Joe Sanok 00:00:00 Hey there, practice of the practice community. Are you ready to take your private practice to the next level? Then mark your calendars for September 16th through 19th, 2024, because Level Up week is back and bigger than ever. Insert rocket emoji here. Join us for four days of live webinars, interactive panels, and exclusive resources tailored just for counselors, therapists and private practice owners. Whether you’re looking to fill your caseload, hire your first clinician or scale your group practice, we’ve got you covered. This is your chance to level up while others give up. Don’t miss out on this game changing event. Register now at practice of the practice. Com forward slash level up and get ready to transform your practice. Remember September 16th through 19th Level up week your ticket to practice success. Register today and let’s level up together. Practice of the practice. Com forward slash. Level up. This is the practice of the Practice podcast with Joe Santokh, session number 1065. I’m Joe Stanwyck, your host, and welcome to the practice of the Practice podcast, where we are here almost every day, depending on the week. Joe Sanok 00:01:26 We’re doing 6 or 7 podcast episodes every single week, helping you to build a thriving private practice you absolutely love. You know, we want both sides of that. We want it to be thriving. We want you to rock it out. If you’re making money paying people good wages, but we also want you to love it. There’s a lot of ways in life to make money, and you know, we want you to enjoy it. We want you to have the free time, the vacation time, the lack of burnout. We want all of that for you because life is really short. There’s a lot of things that we could be doing with our time. We want to make sure it’s something that you absolutely love. So we are doing a series right now with Melissa Schneider, who has a practice with over 60 clinicians. Next month, she’s going to be bringing ten more clinicians on. If you missed yesterday’s episode, we dug into zip codes and why those matter, how to do a competitor analysis, how to really use numbers and be nerdy with how you make decisions around where you’re opening your locations. Joe Sanok 00:02:26 And if you miss that, you definitely want to go back and dig into that one as well. Tomorrow, we’re also going to be jumping in as well on the topic with Melissa around, talking about finding and keeping quality therapists and also handling turnover, how turnover happens. And we’re going to be digging into that also. But today is all about, you know, will taking insurance help you scale your private practice? When I had mental wellness counseling, I opened Mental Wellness Counseling in 2006, sold it in 2019 to Nicole Bahl, who is now one of our consultants with practice to practice. I didn’t take insurance. and the reason for that was I started mental wellness counseling as a side gig counseling practice. I had a full time job at first as a foster care supervisor. Then I was working full time over at the community college, and all the insurance panels were closed. At the time, the insurances were saying, we have enough therapists, we do not want you. So I said, I want to do counseling. Joe Sanok 00:03:21 I want to help pay off student loans. I want to have a little extra money for my family. So I’m just going to do private pay. And I didn’t know what that meant. I didn’t know about super bills. I didn’t know about Psychology Today, none of that. and then when the panels opened back up at that time, for me, it made sense to stay private pay. But when Nicole. When she bought mental illness counseling, one of the very first things she did was to start taking insurance. And she has now has a three location practice and it’s grown. And we’re going to be talking with Melissa about that decision of, should I take insurance? Is that going to help me scale? How do you sort through that? What communities do you have to take insurance in? Where maybe is it a little. You just kind of decide, okay, I only want to be on one. So all these different things. So Melissa, welcome back to the practice of the Practice podcast. Melissa Schneider 00:04:07 Thank you so much Joe. I’m excited to be here to talk about this huge decision that practice owners have to make. Joe Sanok 00:04:13 Yeah. Well, let’s just start with, if someone decides to take insurance, this doesn’t in my in I think my opinion and also correct me if I’m wrong, if someone decides to take insurance later, you can decide to leave those panels. And also if you decide you don’t want to take insurance, you can later apply. So sometimes these decisions in our practice feel like I’m making the decision of a lifetime for the DNA of my practice, but then you actually can change some of that. Is that is that correct? Melissa Schneider 00:04:40 That’s definitely correct. You know, there’s usually some, period of giving notice, maybe 90 days. You have to send in a letter. There could be a process. Sometimes insurance is slow and bad. and you do have to