Businesses Fail For A Reason! Uhoh! Private Practice! BUT You give up.. guaranteed paycheck! guaranteed benefits! guaranteed time off!

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1 Making the Transition into Private Practice Denise Dougherty MA, CCC-SLP Disclosures Financial Disclosure South Carolina Speech-Language-Hearing Association Non-financial Disclosure Past President -American Academy of Private Practice in Speech Pathology and Audiology (AAPPSPA) Veteran s Press Editorial Advisory Board Small Business Administration Statistics! 2/3 of new businesses survive 2 years! Only 44% are in business at least 4 years! 50/50 chance you ll be in business 5 yrs! (4) Business owners didn t do their homework! Without a plan, easy to fail Uhoh! Businesses Fail For A Reason! Started for wrong reason! Didn t think business plan was important Forgot HOW IMPORTANT CAPITAL &CASH RESERVE is to health of new business (5) Ineffective/nonexistent marketing Undesirable location Poorly managed and/or little internal control Expanded TOO Quickly! Didn t change my business practice when things clearly weren t working! (5) Allows Independence Flexibility Specialization Private Practice! BUT You give up.. guaranteed paycheck! guaranteed benefits! guaranteed time off! 1

2 Am I prepared to spend time, money, resources to start business? What services? Whyam I starting a business? What is my target market? From 20 Questions from SBA: Good Preparation for Business Plan! Who is my competition? What is uniqueabout my business? How soon will I be ready? How much money required to set up? How long can I finance company till I make a profit? Will I need a loan? How will I price my services compared to competition? How will I market my business? How will I set up legal structure of the business? Do not skip LEGAL consult From 20 Questions from SBA: Good Preparation for Business Plan! How will I manage business Where will I locate my business? How many employees to start up? What types of supplies do I need? What insurance do I need? What do I need to do to ensure paying taxes correctly? Do not skip CPAconsult Build Your Practice Carefully! Don t Forget the Steps! Develop a Plan Research and Consult Implement Plan Business Matters: A Guide for SLP s ( ASHA) Guide to Successful Private Practice in SLP ( ASHA) Health Plan Coding and Claims Guide (ASHA) Negotiating Health Care Contracts and Calculating Fees (ASHA) Getting your services covered: A guide for working with Insurance and Managed Care Plans (ASHA) The World of Corporate Speech Pathology (Katie Schwartz) Building Your Ideal Private Practice (Lynn Grodzki) Research! AAPPSPA : American Academy of Private Practice in Speech Pathology and Audiology ASHA website CORSPAN : Corporate Speech Pathology Network Chamber of Commerce Small Business Administration Office of Women s Business Ownership Bureau of Labor and Industries IRS Denise Dougherty, MA, CCC-SLP, MFT 11 Who Can Help Me Put The Pieces Together? Find a Mentor SCORE Service Corp of Retired Executives Chamber of Commerce Classes Business and Professional Women s Association Small Business Development Centers Women s Business Centers Minority Business Development Centers Denise Dougherty, MA, CCC-SLP, MFT 12 2

3 Resources for Business Plan Development SBA The Business Plan Road Map to Success (6) Basic Questions What service does my business provide and what need does it fill? Who are my potential customers and why should they come to me for this service? How will I reach my potential customers? Where am I going to find the financial resources I need to start up my business? (6) Give yourself adequate planning time Full time business? Part time business? Business Plan development Local colleges Chamber of Commerce Small Business Association (SBA) Service Corp of Retired Executives (SCORE) Women-Owned Businesses Office state government Time Frame Denise Dougherty, MA, CCC-SLP, MFT 13 Denise Dougherty, MA, CCC-SLP, MFT 14 Yikes! Where to Start?? Business Line of credit? structure Benefits Business Consultants Staff? Advertising Fulltime? Part time? Contracts Expenses Cash? Insurance? Business plan? Supplies Office Lawyer CPA Denise Dougherty, MA, CCC-SLP, MFT 16 Be Prepared For Con$ultation! Business consultation might be free! Local university Small Business Incubator Chamber of Commerce SCORE Lawyer and CPA charge by the hour BE PREPARED! Have basic knowledge and prepared questions prior to appointments! Get recommendations from others - who to use! Not the place to save money! Avoid financial and business mistakes Helpful to have business plan in place prior to consult What is your vision? Lawyer Business name? siness-name/dba.html Fictitious name filings in 50 states Does business name need approval of state licensing board? Investigate state rules/regulations Determine best business structure May vary from state to state Solo practitioner/proprietor? Limited Liability Corporation S Corp vs. C Corp Denise Dougherty, MA, CCC-SLP, MFT 17 Denise Dougherty, MA, CCC-SLP, MFT 18 3

