enough money left over for you to pay all of your overhead and make a profit and pay yourself. So I have definitely, unfortunately seen this situation come up where a group practice owner just sort of picked a number out of the air to pay their staff and then realize that they were paying way too much and then had to walk it back, which is obviously not a good situation to be in. So my advice to you, if you are just getting started with a group practice would be definitely having an accountant help you figure out those numbers because you don’t want to be in a situation where you have to tell your staff, “Oops, sorry, I’m paying you too much and I have to pay you less.” Nobody wants to have that conversation. So that is number one.

And now number two, this is a lesson that I learned the hard way, not keeping credit cards on file so no-show, late cancel fees cannot easily be collected. So we didn’t realize in the beginning that it’s a common practice to keep credit cards on file we didn’t sort of make it mandatory or request it on a regular basis. Then we started doing it when they came in for the first appointment, but then we realized that people who no-showed to the initial appointment, we had no recourse because we didn’t have a credit card on file. So we started then asking for a credit card when they actually scheduled the appointment and we found that that helps weed out the people who are not serious about coming to therapy.

So if you do not keep credit cards on file, definitely start doing this right away. And we have maybe a small handful of people throughout the year that give us some pushback about that and that’s totally fine. If they don’t want to give us their credit card, they don’t have to, but I would say the vast majority do, and it’s really helped us to make sure that we are charging balances or no-show fees without having to chase that person down.

So that was number two, moving on to number three. Something I know a lot of therapists do is they don’t regularly review their expenses on a regular basis to see if expenses can be reduced or eliminated. So I’ll explain that a little bit. So essentially we all know if you’ve been in business for awhile, things change. Like you may be using a certain software for a while and then you figure out a better way of doing it and you change it and then you forget to go back and cancel that software subscription. So what I recommend people do is on a quarterly basis, or even on a monthly basis, just go through all your transactions and see where your money is going. What are you spending money on? And maybe there’s something that you don’t use any more that you could cancel.

Maybe you’re getting super busy and you’re running Google Ads and you can pause the Google Ads for a while because you’re turning away referrals so why would you be paying for Google ads, if you think you’re going to get plenty of referrals without paying for them. So just things like this that it’s easy to kind of have things on autopilot and forget to look but definitely keep tabs on, okay, what am I paying for and am I still using it? And if you’re still using it and it’s working well for your business, then great. Like there’s no reason to cut that expense, but it’s very common that things change and that you might need to change some of your expenses.

Number four is not collecting payments in a timely manner. So what I mean about that is typically when clients come in for session that is at the time at which we have them pay. So we’re mostly insurance-based practice, but we also do some self-pay, but regardless we have them pay at the time of the session. So when the session ends, the therapist is responsible to schedule the next session. And then since the credit card is already on file, they say, oh, do you want me to put your copay or your deductible on your card? And then they can just go click, click, because it’s integrated into our EHR and it’s done.

That way, if anything comes up with the card that’s an issue, maybe they got a new card and they forgot to give it to you or they were using an HSA card and they ran out of money for the year, you can just say, “Oh, it looks like your card got declined. If you have another one you could give me instead because the payment didn’t go through.” So we find this process to be so important in making sure you’re collecting everything you should be collecting, because if you wait till later to run the card and there’s a problem, we find it takes much more time to kind of have the admin call them and say, “Hey, your card declined. Do you have another card?” It’s hard to get people on the phone, they’re at work. It just takes a whole lot more time and it just seems to be so much more streamlined and easy if you run it in the session. And if there’s an issue, you can get an alternative form of payment.

So that is something that I would highly recommend if you don’t already do that, if you charge the card or collect payment at some other time. Like I know some practices who send out like invoices or like statements or something at the end of the week or something like that. Like you’re much less likely to see your money. If you don’t collect it at the time of the service.

Number five is paying too much money in taxes because you aren’t getting professional advice. So let me tell you a story about this. Back in 2018, I believe it was, we got insurance through the marketplace. So we at the time qualified for the tax credit, but then towards the end of the year, realized that we just meet over and above the threshold for the tax credit. So we were going to have to pay back, like, I don’t know some insane amount of money, $12,000, $15,000 because we basically didn’t qualify for the tax credit anymore. So I have a CPA that I’ve used for a long time and she and I were kind of monitoring this to see what was the business making, what was I paying myself, what was going to happen with this marketplace insurance tax credit? So when it became clear that we were going to go over, she said, well, you can either just pay back the tax credit, you will obviously never going to see that money again, or you could put X number of dollars into your retirement, which would then bring you below the threshold and then you wouldn’t have to pay back the tax credit.

