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Breaking away from an agency setting to fly solo is
an appealing idea to many professional counselors who yearn to provide direct
service to their clients and gain control over his or her professional
development. But opening a private practice takes more than just hanging a
shingle and furnishing an office with a cozy couch and Kleenex. A conscientious
therapist may be a bit overwhelmed to find that the tasks they face include
myriad business-related details that cannot be ignored. Starting and managing a
private practice requires discipline, commitment and a quality that few
practitioners learn in their counseling training and even fewer believe blends
ethically with psychotherapy business savvy.
But, many counselors simply
roll up their sleeves and get down to business. Joyce Breasure, past president
of the American Counseling Association and a nationally certified counselor, has
managed her own private practice in Delaware for over 20 years. "In the past 20
years private practice has become a major work environment for professional
counselors,'says Breasure, who cites the following study as proof.
In
1985, the American Counseling Association conducted a survey of its members from
1982 to 1984 to determine the number of counselors entering private practice.
Within those two years, the number of counselors entering private practice
increased 68 percent.
In 1983, of the 30,731 members who reported their
primary work setting, 2, 629 were in private practice. In June 1997, of 30,760
members who reported their primary work setting, 9,684 professional counselors
were in private practice. In 14 years, the number of counselors in private
practice had increased by about 27 percent.
What are some pros and cons
of owning a private practice? Breasure notes the following:
Pros
Counselors control:
- The policies and procedures of how services are
delivered.
- Their own professional development.
- Clinical decisions regarding treatment techniques.
Counselors gain:
- The opportunity to earn a higher income with fewer
restrictions.
- Tax deductions on equipment, books and
materials.
- Immediate acquisition of supplies without
requisitions.
Cons
Counselors are responsible
for:
- All problems and errors.
- Collecting fees.
- Maintaining self-discipline required to start and
maintain the business.
- Generating income (no paid sick leave or vacation
time).
- Cleaning and maintaining the office.
- Advertising.
- Bookkeeping.
The business of counseling
The ability to blend business with counseling is a
skill that must be learned to reap the benefits of a solo practice. "Your first
task is to know the laws and regulations of the area in which you plan to set up
your practice,'says Breasure. "Professional counselors in 44 states and the
District of Columbia are regulated, either through licensure or
certification.'Because of this recognition of the profession by regulatory
bodies, the number of practitioners in private practice will likely continue to
rise,'says Breasure.
Insurance matters
The counseling field is a litigious community and
private practitioners may operate in what may be viewed as high-risk situations.
Breasure, who began teaching ethics 25 years ago, encourages counselors and
therapists to purchase as much malpractice insurance coverage as they can
afford. The cost of coverage is approximately $200 to $600 for $2 million to $4
million.
"Twenty-five years ago there had to be a huge breach of ethics
for a client to sue,'she says." Today, an unhappy client will sue if they didn't
like what you suggested or the changes that took place after they followed your
advice.'
While some therapists chose to "keep it simple," forego insurance
and operate on an out-of-pocket method of payment, others set up computer
systems to record and track Medicare and managed care billing. To become a
Medicare provider, the practitioner can request an application from the Medicare
carrier in his or her area.
Managed care
To become a managed-care provider, practitioners
would contact a managed- care company that they would like to work with and
request an application. Many therapists are opposed to the system and have
abandoned it entirely. "There is every good reason in the world to be opposed to
managed care,'says John Klein, an editor of "Psychotherapy Finances,'a
newsletter for behavioral health providers published by Ridgewood Financial
Institute, Inc., Juno Beach, Fla. "Therapists naturally don't like rationed
care. They believe in the service they are providing and they believe, as I do,
that there should be more behavioral healthcare not less.'"The nature of managed
care,'Klein explains, "is to deliver as few sessions as possible to cut
costs.'Other reasons that therapists are at odds with managed care is that the
amount of paperwork is burdensome and therapists need to justify every third
session to a case manager. "A lot of practitioners make some of their own
trouble with managed care. They spend so much time fighting it that they don't
learn the system, and they don't learn how to make the best of a bad situation
-- they make their own bad situations worse.'
But the therapist who is
able to establish a solid relationship with a managed- care payor can develop a
steady stream of patients and income. Skills that therapists working with case
managers in managed care may need to build are: negotiating skills when
requesting more time or sessions for a client; and how to work more briefly than
they've been trained to perhaps within 6-10 sessions instead of 16-18.