4 Lawyer Review contracts you develop/receive WHO CAN BE YOUR PARTNER!!!!!!! Partnership agreements Prepare for the DIVORCE! Contract agreements w staff or independent contractors Business Structures (2) S Corp Corporate entity no separate corporate tax Separates business assets from owner s assets Income taxed at owner s personal rate LLC Provides limited personal liability for business debts Owners pay taxes on their share C Corp Corporate entity with separate corporate tax Corporation taxed on income Owners taxed on personal income Protects owners assets Solo dba doing business as Report all business income on personal tax return Personally liable for all business debt Personal assets exposed in malpractice Denise Dougherty, MA, CCC-SLP, MFT 20 Tax ID or EIN # -Employer Identification Number /Federal Tax ID Number Must know your business structure Accounting methods usually cash basis for small businesses Develop Chart of Accounts/Set up books Determine relationship Who does what! Monthly Bookkeeping? vs. Taxes vs. Statements? Less they do, costs reduced! Establish system to track expenses for taxes! CPA What do you want! Full time? Need a nest egg! Get organized! Get a head start! Start date? Part time? Smaller nest egg necessary Easier to begin Devise a Plan! BIG? Small? Denise Dougherty, MA, CCC-SLP, MFT 21 Denise Dougherty, MA, CCC-SLP, MFT 22 Full time: Requires lots of planning Financial resources Part time: Hard to juggle full time job plus part time! Can take time with growth Business income not NECESSARY to pay your daily living expenses! Vision Important! If I GROW the business: HOWare my management skills Do I want employees or independent contractors? Can I afford to take on additional staff benefits, work load etc.? Do I want to work this hard to keep others employed? Bank Accounts WORK on your credit score AND SAVING $$$ BEFORE you open your doors!!!! Keep personal and business funds separate! Open a DBA checking account Apply for credit card in business name Rewards programs! Establish Line of Credit!!! Banks reluctant without business plan! Link line of credit to checking account to avoid overdrafts FOR EMERGENCIES ONLY! Denise Dougherty, MA, CCC-SLP, MFT 23 Denise Dougherty, MA, CCC-SLP, MFT 24 4

5 Insurance Malpractice Most contracts require this information up front May dictate amount of coverage you carry Discounts for ACE awards? Each contract you service may need included on policy Policy cost increases for each contract you must list Liability/Renters insurance Cover accidents on property Cover your property/equipment Denise Dougherty, MA, CCC-SLP, MFT 25 Don t FORGET Clearances! Most schools, contracts want clearances! Child abuse Criminal record Fingerprints may be required! CPR certification! ALL of these take time and may put your contract on hold until documentation is provided! Denise Dougherty, MA, CCC-SLP, MFT 26 Where do I find clients?!?!?!?!?!? What are your interests? Preschool? Early intervention contracts Day care facilities/head Start School age? Contracts with school districts Charter Schools? Geriatric population? Home Health? Medicare? Nursing Home contracts prn coverage? Weekends/holidays!! Denise Dougherty, MA, CCC-SLP, MFT 28 Particular specialty to market? Autism spectrum Swallowing Literacy Auditory processing etc What area isn t being served? Check competition! Pediatrics? Social Skill Groups? Adults? Accent Reduction? Corporate Speech Pathology? Denise Dougherty, MA, CCC-SLP, MFT 29 SWOT strengths, weaknesses, opportunities & threats (13) Internal - organization External - environment Strengths Your org. advantages - SMALL What do you do BETTER - EXPERTISE What do people in your market see as your strengths? EXPERTISE Weaknesses What can you improve? What should you avoid? What factors lose you clients? SIZE small Waiting list Opportunities Good ones? Trends you are aware of? telepractice Changes in field? Do your strengths open up opportunities? Threats Obstacles you face? Possible reduction in reimbursements What are your competitors doing? Changing technology? BAD DEBT or CASH FLOW PROBLEMS? Do your weaknesses threaten your business? 5