provide a network services until you are officially terminated on a panel, but it’s all doable. Joe Sanok 00:04:59 Yeah. Okay, so that takes maybe a little of the pressure off of this is the decision of the practice, but it’s also a big decision. Joe Sanok 00:05:05 So walk us through just some of the things people should be asking themselves before they decide, yep, I’m going to take insurance. nope. I’m not. Melissa Schneider 00:05:15 Definitely. So almost every practice owner that I’ve consulted with who isn’t taking insurance didn’t decide that because they sat down, did the math, ran the numbers like compare the two options, and decided not to take insurance. They usually did it because taking insurance sounded like a little complicated and scary and just wasn’t like an area of expertise. And it sounded like just better, right? I get to charge more. I don’t have insurance on my back. Simpler and straightforward. So what I would love to encourage listeners on today is you really want to sit down and run your own numbers. Right. And we’ll talk through what those numbers are. You want to make a decision that makes sense, because it’s going to take your business in the direction you want it to go. It’s going to earn you what you want to earn. It’s going to support the staff size you have in mind, and it makes sense for your physical location. Melissa Schneider 00:06:06 So that’s kind of my first pitch. I also want to sort of come out as a biased practice owner. I’ve opened both kinds of practices in network, out of network, and I can tell you that unless you are a marketing savant or just in a really special area, that taking insurance is going to allow you to grow a large group practice, whereas remaining out of network or cash pay is usually going to cap your staff size in some ways. And so we can sort of talk through these different options. but maybe just, one argument for why I’m suggesting that you consider in network, we started working with Green Oaks Accounting last year, I think because I heard about them on your podcast show and they recently told us that. Did you guys know you are like one of the top ten revenue producing practices nationwide? And we work with 400 practices and we were like, what? So what we’re doing works. and that’s that’s what we’re here to talk about today. Joe Sanok 00:07:09 Are so awesome. Well, so when you have worked with people or when you’re thinking through it, what are some of the the numbers that people should be running? So if we take off the table insurance is complicated. Joe Sanok 00:07:20 I don’t know how to do it. And people not making the decision based on that, which I love that you challenge that idea because whenever someone makes a decision, because of lack of knowledge, to me that’s a great opportunity for you to either one learn how to do that thing or to have someone smarter than yourself. Just do it for you. and so if you just take that off and say, okay, we’re going to run the numbers, we’re going to use data, which, you know, that’s what we did in the first episode right before this of talking about zip codes and using data. So that’s clearly a theme with how you make decisions. what kind of data points should people be looking at when they’re running the numbers around insurance? Melissa Schneider 00:07:54 Definitely. Okay, so I mean, obviously you need a couple puzzle pieces to make your business plan and look at it. You need to know what insurance pays in your area. that can be harder to figure out than you might imagine. My suggestion is just drum up a decent looking therapist in your area, pay them 300 bucks and just have them sit you down and tell you what they’re earning because you just might not be able to find out. Melissa Schneider 00:08:21 Or it could take a few months of like requesting contracts. And it’s just a lot of legwork. So if someone can tell you, like, look, in our area, it’s somewhere between 110 and 130. This panel pays the best and is the easiest to work with. that’s like information you can get if you pay the right person a couple hundred dollars. Not everyone is thinking about like, locking out all competitors. You know, some people are just happy to help, especially if you find someone in like the circle community or there’s just a layer of trust there for why they might want to help you. But you have to know kind of what’s going on in your state and in your geographic area. You know where in new Jersey the rates are higher in North Jersey than they are kind of down by the shore and the Pennsylvania border, just because like cost of living is different. So it doesn’t help to find someone in a different state. So that’s the first thing. Find out what insurance actually pays. Melissa Schneider 00:09:08 I was flabbergasted when we started learning what insurance pays. I had just grown up in this like, you know, rumor mill in the insurance industry. Like, oh, insurance pays like $50. They’re impossible. They never get back to you. That’s all not true. insurance pays well. They pay within, like, five