The Business Side of Counseling:

A Brief Introduction

John P. Duggan,M.A., NCC, LPC, LCPC(S)

Manager, Professional Development

2015 ILT

•The basis of the counseling relationship is foundational to our education and clinical training.

•Upon entering the private practice setting, many of struggle with how to establish and manage a business.

OVERVIEW

•Explore the ins and outs of running a private practice

•How counselors can earn an income

•Briefly examine opportunities and challenges

OVERVIEW

•Assist counselors •Starting or •Revitalizing a practice

•Educators and mentors•Build your foundation•Pay it forward

OVERVIEW

INTRODUCTIONS

• Who are you?• What’s your practice setting?• What do you seek?

• Identify answer one question or concern for today.

• Evaluate the businessDiscuss Revenue (insurance, fee)Introduce compliance issuesExamine clinical applications

GOALS

• Part-time: 6-10 clients/weekFull-time: 10-20+ clients/week

Fee-for-Service / Cash BasedThird Party ReimbursementHybrid (Multiple Revenue Streams: cash, insurance, teaching, consulting, etc.)

PRESUPPOSITIONS

• “Your ability to make a living (revenue / income) is not based on the work you complete; rather, your income will be based on your ability of your business to collect — and KEEP — payment from a client or third-party payer for all of the legitimate services rendered.”

PRESUPPOSITIONS

• Keep Payment?Ideal and real practice“Medical Necessity”DocumentationCodingContractsAudits & DemandsAutomatically Retain Funds

PRESUPPOSITIONS

PRESUPPOSITIONS

…is based on the ability of your business

to collect — and KEEP — payment.

SUGGESTIONS

• Start by (re)building with a solid business and compliance foundation

• Resist clinical specializations until referral and revenue streams are flowing

• Build relationships that generate referrals

SUGGESTIONS

• Remember: unless you’re fabulously wealthy or working in a full time job…

• It’s your goal and responsibility as a business owner to successfully and consistently pay yourself a living wage!

REMINDERS

• Most counselors in private practice pay self-employment taxes, mortgage, retirement, health insurance premiums, etc. on this income!

• Overhead, self employment taxes, professional fees, memberships, EHR, secure email, portal, billing assistant come from your salary!

REMINDERS

• Research the basics• Business Regulations : federal,

state, local, zoning, etc.• Professional requirements:

licensing, training education, professional development

PLANNING

• Financial standards & income• Marketing:

• Outreach “gets you noticed” • Relationships:

• Networking• Mutual support with referral

sources

PLANNING

• Billing standards:• Compliant, regular, monitoring,

prevent errors • Support:

• People, workflow, tool & resources, associations, training

PLANNING

BUSINESS PLANNING

• Assistance and Training• Relationships: Support team• Write Business Plan• Location: easy, safe, lighting,

security, ADA, weather, door locks and office access, sound, etc.)

BUSINESS PLANNING

• Finance and Accounting: banking, budget, QB Online, no PHI when working with accountants

• Legal Structure: incorp, registration, etc.

• Register: with State, County, City / Local Permits, etc.

BUSINESS PLANNING

• TIN: don’t used your SSN• Receipts, Contracts (W9’s),

Sublet (MISC-1099)• State & Local Taxes: Check, register• Business Licenses & Permits:

• Code Requirements

BUSINESS PLANNING

• Employer vs Independent Contractor: • Responsibilities, BAA’s, Time off

for staff, Tax Structure• Insurance: Malpractice, General,

Cyber• Other: NPI, CAQH, Exclusions (

exclusions.oig.hss.gov)

BUSINESS PLANNING

• Resources: software, files, computer, EHR, internet, etc.

• Monitor work: you are responsible for the mistakes made by others

• Stark Law and State Regs: referrals, kick-backs, fee-splitting, etc.