"While the economy is strong, many clients will continue to pay for
therapy, but a recession would change that and therapists would have to depend
on some third-party payors.'Klein suggests that practitioners not completely
disconnect themselves from managed care, but instead supplement their
managed-care income with private pay income.
"Managed care is where a
tremendous amount of behavioral healthcare is going to take place so you can't
be divorced from that system entirely, but at the same time you don't want to
depend on it entirely,'says Klein. "If you find that 70-80 percent of your
practice income derives from managed care you are in a downspiral in terms of
income, because rates are going down and, so far, there is no bottom in sight.
So, if most of your practice is managed care, you can almost guarantee that you
are going to make less money next year than you did this
year.'
Elizabeth, "Betsy,'Chadwick, MDiv, MSW, ACSW, does not spend
energy
promoting herself as a managed-care provider. "I feel strongly that
working under that umbrella sabotages my energy, enthusiasm and excitement,'says
Chadwick, a certified Imago Relationship Therapist and Reiki II Practitioner.
"I have worked under some managed-care companies happily and I've worked
under others miserably. It depends on the company and the plan the person has in
the company.'Chadwick says that managed care doesn't allow her the freedom or
time to conduct therapy in the manner in which she would like. She also sees a
limit to the degree of confidentiality that she can assure clients that use
managed care, and cautions them beforehand. "With a managed-care company the
person at the 800 number is going to be in the clinical sessions,'she says.
"That means that I, the therapist, cannot promise the client confidentiality.
And I can't promise clients that I'll be able to do therapy the way I would
prefer to do it, because I may be told what to do by the managed-care
company.'
Karen Peterson, PhD, prefers serving private-pay clients. By
foregoing insurance and maintaining handwritten records, she eliminates onerous
paperwork, and doesn't need to keep an elaborate computer program to track
sessions, or churn out treatment reports at set times.
"I don't like
contracting with insurance companies or any third-party payors for that matter,
because by definition, it can create a risk in the therapeutic
alliance.'Peterson says that clients get distressed if their insurance company
defaults. "It's not my responsibility whether the insurance company pays
me,'says Peterson. "The client needs to pay me first and then get reimbursed by
their insurance company.'"I personally am not on any insurance plans and I do
not intend to be and I used to be on a lot of them.'
The author of The
Tomorrow Trap: Unlocking the Secrets of the Procras-
tination-Protection
Syndrome, Peterson says that therapists who create a specialty niche for
themselves can attract a substantial amount of clients who will be willing to
pay out of pocket for the therapist's realm of expertise. "I am a maverick,'says
Peterson. "I am very different from many therapists in private practice in that
I have a specialty in the procrastination/writer's block area. So, I strongly
recommend that therapists develop a specialty, because that enables them to
stand out from the crowd a little bit. Clients will come to them and forego
their insurance if they feel that the therapist's services are what they
need.'Peterson encourages newcomers to private practice to create their own
niche. While the caseload may be less, the therapist will be less prone to
burnout, able to maintain a higher standard of service and will be paid out of
pocket.
"Managed care fees are often 50 percent or less of what the
customary fee would be in that area,'explains Peterson. "You can become
inundated with clients, you may not have enough time for them and you're not
getting paid sufficiently to feel comfortable turning away even
moreclients.'
Fees
Fees for counseling services vary according to
location. A practitioner starting a private practice should research and compare
his or her services to other mental-health professionals in the area to
determine a fair and reasonable fee.
Sliding-scale fees are attractive to
clients without insurance or whose insurance does not cover mental health
because they can receive treatment within their financial structure.
"Determining the average co-pay fee in the area is a good base from which to set
a sliding scale fee,'offers Breasure.
But setting fees can sometimes be
easier than collecting them, admits Breasure. "Someone who received help may
have to be turned over to a collection agency and for some counselors this goes
against the helping process,'she says.
Therapist, promote
thyself!
According to Chadwick, a practitioner in the
psychotherapy field for 20 years and creator of two different private practices,
the biggest obstacle for therapists and the most important part of marketing is
how the therapist views self-promotion.
Most therapists, she reveals,
perceive marketing as a foreign entity that is something that they have to learn
to do, and believe marketing has nothing to do with their current profession.
"Let's define marketing as any activity and attitude that furthers your
business,'says Chadwick. "If you define marketing that way, obviously the most
important place to start is the premise of what it means to market
yourself.'
Chadwick advises therapists to learn to know and say out loud,
without
arrogance or aggression, that the service they offer is good.