days. and we get 99% of our expected reimbursement back from them. there are headaches, which we can talk about, but, you know, don’t rule them out. So the first thing is you need to know what they pay. The second thing is you want to do a decent job of guessing how quickly you would gain new clients, with insurance versus without. So this can also be hard. You may need to track down a couple of people, sit down and consult with them, find out kind of how their business works. But I can tell you from opening both kinds of practices in our area that I can fill a commission in 5 or 6 weeks, maybe ten, at the max in our insurance based practice, in an out-of-network practice, I would say, if someone isn’t, like, really great at networking and you’re marketing isn’t, like, top class could take people a year, to build up a caseload. Melissa Schneider 00:10:19 And there’s, like, more turnover. People come to fewer sessions over time. Excuse me? Over time. So you want to, like, sit down and kind of guess, like, okay, let’s say I can feel pretty confident, right, that I’m going to get 15 or 20 new clients a month at the insurance practice. You can just model it out, right? Like if I hire three people, they get 20 clients a month. That means they’re kind of full with, you know, people leaving and biweekly clients and cancellations. Maybe they’re full at 30 or 35, so that means by month to their full. Then we’re just operating, you know, for the next 18 months or so. Hopefully they stay with us. And so you can literally sort of do a decent job of guessing what that in-network therapist would create as far as revenue, what your profit would be. You know, you can kind of think about how you would pay them or who they are. But so those are kind of the numbers you need, right? What are they paying per session? How many sessions could we do in a month? What would we earn in total? What would it cost us to operate? And you know, so it’s kind of like ten things, right? You can factor in some of your expenses, but they’re going to be the same, you know, like your malpractice, your medical record system, that sort of thing. Melissa Schneider 00:11:24 Your insurance is all kind of flat across the two decisions. I would also say that in my experience, unless again, you’re like the best marketing, in your area, I think that an out-of-network or self-pay practice has a natural cap. You know that if there’s 15 or 20 competitors in your city and a population of a certain size. It’s only so many people that have enough, just extra capital, you know, to pay upfront and wait for insurance reimbursement if they have out-of-network benefits or if they have an HSA they can use. a lot of people would prefer to be in network. I think the public is more educated about the availability of in-network therapy. Now. and just to give you kind of a sense, right, at our out-of-network practice, we just launched our second four. So we have eight clinicians total. They maybe do 50 or 60 sessions a week. At this point. I expect they’ll keep growing over the next six months. Maybe they’ll do 150 a week. We do maybe 1500 a week at our in-network business. Melissa Schneider 00:12:27 And it feels like I mean, there’s just there’s probably I think there’s like 700 outreaches every month on psych today at that practice. So the demand feels like a tsunami compared to, like trying hard to land every new client in our Arab network. So I think I would be thinking about all of those things. Right. What’s kind of just the numbers on a spreadsheet? What I earn more or less, you know, going with either one of these decisions. the only kind of additional cost to keep in mind if you’re in network is that you’ll probably need a medical billing service at some point. the good thing is that these are inexpensive services. There’s a thousand of them. and it’s a very structured industry. So if you’re like, I know nothing about medical billing, just set up five consultation calls. They’ll tell you everything about it for free. They want your business. they’re going to be there to help you with it. They’re going to be there to get the credentialing going, get the contracts set you up with things like submit your claims, deal with the issues. Melissa Schneider 00:13:22 and it usually costs somewhere between 2 and 3% of your revenue. you might be able to do it cheaper if you bring someone in-house, too. So if this is an area you don’t know a lot about, like a decent medical billing company is like an easy solution. Joe Sanok 00:13:44 Do you often find yourself overwhelmed by the influx of client calls you receive? Receptionists are expensive, but you can’t afford to let your patients go to voicemail. You care for your clients, so you try to phone them back. But more often than not, it’s too late. They’ve gone to another practice. When you partner with well-received, you capture every opportunity. Your calls are answered by professional medical receptionists 24 over seven, and they can support you with more than just messaging. They offer new patient