This episode is brought to you by PAR. The Feifer Assessment of Writing examines why students may struggle with writing. The FAW and the FAW screening form are available on PARiConnect-PAR’s online assessment platform. Learn more at parinc.com\faw.
Hey everyone. Here we are back with another business episode. This episode is for all of you who have considered transitioning from insurance to private pay and struggled with what to do in terms of access for folks who may not be able to pay. This is a [00:01:00] major topic of conversation during our interview today. And there are many other things that we talk about that I think will be super helpful.
Let me produce my guests, and then I’ll tell you a little bit more about the episode as we go along.
My guest today is a longtime friend, Dr. Annie VanSkiver. Annie is a private practice owner in Williamsburg, Virginia. She opened her practice in 2017 after transitioning out of employment at a local State hospital where she served as assistant forensic coordinator for 8 years. The inspiration for her practice came from this podcast. So you can tell right away, this is aside, of course, that Annie is very complimentary of the podcast, both in her bio that she provided and during the interview. I’m not sure how to handle that because it’s very [00:02:00] humbling. But anyway, this is just the first instance and a little bit of warning that Annie is very complimentary. And I promise I didn’t pay her to say any of those things.
So as she was saying in her bio, as I was saying in her bio, Annie got her inspiration from the podcast. Her passion is testing and data, and she never thought that she could open a practice that only does testing. She loves working with kids and families to help those kiddos, especially around learning disabilities, autism, ADHD, and other developmental differences.
Her husband is a special education teacher and together they have three amazing kids through birth and adoption, one with complex needs. Her dogs are named after Harry Potter characters, which also adorn her office, which creates an excellent starting point for a conversation with her clients!
As you’ll see, Annie is [00:03:00] wonderful in all regards. I am just honored to be talking with her. I have been part of her journey over the years and to see where she has ended up, but now having her on the podcast is just an awesome experience.
So we are talking all about transitioning from insurance to private pay. We talk about, of course, how to get off insurance panels, logistically speaking. We talk about contracts that can help supplement private pay clients. We talk about how to let referral sources know when you’re going off panels. We also spend a lot of time, like I mentioned, on the topic of balancing access for clients with profitability. I think this is often a false dichotomy that gets set up that you either have to be private pay or you have to provide access for folks, and Annie has found a way to do both [00:04:00] and I think is doing it very well. And that’s a big reason I wanted to have her on the podcast so she could talk through her decision-making process and strategy with that.
So we cover a lot. This is chock full of amazing information, and I think there’s a lot to take away. So without further ado, let’s transition to my conversation with Dr. Annie VanSkiver.
Hey, Annie. Welcome to the podcast.
Dr. Annie: Hi, thanks for having me.
Dr. Sharp: Yes. I’m so glad that you agreed to come on and talk to me today. I feel like we’ve had so many interactions in so many different venues over the last few years that here we are at the pinnacle of our relationship with you coming on [00:05:00] the podcast.
Dr. Annie: Oh, thanks. I feel like I’ve achieved something great because I’m on your podcast since this is what literally started my practice.
Dr. Sharp: It’s full circle. Well, I’m seriously honored to have you. And I think it’s really cool having seen your journey over the last few years and knowing that you’ve gotten to this place, that feels really good. I’m excited to have a conversation with you about that and share that with other folks who might benefit as well. So, thanks. I’m glad you’re here.
Dr. Annie: Sure, thank you so much.
Dr. Sharp: Okay. So let’s dive in here. I wonder if we might set the stage for people. I would love to have you just describe your practice in the old days. So, pre-private pay. What did your practice look like when you first started and those first couple of years?
Dr. Annie: That’s a good question. So the practice [00:06:00] started, I have to throw on my plug for you because the practice started when I was adopting my third child and I was doing a lot of running because that is what I do when I’m stressed out about things. And I started listening to your podcast and it occurred to me that I could have this practice that was testing only. I’m a terrible therapist, quite frankly. So, I had never dreamed I could come into private practice, but I started listening to podcasts and the idea came into my head that we could maybe do this.