6 Programs Interactive Metronome? Floortime? Fast Forword? VitalStim? Lee Silverman? PROMPT? Lexercise? Orofacial myology? Any other specialized program What Can YOU Offer? Denise Dougherty, MA, CCC-SLP, MFT 31 Hours/Location Evening/Weekend Hrs.? Consistent SLP? Services in Clients Home?** Telepractice? Professional Issues in Telepractice/Telespeech for SLP s Ad Hoc Committee Knowledge and Skills for Speech-Language Pathologists Delivering Services Via Telepractice ASHA 2005 Must be licensed in client s state Reimbursement issues What Can YOU Offer? Factor Me Strength Weakness Co. A Co. B Customer Products STIM, etc. (1-5) Price INS. CASH Quality ACE AWARD Selection SOLO SLP Hours Day/Nite Wkends Reliability reliable Stability yrs. in practice Expertise peds adults Reputation good Location Appearance Advertising quiet area parking clean yellow pages internet Marketing Necessities Website development Letterhead, Business Cards, Brochures ASHA, Office Supply stores, Online vendors Give aways! Online suppliers of pens, notepads, sticky notes etc. Check vo-tech schools possible projects for credit to assist developing businesses Web site development Brochure layout Design letterhead/cards Denise Dougherty, MA, CCC-SLP, MFT 34 Develop list of potential clients/referral sources Join organizations Chamber of Commerce Business and Professional Women s Association Quota Club Make contact with businesses you ve identified as possible referral sources Drop off brochures, business cards, personalized giveaways Repeat marketing is better than one visit only! BE PREPARED TO WAIT! Marketing efforts take time before they pay off! Adverti$ing Cost vs. return? Expen$$$$$ive!!! Newspaper? Yellow pages? Website? Radio? TV? Local Cable? Electronic Billboards Brochures? Information packet? Press Release? Business News section of newspaper FREE!!!!! SLP OPEN FOR BUSINESS!!!! Denise Dougherty, MA, CCC-SLP, MFT 35 Denise Dougherty, MA, CCC-SLP, MFT 36 6

7 Office? Work at Home? Check deed restrictions!!! Therapy vs. paperwork! Rent Space? Room in professional office? Small office space? Handicap access? Parking? Be realistic about square footage! Need nest egg for slow months Share/Rent Office Space with another Professional? Who is in charge of common areas? Good reputation? Share office staff? Room for your own? Separate phone/fax lines? Share other office equipment copier? How will growth of your practice be handled? Denise Dougherty, MA, CCC-SLP, MFT 37 Denise Dougherty, MA, CCC-SLP, MFT 38 No Office? NO PROBLEM! Early Intervention Charter Schools School Contracts Home Health Nursing Home PRN coverage Shopping for Office Equipment Stay basic! Fax/copier/scanner Fax via computer vs. land line Computer/printer Phone cell vs. land line VOIP? Vonage? Locking file cabinet Table/desk What is bare minimum to get Started? supplies tests etc. Denise Dougherty, MA, CCC-SLP, MFT 39 Denise Dougherty, MA, CCC-SLP, MFT 40 Ca$h or In$urance!?!?!?! Local economy may make decision for you! Insurance Provider?!?!? Applications require much documentation! Up to 120 days for approval Ability to check client benefits online CAQH Council for Affordable Quality Health Care Credentialing application database 500+ health plans/providers upd.caqh.org Must attest every 120 days Electronic billing Electronic funds transfer Be prepared to spend time on phone w insurance Need NPI number (National Provider Identifier) Denise Dougherty, MA, CCC-SLP, MFT 41 Ca$h!?!?!?! EASY! Can clients AFFORDto pay you! ASHA Superbill! Clients will need codes provided for reimbursement COLLECT AT TIME OF SERVICE!!!!! Credit cards? Debit cards? Fee associated with their use -% charged to business Pay for equipment even if not used! Convenient but costly SQUARE free app and phone attachment to scan cards -% charged to business Pay in Advance? Barter IRS treats as income received Headliner Volume 281 Nov. 30, 09 Denise Dougherty, MA, CCC-SLP, MFT 42 7