So I had no idea that it was possible until she told me that that was a potential solution. So that’s what I did. I took my, I forget exactly how much money it was, but several thousand dollars put it into my tax, not my tax, my retirement account which obviously I will then get the benefit of that money earning interest and then eventually when I do retire, I’ll be able to use it instead of just paying back the government and never see that money again. But the moral of the story here is that I would have had no idea that was even possible if I hadn’t had an accountant. I am not a tax professional by any means. I don’t think Turbo Tax would have been able to sort of figure that out for me.

That’s where, especially when you’re running a group practice, obviously the financial picture is getting a lot more complicated, there’s a lot more transactions, now you’re paying people and taxes is one of the biggest things that you’re going to pay money for, like one of the biggest expenses that you will ever have in your practice. So it is absolutely worth the money to pay the accountant. She saved me like $12,000 or something like that that year. And comparatively, I may be paid her a thousand dollars to do my taxes. So it was an absolute no brainer to have her help me and figure that out. So if you don’t have a tax professional, if you’re still using some kind of tax software and trying to do it yourself, like please go get a tax professional because they will save you money. They will, if they’re good, they will be communicating with you throughout the year, kind of monitoring how much you should be paying in quarterly taxes and helping you figure out how to really maximize your tax deductions and all of that kind of stuff. So don’t skimp in that, in that area.

So now we’re moving on to number six and that is not having a clear policy about sliding scale or pro bono therapy services. So obviously when you have people working in your practice, people’s interpretations of if they should be giving a client a discount or seeing them for free might be different than your interpretation as the owner. So that’s why you have to make it really clear to your staff. “Okay, there’s a procedure, there’s a process or there’s something in place. We have two spots per month per therapist for a sliding scale or a pro bono therapy and here’s kind of the reasons why somebody would qualify for that.” So what I’ve seen happen in practices is there’s no clear policy and everybody is just sort of doing whatever they think is appropriate and then you realize you’re giving away a ton of reduced and free therapy slots, which is wonderful, but at the same time, we’re business owners and we need to be making sure we are bringing in enough money to cover our overhead, to pay ourselves so that we can not be working all the time and all of that kind of thing.

So if you don’t have something like that written out, or if there’s not kind of a clear policy around that, that’s something you can start doing this week. And I would say, obviously too, one thing I noticed that practice owners tend to forget is that if you’re giving someone a pro bono slot or a reduced sliding scale spot, there needs to be some sort of entity where you’re going to sort of reassess where the person is, if they are still not able to pay, if they maybe need to receive therapy somewhere else or maybe they need to apply for Medicaid, just whatever the situation is.

So don’t basically say, “Oh yes, I can give you this reduced fee slot and never let them know that there is potentially a deadline,” or at least a timer you’re going to reassess the situation and decide if you’re going to continue to do that. Because people will just assume like, oh, this means it goes on forever and ever, and you’re thinking like, oh three months from now, I’m not going to offer this anymore, but if you don’t have that conversation, obviously you can be on two different pages about that. So really important to have those conversations with your clients and have a policy about that.

So number seven, in terms of money, leaks is not marketing consistently, not anticipating the slow times of the year and adjusting your marketing accordingly. So typically, what happens in a practice is maybe you’re starting out, you need clients, you just hired some new people and you got to market, market, market, and you have all these people like really do a big marketing push into the community to get new clients for your new staff. That is great but then what happens is you get busy, you get busy with your own clients and you sort of don’t market at all. It just sort of drops off and then obviously as people get better and they start sort of graduating, you need more clients it’s like, oh my gosh, like, “Oh, we have all these open slots,” like all of a sudden, and then you start like fever marketing again. So that’s where it’s much easier to be consistent with your marketing than it is to have it be sort of a feast or famine cycle. So what this means is like, you’re going to put on your calendar every three months, I’m going to reach out to this referral source. I’m not going to just reach out to them once and then haphazardly remember next year that I need to reach out to them again.