At the time, I was employed at a State hospital working with not guilty by reason of insanity equities predominantly and doing a lot of evaluation work around that. But in my former life, I was a school psychologist. I worked with children outpatient for a long time. So I had this thought of maybe blending the two ideas.
So when I originally went into practice, I went in with a partner who is amazing and wonderful. And we had this vision of doing all [00:07:00] evaluation, part forensic and part with children. And it worked really well, but we noticed, I’m sure everybody will laugh when they hear this, but it was really different. They were two completely different practices. And that’s what we ended up deciding to do was just to split the two practices into one, all forensic, which Dr. Andrew Osborne heads up, and mine, which is all children. And we figured that out when we got on the insurance panels because forensic work is all private pay. The insurance panels were a whole different animal.
So, when we first started, that’s how we organically evolved. And then it became me and myself with an admin assistant, practice manager now, and then myself with… I had a psychiatrist and then we had a couple of interns, but the whole time we were taking all health insurance. We were on every panel I could get my hands [00:08:00] on.
Dr. Sharp: Right. This is a little bit of a digression right off the bat. So forgive me for that. But when you set up the practice initially, were you partnered with Dr. Osborne? Was that a business partnership that you had to then dissolve when you split your practices?
Dr. Annie: That’s a great question. And it’s not really devolving. I should have mentioned that. So, no, we were actually in the process of forming the partnership. I had an LLC under just my name, and then we named the practice. We talked it through when we had this vision and then we got our attorney involved when I finally quit the State hospital. We were in the process of talking about merging it into an actual partnership when we started to realize that it was two different practices. So it worked out really well. My attorney was happy we figured it out early.
Dr. Sharp: I bet everybody was.
Dr. Annie: Yeah. And he actually advised us not to form a formal partnership unless there was a [00:09:00] really important reason to do so because it’s so hard to get out of it.
Dr. Sharp: Right. That’s the advice that I tend to give folks. If you can avoid a partnership, just avoid it and find another route.
Dr. Annie: Right.
Dr. Sharp: Yeah. It’s a tricky business. Okay. So help me understand. I know what my motivation was for getting on insurance panels in the beginning. I’m curious what your motivation was when you decided to jump on all these panels.
Dr. Annie: Sure. So, I’m the mom of three kiddos and I have my entire career worked with disenfranchised populations. So people without access to services. My first internship, I guess it would have been a practicum experience in graduate school, was in a rural area where we brought testing into the community. And we went specifically for preschoolers.
And I remember being in homes that were Amish because that was how they got services. [00:10:00] We were in a really rural area and I liked working with juvenile justice a lot. I’ve spent a lot of my career bringing services to people by accident. It was just the way it was set up, up there. That was in New York. Then I had my own kids. I was working at the State hospital and I started noticing some things with my first son developmentally that things were a little weird.
I kept mentioning it’s preschool and they didn’t say anything. They thought it was fine. He was just a boy being a boy. He was a typical child, blah, blah, blah. And by three years into this, they told us we needed to get him evaluated for autism. He was four years old. He was in preschool at that point. We sat on a waiting list for 10 months before we could get in. And that was just for the intake. We got through the intake and testing process, which took another three [00:11:00] months. When we finally got our diagnosis, we had lost all that time in early intervention.
So, that was my impetus for wanting to start a private practice in our area. I desperately wanted to not have that barrier for people trying to get access to services for early intervention. And then it became really noticeable that there were not any practices in town that were doing psychological testing that also were taking all health insurance and serving particularly Medicaid. That was really important to me. So that’s how the vision started with trying to bring testing to everyone. Just really weird when we talk about a private pay practice, but we’ll get there.
Dr. Sharp: Right. Well, yeah, I think we will get there because I think that’s a common misconception for folks that not taking insurance or being private pay means you don’t provide [00:12:00] access. We’re going to put a pin in that and circle back to it for sure. But I think that motivation is the same as for a lot of us. It’s an access issue and we think that insurance equals access and then it does in a lot of ways. I know for me too, it’s funny looking back, like, I didn’t even know that you couldn’t not take insurance.