8 Medicare Provider? Review guidelines/forms on ASHA website may determine it s NOT for you! Solo provider application Group practices application Electronic transfer form Agreement to accept payment amount NPI number (National Provider Identifier) Coding References ICD9 ICD10 Client waiver may decide anytimewithin 1 year to use Medicare benefits for therapy completed MUSTsubmit to Medicare and become provider Coding Resources reimbursement/ Health Plan Coding and Claims Guide New ASHA Book 2014 Coding and Billing for Audiology and Speech-Language Pathology Denise Dougherty, MA, CCC-SLP, MFT 43 Denise Dougherty, MA, CCC-SLP, MFT 44 Solo Practice? Tag You re IT!!!! You keep the $$$$! Caseload limitations Employees Or Independent Contractors? BE CAREFUL! Consult with lawyer may not meet test Office assistant? checks & balances for handling $$! Billing? Bookkeeper? Other Disciplines PT, OT, ABA, Tutors, etc Check with lawyer -any restrictions on services you can offer? Payroll Services? Cleaning? Staff??? Denise Dougherty, MA, CCC-SLP, MFT 46 Independent Contractor Employee Paid on completed job basis No employee benefits Provides own tools Operates under own name Pays own taxes Received 1099 Can hire, supervise, pay assistants In business for himself Business cards? Works for more than one company? Examples of Tests! (1) not complete list of questions in test! Paid on time basis (per week) Employee benefits Provides worker w tools needed Operates under firm s name Employer withholds taxes Receives W-2 Cannot hire, supervise or pay assistants Method/result of services controlled by employer Denise Dougherty, MA, CCC-SLP, MFT 47 Common Law Rules Behavioral does company control or have the right to control what the worker does and how the worker does his job? Financial are business aspects of worker s job controlled by the payer including how worker is paid, expenses reimbursed, who provides tools/supplies Type of Relationship are there written contracts or employee type benefits such as pension plan, insurance, vacation pay FORM SS-8 = if unclear, file this form with IRS and IRS officially determines status! 8