intake, after hours service, bilingual services, medical appointment scheduling, medical live chat, and so much more. All this at a fraction of the cost of an in-house receptionist. Your patients are well received priority as a practice of the practice listener. Joe Sanok 00:14:33 You can get an exclusive 50% off your first two months of service. Head on over to well received. Com forward slash Joe to start growing your practice today. What are you doing October 1st through third? I want to hang out with you just south of Nashville, Tennessee. Down in Franklin. I’m going to be key noting the Mental Health Marketing Conference, and I would love for you to be there. We are also sponsoring the clinical track, where there are going to be tons of amazing trainings, all for you in private practice. This is the national gathering for marketers and clinicians in mental and behavioral health. You’re not going to want to miss this awesome conference. It’s the one conference on keynotes this year, and you can read more over at MH marketing. Org. Also, Steve over at Mental Health Marketing has given 25% off to any practice of the practice. Listeners that want to come to this, whether you’re coming in person or online, you’re going to want to use promo Code Joe at checkout to get 25% off. Joe Sanok 00:15:30 I would love for you to come in person for my closing keynote on Thursday, October 3rd at the Mental Health Marketing Conference, but if you can come online, that works as well. Can’t wait to hang out with you in Tennessee. Again, that’s MH marketing. Org and use promo code Joe at checkout to hang out with me October 1st through third 2024. Are there other things to think about? You know, so we’ve got some listeners that have, you know, group practices or solo practices that are, say, five clinicians or fewer. and then, you know, I think that as people start to grow above five, you know, getting to like 10 or 20, it starts to scale differently. What should people with smaller practices when it comes to insurance? What should they think about? What should they account for? What kind of learning should they be doing? Versus, you know, just outsourcing right away to billing companies, yet the smaller kind of group practices or solo practices? Let’s start there. Joe Sanok 00:16:23 What should they be thinking about when it comes to insurance? Melissa Schneider 00:16:26 Yeah. So let’s say that, you know, you’re kind of like you said, talking about a practice of maybe five, six. You know, they’re pretty happy with that size. Not trying to be like a mega practice. I think I would be asking myself, do I see a value in having provisionally licensed therapist who might be under supervision? do I see a value in bringing them in teaching and training and having that kind of be my staff base? you can pay them less. You know, they they’re still learning and they can’t open their own practice yet. And at 5 or 6, like one supervisor, it depends on your state laws. But at least in new Jersey, you have a cap of six that you can supervise. I know some states. There’s no cap or the cap might be higher. So I would be thinking about does that model serve me better? You know, my staff costs are lower, my turnover might be higher, my training and initial investment might be higher. Melissa Schneider 00:17:17 Or do I really picture myself having, like, a long term, fairly settled staff of more seasoned professionals who have their full license and for whatever reason, they don’t want to run their own business? then you might be thinking about being out-of-network, but again, you have to think about like if if each person on this team isn’t as good at networking as I am. it might be better for the practice owner to, like, be out of network or private pay, you know, charge more for their services, but take insurance for their group because you can just give people clients a lot more easily. So I would be kind of thinking about like, what is my vision for who I want on the team? You know, where am I? Sort of like heart and skill set lies. Do I love, like teaching and training, or would I rather have a more independent staff that might be able to command, you know, sort of higher fees? and maybe we don’t mind if some of them are part time. Joe Sanok 00:18:12 and then as people start to scale, I know that there’s, I witness a lot of kind of mindset shifts, you know, to get to five clinicians. The owner can wear multiple hats. They can they can be everything to everyone. And then it seems like 5 to 10. That’s really like the break point where you start to feel like you’re losing control of things because you did everything. And maybe it’s time to start outsourcing. Talk about maybe that transition. especially around insurance. when you’re going from, say, five clinicians to 10 to 15 and then really getting into the scaling after that. Melissa Schneider 00:18:47 Definitely. So I think if you want a practice that is 10 or 15, I would really be strongly considering insurance. I just think it would be hard to, it would just