Like I just thought that’s what you did. This was whatever it was 12 years ago or something, and I was like, my doctor takes insurance and every medical professional I’ve ever seen takes insurance. So I’ll take insurance.
Dr. Annie: Yeah, I thought the exact same thing.
Dr. Sharp: I didn’t know there was another option. And then the access. Access is important. So I had that in my mind as well. I think a lot of people probably jump on insurance panels to have a [00:13:00] steady referral stream and perceived ease of building a practice as well.
Dr. Annie: Yes. And that was a fear when we first started too. I actually had no clue that we couldn’t avoid insurance in any way, but I remember getting the first phone calls and being like, “Yes, people are going to be cool.” We chose not to offer therapy here, which I think could have financially helped a little bit in the beginning possibly. But I remember how many people I had to tell that we didn’t take health insurance yet just because we were waiting to be paneled and all of them freaking out and going to another practice and all these things.
So yeah, it’s nerve-wracking at first. You have to be prepared with the vision that it’s going to look a certain way, but it won’t end up that way, hopefully.
Dr. Sharp: Right. So where did things go from there? I’m really curious [00:14:00] to dive into or to learn more about the tipping point. How did insurance work for you? Was it working? Was it not working? When did you start to think, maybe I don’t want to do this anymore?
Dr. Annie: That’s a good question. You can’t see me because this is a podcast, but I’m laughing because all of those things are resonating. Our tipping points came later than it should have, I think. From the beginning, I’m a very social person. I like to talk to people. And that was something I missed when I went into private practice, the colleagues’ aspect of things. And so, I did consult with you a lot in order to feel like I had both partnerships in building this process but also somebody that I could ask all these hard questions I have.
[00:15:00] I did the beginner mastermind group and then we did private consulting, and I started to notice a lot of my questions were focusing on finances. How do I do this better? We had initially started billing ourselves. Then we hired a billing company, which was wonderful, but we ran into a lot of problems and we noticed that we were not getting reimbursed very much.So we went through problem-solving with them quite a bit over a 6-month process and then figured out that probably wasn’t the best fit for us company-wise, so we decided to move to a different company. No big deal. Everything was fine. But I was still noticing a cash flow problem. So then I brought on a therapist, and I had this vision that we could make a more holistic practice, but I’m a terrible therapist. I’m not going to lie. And it just wasn’t the right fit for us and for me, and for what I had hoped this would be, which is an evaluations-only center that would bring services for testing specifically to [00:16:00] everybody.
Then COVID hit. And at that point, we were two and a half years into private practice. We are two years into taking insurance. We were still not profitable.
Dr. Sharp: Wait, can I pause you?
Dr. Annie: Yes, please.
Dr. Sharp: You mean, you literally were not profitable at that point? Like there was zero profit?
Dr. Annie: There was zero profit after we paid salaries. Yeah, that was …
Dr. Sharp: Right.
Dr. Annie: So we were getting to a point.. we felt really proud though because we were getting to a point where we could make payroll. That was a big deal. And again, not knowing this, we sort of thought that that was part of the process. And it is. So our accountant always said, it takes three years to build a business. And so we were [00:17:00] just going by the, I say weeks, it was my practice manager who I don’t think I could live without, that was really helping me through this process at this point.
We were just kind of going with the, all right, we were originally unable to pay ourselves. Then we got on the panels and we started getting more referrals. And then that started to organically work itself out. I actually kept all my datebooks and it’s funny to look at the number of referrals increase. And then, we were able to consistently make payroll. And then we were able to consistently maybe do a little more than payroll and then COVID hit.
So, it was interesting timing because we had already been struggling and you probably remember that was a lot of our private consulting, but the reason that we were struggling was not because of a lack of referrals or because of the reimbursed, which is not great all the time, but it was more because the type of [00:18:00] evaluations that I enjoyed doing, that I really loved and that I felt I was best at and what made us stand out were not able to be reimbursed in the way that would have made it profitable. If that makes any sense.
Dr. Sharp: Can you give some details around that when you say the type of evaluation and why they didn’t lend themselves to the reimbursement you needed?