"Successful marketing requires a fundamental attitude; a place inside of
yourself where you know that you are really worth being known. It's an attitude
of self-worth an attitude of confidence and abundance,'says Chadwick. "If you
don't have that confidence it doesn't matter how many techniques you
learn.'
Many therapists, get into therapy because of dysfunctional family
backgrounds and a sensitivity to the importance of therapy. "It is hard for us
to claim our value, so the marketing motivation has to be 'I know I'm good and
I'm going to plant marketing seeds of what I have to offer in all different
forms and everywhere I can. I'm going to tell everybody what I'm doing and how
great I am and the perfect clients are going to come to me.''
The
marketing strategies Chadwick suggests are the ones that cost the least, and are
simple and useable in multiple situations, such as an ad in the Yellow Pages.
Here's how to do it:
- Adjust the cost to fit your budget
- Write a few lines of pertinent copy free of jargon
in a small box to inform readers of evening and/or Saturday hours, and the mode
of the counseling: individual, couples, families, groups.
- Clients seeking a therapist are usually in
distress. Offer a free phone consultation.
Highlight your name in
red.
- A business ad beginning with the letter "A'is one
of the first they will see a letter toward the end of the alphabet is one of the
last. Aim for one or the other placement.
A business name instead of your own name gives the
reader information about the nature of the business. (Chadwick's business name
is LifeWorks, a tag that offers a philosophy and hope.)
Plant seeds
- Volunteer time to conduct a free support group one
night a month.
- Market the things you love to do.
- Use 1,000 business cards every six months. Pass to:
grocery store clerks (ask them to pass them on), taxi drivers, servers, store
bulletin boards.
- Use photo flyers.
- Use note cards with your business name. At every
opportunity send handwritten notes of appreciation to everybody.
- Join your Chamber of Commerce and become
known.
- Create a Web site on the Internet and link it to
other sources.
- Give the first counseling session for free unless
the client decides to continue, at which point the first hour becomes
billable.
- Offer some community workshops and seminars for
free.
Write magazine articles, a newspaper column or a
book.
Software:
Many therapists choose computer software to control
their paperwork. Lots of helpful programs abound with various applications. Take
a look: The Paper Office, by Edward L. Zuckerman, Guilford Press, $55. Clinical
Documen-tation Sourcebook, by Donald E, Wiger, John Wiley Sons, Inc., provides
sample forms for every stage of the treatment process in book form and on
computer disk. It is one in a series of about 20 Practice Planners with topics
related to mental health. A total office management solution for groups and solo
practices is Therapist Helper, available through www.TherapyShop.com.
Bluewater Management Systems, features Bluewater Management Counseling
and addiction support environment. BMCASE has outcome assessment software that
tracks existing patients and provides data in graphic form. Capabilities include
the ability to develop and refine clinical treatment approaches or counseling
strategies. The company provides management consulting and software solutions in
all areas of industry and healthcare. More information may be obtained at
www.surf.-to/blueh2ms.
Klein advises therapists to consider the
following three points when shopping for software:
1. Don't buy the
cheap ones.
2. Find time-tested programs.
3. Find a program
capable of processing electronic claims.
Software can help therapists
keep track of money that they cannot keep track of in their head, and manipulate
data more easily than if it were on paper and in files. This is particularly
helpful when organizing managed-care records, which can get complicated, when
assessing how many sessions have been approved, how many have accrued, and the
amount of fees to collect.
Horror stories abound about clinicians who
continue to see patients beyond their session allotment. "That's a decision you
can make on your own,'says Klein, "if you want to do some pro bono work or you
want to discount your fees for those patients who need it.'
However, Klein
explains, "if the company has approved six sessions, and the therapist has seen
the client 12, the therapist will not be paid. To make matters worse, there are
no hard and fast rules to memorize the number of sessions each company provides
for.'
Therapists have to know what their companies specify and it may vary
even within a company. Keeping track of the variables is imperative to being
organized and running a smooth business.
"I've spoken to clinicians who
literally went out of business, because even though they were busy all day, they
weren't keeping track of their own money. They were working for free and they
didn't even know it,'says Klein. "They had to work for somebody else, because
they didn't want to take on the tasks; they didn't want to be a business person.
Clinicians, if they are going to stay in private practice, even if it takes a
few hours a day, have to be businesspeople, not just therapists.'
Jan
Marie Werblin is associate editor
of Professional Counselor
magazine.
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