be hard to give people full time work unless again, you’re like amazing at marketing. So I would be strongly considering insurance at that point. I agree with you that I think somewhere around eight staff is usually the most that one sort of manager, owner or boss person can effectively manage. Melissa Schneider 00:19:19 You know, you kind of start to lose the reins after that point. So I would certainly be looking at raising up someone else. You know, it could be a combination manager, supervisor. it could be that you have like a, you know, a capable younger person who would be great at like onboarding and training and like, you know, just helping people figure out systems and processes. And maybe you’re just bringing in a supervisor who can like, you know, run groups, sign off on state paperwork, or do individual supervision. sometimes they’re the same person. But I would definitely be thinking, and I would get, administrative support like far before then, you know, as soon as you’re not great at answering the phone eight hours a day, you need someone to help you. And that’s usually almost right away. They could be there five hours a week to start. They could be a virtual assistant or in person. But I think, particularly around the clinical support, you know, kind of having the expectation that you’ll need another manager or team lead or supervisor by the year, seventh or eighth hire. Melissa Schneider 00:20:17 And then probably somewhere when your revenues and claims going out are like, maybe you’re sending out 1500 claims a month or even a thousand when it’s like becoming too much to manage, like calling about denials and that kind of thing. That’s usually when the the cost of a medical billing service is starting to make sense. You know, they usually have kind of a you have to spend X amount. and then it’s like 2 or 3% of your revenue is kind of the upper commitment. And so it kind of grows with you. And it can be worth thinking about that coming in. I feel like we had a medical billing service by the time we had our eighth or ninth higher, I think it was somewhere around there. And these were full time clinicians who were mostly going for like 25 or 30 sessions a week. Joe Sanok 00:21:01 Now for you, what was hard about that transition like as you started to grow, were there mindsets that you had to kind of challenge. or were you just like amazing at it from the beginning? I know the answer there. Joe Sanok 00:21:13 Oh like you’re just like naturally insane at running a business. no. But like, for you, like, what were some of those mindsets that were hard to let go of as you started to scale beyond your own time? Melissa Schneider 00:21:25 Yeah, I think there were so many things. I mean, we did so many things wrong that could be a whole episode in itself. But I think in the beginning I just kind of had this very, like, hopeful perspective on humanity. I didn’t have like sort of a cagey eye on our, you know, interviews or our new hires. I just thought people in this field are going to be decent at it, that kind of thing. and so I think a huge thing we learned over time, and I know we’re going to do a separate episode on this soon, was just like, how to pick the right therapist for our practice. that, that kind of related to so many other challenges you might have as a manager or a boss in your group practice. I also I was like, totally happy to delegate, like random stuff. Melissa Schneider 00:22:08 I think I really like teaching and processes, and I was happy to, like, show the person that have them do it, then like spot check until they were independent on things. So I didn’t have any trouble. Like giving away the admin tasks, you know, to to my office manager. I thought it was actually really great to have someone who was, you know, it’s kind of in the next room. It could help with things. I think other mindsets were just over time, we realized that we need to teach people almost everything. even if you’ve gone to grad school or you’ve done private practice work or you’ve been a therapist somewhere else, you just cannot assume that people know how to do a bio psychosocial, that they know how to write a good treatment plan, that they’re using therapy to treat a condition and, like, move the needle on things. You know, there there was just, all the assumptions about like, oh, people are coming in trained. We kind of just had to dismantle all of that and think, like, what do we need them to know? and so over time, we’ve really evolved kind of that early process so that we have good people in place and we have fewer. Melissa Schneider 00:23:11 So you never escape it entirely, just fewer kind of, you know, staff challenges or needing to let a person go or just sort of major quality breakdowns. so I think, you know, that certainly growing a business of any kind, you should expect new problems all the time. But over time, you know, we slowly solve some of them or get better and better at some of them. Joe Sanok 00:23:33 Oh, it’s so awesome. yeah. And I think that those eyes of kind