9 Payment, Billing, Documentation Can be EXPEN$IVE! Computer Programs Check for HIPAA compliance If my clients are Home health? Early Intervention? Schools typical brick and mortar vs. charter? Hospital? Long term care? Don t Need a Documentation Program! These clients have their system! Forms: Inquiry, intake, pt registration Consent forms video/audio recording consent release forms History Insurance card Policies, agreement for services, cancellation policy, privacy Record Keeping RECORD RETENTION: safe until 25 th birthday for pediatrics or for adults, 7 years past last visit Home health, charter school, EI will have copies of your documentation Denise Dougherty, MA, CCC-SLP, MFT 49 Denise Dougherty, MA, CCC-SLP, MFT 50 Salary/Benefits (2) DON T GIVE IT ALL AWAY!!!!!! Nonexempt Hourly rate for hrs. worked each week Eligible for overtime if over 40 hours in 1 week Exempt Salary basis Paid based on full time equivalent status (FTE) May work more/less than their allotted work schedule as needed No overtime pay Denise Dougherty, MA, CCC-SLP, MFT 51 Hourly or salary Base Pay Per Visit Inclusive of time/effort to eval, treat, consult, document and travel Compensation(2) Variable Pay One time basis/intermittently Bonus to accept position Incentives Stock options Indirect Pay REQUIRED Soc. security, unemployment, workman's comp OPTIONAL medical, dental, life ins., paid time off, 401k, license fees/dues, continuing education Denise Dougherty, MA, CCC-SLP, MFT 52 Unemployment! Some employees successfullywin unemployment benefits if you can t provide them with clients or there is a drop in caseload!!!! Office Manual Policies/Procedures Job description HIPAA adhere to HIPAA if electronic transmissions/clearing house for claim submission Have You Heard about HIPAA? A Practical HIPAA Compliance Guide for Audiologists and Speech Pathologists Veteran s Press Continuing Education Repay continuing education costs if employee leaves stipulate time frame and repayment Expectations Case load, time management Noncompete compensation agreement Staff may start own business with your clients! Permit competition but charge fee for privilege Disciplinary actions Spell out policies and FOLLOW THEM! Clearances Denise Dougherty, MA, CCC-SLP, MFT 54 9

10 Factors to Consider in Pricing! Can t bill for every hour you/employee is in office How many days in the office/hours for billable services? Make adjustments for holidays, vacations What profit do you expect to make mayhave to make ADJUSTMENTS! Medicare reimbursement/insurance reimbursements are what they are! Your client (company you contract with) may have set rate of reimbursement and is NOT negotiable! Denise Dougherty, MA, CCC-SLP, MFT 55 One Approach (2) Billable hrs per week per staff Profit margin you would like Divide weekly cost of doing business by billable hrs per week Add margin 20 hrs x 2 staff = 40 hrs per wk 30% $ $100 x.30 = $130 per hour Denise Dougherty, MA, CCC-SLP, MFT 56 4 hrs of billable service per day ANOTHER APPROACH! 5 workdays a week 20 days off per yr. (holidays, vacation) 220 workdays 4 hrs. per day 880 billable hrs. per yr. $100 per hr. = $88,000 (3) SOUNDS GREAT!!!! BUT. $88,000 in your pocket? I DON T THINK SO! Denise Dougherty, MA, CCC-SLP, MFT 57 Denise Dougherty, MA, CCC-SLP, MFT 58 $88,00 MINUS!!!!!!!!:(2) Recurring Fixed Costs Recurring Variable Costs Rent/mortgage Phone Loan/lease Utilities Yellow pages/internet Supplies/materials $ $ Pricing (2) Recurring Fixed Expenses + Recurring Variable Expenses + Direct Costs Directly related to providing service Indirect Costs Not necessarily related directly to providing service Staff salary or contract rate Mileage reimbursement Fringe benefits Continuing ed, liability insurance, Marketing, Accrued time off advertising, subscriptions Denise Dougherty, MA, CCC-SLP, MFT 59 $ Direct Costs + Indirect Costs = $ Costs of Doing Business per yr/mo/wk/day $$$$$$ Denise Dougherty, MA, CCC-SLP, MFT 60 10

11 So NOW. what does that $88,000 look like? Denise Dougherty, MA, CCC-SLP, MFT 62 MAY NEED TO (the ups and downs!) (2) DECISIONS DECISIONS!!!! Decrease costs Decrease expenses Decrease staff Increase productivity Increase organization Improve time management (12) ADD OTHER DISCIPLINES!! GROW MY SLP PRACTICE!!!! STAY THE SAME!!!! DOWNSIZE!!! Denise Dougherty, MA, CCC-SLP, MFT 63 Hmmmm! Can you afford expansion? LEGALLY, can you provide the other services? Can you sustain the growth or is this just a spurt? Can you find reliablestaff? Stability of contracts? Do I want to eliminate contracts are problematic? DO YOU WANT THE EXTRA RESPONSIBILITIES?? How has your vision changed? SHOULD change over time! 11