Like you have it scheduled, it’s a process that you go through. We find that if you don’t kind of remind people every three months that you’re still there, they forget about you. So that is the process that we have in place. And then the other piece of this is there are going to be slow times of the year. For us that’s always the end of the school year, the week of 4th of July, the week between Christmas and new year’s, but typically during the regular school year is the busiest time and then the summer tends to slow down a bit. So in May, I’m ahead of knowing it’s going to slow down, like the first or second week in June. I will really ramp up my marketing. So I’ll have that all planned out ahead of time so that is not a surprise. So I don’t have then therapists sitting around, like, “I don’t have enough clients,” because it’s July.

I anticipated that and I spent more marketing money and time ahead of July to make sure that they at least were full by the time July came. Obviously, that’s not a perfect system, but it definitely will help, especially because I know a lots of practices, their revenue will go down in the summertime. So even if you just want to get to the point where like, summer’s like you’re breaking even that’s much better obviously than losing money. But that’s a really good thing to think about and plan for.

So the next one is current resources and what I mean, resources, I’m talking about office space, available therapists hours not being fully utilized. So obviously, during COVID times, this is a weird thing, but pre-COVID, I was always amazed at people who had like office space and they weren’t using it to its fullest capacity. You can really use an office 12 hours a day. And my staff always shared offices. Nobody ever had their own office. It was like Sarah came in from eight to four and then Julie came in from 4:30 and worked till 8:30. Like the office was utilized almost all of the time. And obviously before we had tele-health you really needed to kind of stack your appointments that way in order to really maximize the space that you had. So you may have other resources that I haven’t mentioned and it might be advantageous to like spend a few minutes thinking about what do I have that I could make money from or use more to its fullest extent that I haven’t been? So yes, that’s another money leak that can happen.

The next one is rent taxes or other expenses too high in proportion to income. So we talked already about the tax piece and how important it is to have a tax professional. If you don’t know what your kind of budget should look like or kind of what the rule of thumb is for rent I can give you kind of general guidelines. Obviously, depending on your situation, this may be different. So my consulting clients in Manhattan, their rent is sky high. They are probably not able to keep their rent in proportion to their income but we find ways to work around that. So general rule of thumb is rent should be about 10% of your gross income. So if you, as a group practice are making $400,000 per year, then your rent for the year should be $40,000 or less, if that makes sense, because that’s about 10% of $400,000. So you can divide that up into 12 months and figure out what that is in terms of a monthly rent payment.

Something else, and I got these numbers from Green Oak Accounting, is your overhead, and I’m just talking about what you spend on marketing and office supplies and that kind of thing should be about 20% of your budget. So if you’re spending 30, 40% of your budget on those things, you may want to look at what can be adjusted so that it is more in proportion. So Green Oak Accounting has lots of great resources on their website. It’s greenoakaccounting.com and I am a client. They do not pay me to say this. I just really love their services and they’ve given me a lot of great information that I teach to my consulting clients. So definitely check out the resources that they have available.

All right, so now we’re going to get into specifics related to an insurance-based practice versus a self-pay practice. So I have four different bullet points here for the insurance-based practices where you can have money leaks. The first one is insurance billing problems. We don’t know anything about that. So if you are having some problems with your billing, it’s probably causing a delay in your payment or else you’re not getting paid at all. So it’s really important that you are on top of what’s called an aging report. In your EHR, you probably have something like this. It may not be called the exact same thing, but essentially it is showing you all of the money that’s outstanding. So for example, as soon as a balance is older than 30 days, it shows up on our aging report in our EHR and my admin can then go in and figure out, “Okay, did this claim get denied? Why? We need to resubmit it. Or for some reason, the client didn’t pay. I need to follow up with the client.”

So this is so, so important to keep on top of and not just like, oh, let’s look at this once a quarter. Like she probably looks at it at least once a week because we all know if you don’t submit claims in a timely manner or appeals, there’s no sort of going back at that point. Like if it’s older than 90 days, 120 days, they just say too bad. So you really need to to keep up on all of that and that’s where having a biller or an administrative assistant is wonderful.

The second one is accepting too many insurances slash EAPs. So EAPs are employee assistance programs that are low-payers. So when you take lots of different insurances and you add them all together, you get an average. And obviously, if you have low payers, they’re dragging down the average. So the issue with taking too many insurances is that it can get confusing with billing. It can get confusing to the therapists. EAPs are great because they feed you clients but the trade-off is that they’re typically paying you at a lower rate. So when we were new, a new practice, we took a lot of EAPs and then as we became more well-known and got full, we dropped almost all of them because we didn’t need them anymore to get clients. So if you’re accepting a ton of different insurances and you have plenty of clients, just make it easier for yourself and drop the lower payers. You’re automatically going to give yourself a raise and probably just make the whole billing process simpler for yourself.