Dr. Annie: Yeah. And this is all with the caveat that it’s also possible that we never learned very well how to maximize insurance reimbursement and that we still were making mistakes at the end there. But we had a great billing company. We still do. We still use them because we still accept TRICARE, and they’re amazing and I love them. And they kind of helped us find some problems.
But in our experience, and this might differ from state to state, but in our experience, insurance is very good about reimbursing psychological testing specifically for [00:19:00] what I like to think of as ruling things out and confirming a diagnosis. So they answer the question. So we have an ADHD diagnosis that we’re trying to find out if this is accurate or not, and they will answer the question with us, right? So they’ll pay for those services, but I enjoyed answering the question and then the follow-up question, which is, is it ADHD? No. Cool. What is it? And I wanted to do more.
And so that was part of what was happening. I would give, not in every case, but in some cases, I’d want to give these big, long batteries to try to figure stuff out and the insurance company would stop us at three hours or whatever. And part of that might’ve been us, and part of it was lousy luck. We would especially have that problem with Medicaid.
Dr. Sharp: Yeah, sure.
Dr. Annie: Yeah, it’s hard.
Dr. Sharp: It is. So y’all were noticing reimbursement problems. And, I’m kind of reading [00:20:00] between the lines, like working more than you were getting paid for, like just not getting and being limited in the kind of work that you liked.
Dr. Annie: Yeah, working more than we were getting paid for, for sure. Kim, who is my practice manager, was following our reimbursement rates and there were several times we’d get $200 for the whole thing. We know some of that was billing problems, but even with the help of an expert billing company, we were struggling. So yeah, it was, it was interesting. It was a little challenging.
Dr. Sharp: You’re holding it together really well, but I feel like a lot of people would be freaking out.
Dr. Annie: Well, honestly, that Facebook group was really helpful because so many people post questions, and then I had the opportunity. I spoke to you, two other members of the Facebook community who were running private practice companies that only took insurance. And it was really, [00:21:00] really validating to speak to those two women who explained how they did it, how they made it work. It just wasn’t fitting with the way I worked, which was, you see 6 to 8 clients and you turn around 6 to 8 reports a week or whatever it was. And I was like, “Oh, okay, well, I am not that good.”
Dr. Sharp: Sure. I think that at least in my experience, it helps a lot to have a testing practice that takes insurance if you are doing a lot of volume or you have a psychometrist model or you are scaling. All those fit together.
Dr. Annie: Right. And you have maybe you’re billing for therapy because that can certainly,… there’s a practice in town that is lovely and they do testing, but it’s about 10% of their work and the rest is all therapy. They always say that therapy practice carries us.
[00:22:00] Dr. Sharp: Sure. So COVID hits and you’re it sounds like struggling a little bit with the reimbursement and cash flow and that sort of thing. So then what happens?Dr. Annie: So when COVID had it, we always chose to look at the bright side, and one thing that was positive for us was that because we had to shut down, we were able to deep dive into our books and figure out exactly what was going on. And so we used that time to really look at every claim, every reimbursement, and then to come up with averages. What are we averaging from each company? And at the same time, I’ll be honest, I was simultaneously applying for jobs because I didn’t know if this was going to work.
Dr. Sharp: Oh Geez. I did not know that part of the story.
Dr. Annie: I was thinking this wasn’t going to work. And so we started deep diving into books. We use the spreadsheet that you gave me. Thank you for that. And we realized that [00:23:00] we just weren’t going to be able to do it, not at the salary that is not even a good, I mean, it’s a great salary. I’m not complaining. But not even at the salary I was attempting to pay myself, which is just what we needed to kind of make the bills, so forget profit.
We had to have an honest discussion of… Oh, and at that point, I forgot this part of the story. We had hired a therapist and we made the decision that that wasn’t mutually beneficial. She wasn’t getting what she needed. We weren’t getting what we needed. And so she had moved on. So there was that income stream too.
So, we decided that we were facing the decision of closing the practice or switching off of insurance. That was the decision we had to make because we couldn’t sustain both.