of systems and all of that, we continue to kind of iterate with say our consulting team to, you know, have good onboarding, but then also, you know, there’s always going to be holes or things that, you know, we want consistency between our consultants and, you know, you just joining the team. I’m sure that as you know, Jen and I and you work together to onboard you that will have kind of those those that lens that you’ve had in your practice. with practice and practice to only improve our side too. Joe Sanok 00:24:04 there’s so much we could cover here, but, tomorrow we’re going to be talking all about how do you find and retain really good quality therapists? and then, you know, talking about how there is turnover and discussing how do you handle that? How do you plan for that, all of that. So I’m really excited for that. I’m going to ask you again, you get to answer this question quite a bit. if every private practitioner in the world were listening right now, what would you want them to know? Melissa Schneider 00:24:28 I think I would want them to know that they may have bought into rumors about taking insurance that are most likely 90% wrong, so that I would really encourage, you know, get a medical billing person, talk to them, you know, find out what insurance pays in your area, get a sense of how hard it is to work with, and make a good business decision. and that’s the kind of thing a consultant could help you with. And the ramifications of making that good call early on in your business are large. Melissa Schneider 00:25:01 and also, like you said, it’s a decision that can be reversed, right? Strategy can be pivoted. But I think it’s worth looking into and ruling out thoughtfully rather than avoiding out of fear. Joe Sanok 00:25:12 So amazing. Well, if you want to work with Melissa, who’s one of the top ten most profitable counseling practices in the United States, according to Green Oak. you’re going to want to apply to work with her over at practice of the practice. Com forward slash apply. She’s our newest consultant here on the team, helping you with growing and scaling your group practices and super data driven, which has been really fun to dig into as well. Melissa. Thank you so much for being on the practice of the practice podcast today. Melissa Schneider 00:25:41 Thank you Joe. Joe Sanok 00:25:50 Well, I’m not sure what you are doing in early October, but I would love to hang out with you down at the Mental Health Marketing Conference. We are going to be down there, hanging out on October 1st through third down in Franklin, Tennessee, just south of Nashville. Joe Sanok 00:26:06 it’s going to be awesome. I’m doing the closing keynote on Thursday. We’re also sponsoring, the clinician track, throughout the week, just to help practices grow. that doesn’t mean that we’re doing all of the, presentation for that track. we are just sponsoring that track and giving back to the community in that way. I’ll be talking about Thursday’s The New Friday. I’ll be talking about living a life that matters, thinking through things in a just a different way on Thursday. So if that sounds good to you, let’s hang out. down in Tennessee. you can head on over to MH marketing. Org. You can get 25% off. Steve, who’s running the conference, gave us this promo code, Joe, to give you 25% off of your ticket. So make sure you come hang out. There’s also if you want to stream it, you can also stream it. So sign up for the streaming one if you don’t have the ability to come hang out in person. Again, that’s MH marketing.org. And, you know, I really wish that I had had the option to have a company answering my phones. Joe Sanok 00:27:03 I had someone that answered the phones, but mostly it was like, you know, they might be on a call. They might miss it. but to have a company that does it, Melissa was talking yesterday about how few people even return calls. Like about 50% of practices don’t even like return calls. And then those that are remaining, about a third or so don’t even have some to answer live. It’s going to help you convert differently. And when you partner with well-received, you capture every single one of those opportunities. Your calls are answered by a professional medical receptionist 24 over seven. What’s great is you pay by the minute for the month. Instead of just having someone just sit there and you can get 50% off your first three months. Head on over to well received.com/joe. Again, that’s well received.com/joe to start growing your practice today. Thank you so much for letting me into your ears and into your brain. Have a great day. I’ll talk to you soon. Special thanks to the band Silences Sexy for that intro music. Joe Sanok 00:27:57 And this podcast is designed to provide accurate and authoritative information in regard to the subject matter covered. It is given with the understanding that neither the host, the producers, the publishers or guests are rendering legal, accounting, clinical or other professional information. If you want a professional, you should find one.