The next one is not comparing payments on EOB. That stands for explanation of benefit forms to what was expected. So there’s definitely practices that submit the claims, it comes back from the insurance company, you get your deposit, but they never compare on that EOB form to what they expected to be paid in their EHR system. So that’s where you’re going to find out if a claim got denied, what the reason was, there’s usually codes on there. You can look on the key to see why did this thing get rejected? There should be a way to tell in your system if maybe a claim never got to the insurance company. So that happens sometimes. It gets dropped in between the clearing house and the insurance company. So also seeing like if you don’t get any information at all about certain claims, like, well, what happened to it and probably somehow there was an error and it got dropped in the clearinghouse. So definitely check to make sure that the claims are correct, that they paid you what you thought you were going to get paid, and obviously if not, you can go back and resubmit to make sure you’re getting paid everything you should be getting.

And the last one for insurance-based practices is not regularly requesting raises from insurance companies. I’m always surprised at the number of practice owners who ask me like, “Well, should I ask the insurance company for a raise?” And I think like, well, why not? Like the worst thing that could happen is they would say no. And I think if we all started asking on a regular basis for raises, it would make a big difference. I know I wrote a letter to a smaller behavioral health company that is common in my area and the VP of something actually called me and said, “I got your letter and I really appreciate you taking the time to write it and tell us from your perspective, what it’s like to have to run a business and not being paid what you feel like it. You should be getting paid in order to serve our members and that kind of thing.” She basically told me we’ve been getting lots of these letters and we’re actually now looking at raising our rates because we got so many complaints that we felt like we needed to do something. So don’t underestimate the power of asking for a raise. And even if it feels frustrating and you’re like, “Oh, I’ve asked for a raise every six months for the last three years and I’m ignored,” keep doing it because if we all do it, then we’re all hopefully going to get a raise.

So now we’re going to move on to money leaks for a self-pay practice. So obviously you don’t have to deal with all of the insurance stuff in a self-pay practice. But one way you’re leaving money on the table as if you don’t regularly raise your rates. So you should probably be raising your rates at least once a year. If you’re full and turning people away, you should probably consider raising your rates at that time as well. So that might be more than once a year. But everybody’s costs to run a business go up. What you need to pay your bills and support your family or yourself increases every year. So you definitely need to be raising your rates.

And then the last one is not billing the client at the time of the session. So I know we had talked about that earlier with making sure you keep credit cards on file and charging it when you’re in the session with the client. It’s super important for self pay practices. Obviously you’re not submitting anything to insurance or waiting to get paid from them. So if you don’t get the money at the time of the session, likely you may not see it again, especially if the client ghosts you or something like that. So somethings to watch out for if you have a self pay practice. So that was a lot of stuff.

We are at the end of the list. I hope that was helpful. Again, that was actually a webinar that I did through our membership community Group Practice Boss. So it was cool because we do them live. So when our members come we present the information and then we can answer questions and people obviously have specific things in their own practice that they’re wondering how to apply the information to. So we can kind of talk through that. So it was really cool doing the webinar and just hearing feedback from people and at the end we talked about like, okay, what changes are you going to make now that this stuff? And there were a lot of people who were like, “Oh yes, I’m going to start checking my EOBs and I’m going to start looking at my expenses every month and make sure that I’m not spending money on something I don’t need to be spending money on and that kind of thing.”

So I think obviously we all get really busy and it’s easy to forget that we need to be paying attention to these things or delegating this out to other people to have that be tracking it for us. But we’re all doing hard work and obviously it’s important to get paid for the work that we’re doing. So I hope that you learn something new from this podcast episode. And if you are an established your practice owner and you want to join Group Practice Boss, you can go to www.practiceofthepractice.com/grouppracticeboss. I hope you have a great day and I’ll talk to you later.

Thank you again to the Therapy For Your Money Podcast and Green Oak Accounting for being a sponsor of our podcast. We are a big fan. I use Green Oak Accounting for my practice. And if you want to check out my podcast episode on the Therapy For Your Money Podcast, I was episode number 20.

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This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. This is given with the understanding that neither the host, Practice of the Practice, or the guests are providing legal, mental health, or other professional information. If you need a professional, you should find one.