12 UHOH!!!! Things not going well??? Look at your process! Marketing? Have you done any? Hours? Not convenient for clients? Location? Parking issues? Building issues? Too much traveling? Could you see more clients if you were in the office? Renegotiate contract/build those costs in! Cancellations!?????! No show policies!****** Improve your skills to offer more services Dysphagia? OM? Literacy? Auditory processing? Too selective? May need to add different types of contracts Home health? PRN at local facilities? Whatever will bring in the revenue! DON T BURY YOUR HEAD IN THE SAND!!!! How can you make EXISTINGpractice more profitable Profit and growth NOTthe same Lower cost Increase productivity Increase organization SMALL steps Stop fighting change CHANGE! Be flexible key strategy! Pricing, accessibility, services (12) Denise Dougherty, MA, CCC-SLP, MFT 67 Denise Dougherty, MA, CCC-SLP, MFT 68 It all goes back to THIS! Research and Consult Develop a Plan Implement Plan Q & A? RESOURCES Small Business Administration Articles Follow These Steps to Starting a Business 20 Questions Before Starting a Business Use Our Starting Up Assessment Tool Is Entrepreneurship For You? Preparing for an Emergency Can Determine Your Success Understand Your Market and Economic Conditions Payment, Billing and Documentation Programs NOT A COMPLETE LIST ALWAYS CHANGING! Intuit Quickbooks and Quicken accounting/billing and checkbook Scheduleview.com scheduling free demo Therapist Helper accounting, docs, scheduler Free trial (3) Practice Resource accounting, docs, scheduler Treatwrite doc, etc. (3) Free Record and save notes/audio recordings etc. Free Works with windows, mac Work on/offline Saves files Therasource -accounting, docs, payroll, scheduler Denise Dougherty, MA, CCC-SLP, MFT 71 12

13 Bibliography (1)Gritz, J. M. (1996). Private Practice Record Keeping. Louise Zingeser, S. T. Stram, J. Langsam, D. Paul-Brown. Guide to Successful Private Practice in Speech-Language Pathology(pp ). Rockville, MD: American Speech-Language-Hearing Association. (2)Lee Ann C. Golper, J. E. Brown (2004). Business Matters: A Guide for Speech-Language Pathologists. Rockville, MD: American Speech- Language-Hearing Association. (3) Newhouse, M. (2011). How to Start a Private Practice. American Academy of Private Practice in Speech Pathology and Audiology. Omaha: AAPPSPA. (4) Schaefer, P. (2006). The Seven Pitfalls of Business Failure. Retrieved January 29, 2011, from (5) Why do Many Small Businesses Fail? (2011).Retrieved January 31, from allbusiness.com:www.allbusiness.com. (6) Where Can I Get Information on Preparing a Business Plan for a Start-up Business? (2011). Retrieved January 31, from allbusiness.com: (7)Business Plan Basics. (2011). Retrieved January 31, from allbusiness.com:www.allbusiness.com (8)Dougherty, D. (2008, September 02). Transitioning to Private Practice. The ASHA Leader. (9) Ta eed,c. (2011, May 26). Nine Factors to Consider When Determining Your Price. Retrieved February 8, 2011, from freelaneswitch.com:www.freelanceswitch.com (10)Reiger, S. (n.d.).how To Calculate a Minimum Fee For Your Services. Retrieved February 8, 2001, from (11) Grodzki, L. (2000). Building Your Ideal Private Practice: A Guide For Therapists and Other Healing Professionals. New York: WW Norton. (12) Grodzki, L. (2009) Crisis-Proof Your Practice: How To Survive and Thrive in an Uncertain Economy. New York: WW Norton 13) Bourne, Steve. AAPPSPA Conference 2008 Denise Dougherty, MA, CCC-SLP, MFT 73 Denise Dougherty, MA, CCC-SLP, MFT 74 13

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