BUSINESS PLANNING

• Anti-Trust: don’t discuss fees/contracts

• Focus: client care and privacy, quality services, systematic, organized

• Financial Regs: • Credit cards, receipts, PCI

Compliance, Red Flag, PHI, reconcile

BUSINESS PLANNING

FIRST THINGS FIRST

• Manual: Create Daily Policies and Procedures Manual

• HIPAA / HITECH: Complete & Document Annual Training

• Staff meetings & trainings: hold regular sessions for staff and BA’s

OTHER TASKS

• Minimize risk• Maximize efficiencies• Routinely visit website for

licensure board• Changing locations: update with

state, licensure board, ADD new locations

OTHER TASKS

REQUESTTreatment

FINANCIALResponsibility

REGISTERTREAT /

DOCUMENT

PAYMENT / CLAIM

InstaCode. (2015). 2015 Behavioral Health Multibook (1 ed.). Spanish Fork, UT: Insta Code Institute, p, 3B.

REVENUE CYCLE

• Employee Assistance (EAP)• Health Maintenance Organization

(HMO)• Preferred Provider Organization

(PPO)• Exclusive Provider Organization

(EPO)• Point-of-Service (POS)

THIRD PARTY PAYERS

• Military and Veterans • TriCare, Civilian, VA/DoD, • Dept. of State, etc.

• Federal Employee Health Benefits• COBRA• Workers’ Compensation• Medicaid [carveout]

THIRD PARTY PAYERS

• Advantages• Marketing handled for you• Quality Assurance• Fall-back in the event of crisis

THIRD PARTY PAYERS

• Disadvantages• Potential costs associated• Lower fees without ability to

“balance bill”• Paperwork

THIRD PARTY PAYERS

• ONE Standard fee schedule• Refrain from term “sliding”• Contractual Obligations• TOS/Prompt Payment• Financial Hardship - document• Price Fixing ILLEGAL• State Laws?

SETTING FEES

COMPLIANCE

WRITTEN PLAN

• PPACA Health Exchange Plans: Check benefits every 30-days if policy is <90-days old!

• Check state of origin of Insurance Plan: determine “who” regulates the plan• Federal (ERISA, COBRA, etc.)• In-State or Out-of-State

COMMON ISSUES

• Federal plans: exempt from state insurance commission laws

• Call insurance: before first visit! • Verify: Active coverage and

commonly CPT Codes

COMMON ISSUES

• State Laws: for may impact cash-only practices, too!

• Referral Rationale: consider always asking for referral from physician

• Document: “medical necessity”• Fees: Missed and “no shows”

COMMON ISSUES

• Complex Payment Models: Value and outcome based

• More Eligibility Checks: to verify active coverage required (Demands for Money)

• Data Crunching: claim history monitored, dx codes used, duration of tx, etc.

COMMON ISSUES

1) ICD-10-CM: • Only Federally approved codes (HIPAA)• No criteria to determine a diagnosis• “electronic” and “billing” using

2) CMS on DMS-5: • It’s still needed to determine an

accurate diagnosis• “diagnostic decision”

OCTOBER 1, 2015

BUSINESS & CLINICAL

• Interval Hx• Progress (DOS)• Signs and Symptoms (re: dx)• Medical, Pain, Mobility?• Ratings and Outcome Measures• Behavior

PROGRESS NOTE

• Rx Issues: (Adherence, Side Effects, ADR’s)

• MSE: (AIMS, Weight / BMI)• Dx: Required, signs/symptoms• Hx: Medical, Social, Family• Therapy Content: (Protected)• Techniques: Outline in note

PROGRESS NOTE

• Recommendations• Plan• Justification of Care• Risk (SI, HI, NSSI)• DOS: (Start, Stop, Duration, CPT)• Follow-up/Plan: Next Appt.• Signature: valid signature

PROGRESS NOTE

• Name one item you’ve learned or question raised

• How can you take this insight or question and apply it to your work• Private practice• Education• Constituencies

PRAXIS

• Now that I know ________.• I choose to _____________.• And this means _________.

• What’s your “take away” from today?

PRAXIS

• Now that I know that a TIN is needed on statements and will protect my privacy,

• I choose to contact the IRS and get a TIN for my business,

• And this means I will offer clients valid receipts and protect my privacy.

PRAXIS

SUPPORT

SUPPORT