Dr. Sharp: Oh my God. That feels heavy.
Dr. Annie: Yeah, It was a little heavy. And then there was like, Oh God, it’s crazy.
Dr. Sharp: Oh my God, what did that decision [00:24:00] making process look like? How’d you go about solving that problem?
Dr. Annie: A lot of it was just a hard look at the numbers and really breaking down what we needed for overhead per month, which was surprisingly hefty, and very interesting to do when you’re unable to even use your offices. I think it was really the first time that I had thought about, we’re paying money to make money, right? Like sort of seeing it in that way and not worrying about paying the rent separate from paying Kim separate from paying myself.
So putting it all together and seeing that on a spreadsheet was really eye-opening and disturbing. And then, we followed a process. I [00:25:00] mean, Kim is a budgeter by nature and we figured out what we needed to make per month. And then how many insurance testing cases that would be. And there was no way we could do it and sustain it. So that was when we had that hard conversation of, okay, I think we need to make some major decisions here.
Dr. Sharp: Right. Now, were you working with an accountant during that time, or was it, Kim? I mean, is that just part of her job as the office manager?
Dr. Annie: It’s funny. It wasn’t intentionally part of her job. We do have an accountant and we were not working with her. However, if I didn’t have Kim, I would have been working with her. Kim, her background is in budgeting.
I will tell you though, I was awful at seeing that. It is not the way my brain works and I would never have figured that out without seeking help from an outside person. So I [00:26:00] think, if you end up deep diving into your own books, your accountant or your bookkeeper is where it’s at. That was 100% necessary.
Dr. Sharp: Yeah, I couldn’t agree more. I consider myself fairly math adept and comfortable with numbers, and so forth. But yeah, getting a really good accountant or bookkeeper has been a game-changer, the way that they can break down the numbers. I don’t know if this applies to you, but for me, it was super helpful to have someone external who would take the emotion out of it. And just, it’s like black and white, this is what we need. Here’s what we’d have to do to make that money. That’s it. There’s no emotion. It’s just facts and now we can work with them. I don’t know about your experience.
Dr. Annie: It’s exactly right because our heart is in our business. I remember every new consulting experience with you, we start with, [00:27:00] what is your major goal? And I’d always say, “Oh, I want to bring testing to everybody. That’s what I want to do. I want to just be ease of access.” And when that’s what you’re worried about and focusing on, or the kiddos that you’re serving or you’re worried that Johnny next month is not going to get his IEP if you don’t help, this part is really hard. So yeah, I agree. Working with an outside person who knows money is good.
Dr. Sharp: It helps. Well, I think a lot of us have that. I think a lot of us struggle. The emotional part is huge.
So you look at your numbers and you make this decision. I’m curious about the process of figuring out, Hey, going off insurance is a better choice than closing the practice. How did you ballpark what you would be bringing in as a private pay practice when you hadn’t really done that before?
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All right, let’s get back to the podcast.
Dr. Annie: Great question. I think I just was winging a prayer. No, I really, really didn’t want to close [00:29:00] the practice, but I knew, so we’re a two-income household and we have to be, it’s not by choice. Well, it is by choice. So we knew we had to do something so that I had to work. When we looked at the number of insurance evaluations we had to do, I didn’t think it was sustainable and I didn’t think it would be a comfortable life plan for me to try to bang out that many evals and things like that and then also, still have the fun that goes along with having a private practice, which is, being able to take your kid to school or whatever.
So, we looked at numbers, then we started doing some research into what other people were charging, which was really fun because nobody wants to tell you that. So we would cold-call other agencies and find out, and then so many people are kind and put their fees on their website. So that was helpful. And [00:30:00] then we looked at, of course, demographically. These guys are in Atlanta, Georgia, and we’re here in Williamsburg, Virginia, what could that comparatively mean? And figured out what we thought was a fair rate, which we actually very quickly increased, but I’ll get to that.
And then, lastly, and this was just my choice and I don’t think we had to do it this way, but I also chose to seek out some contracts so that I had a steady stream of something just in case things went south. So, we have contracts with a couple of residential treatment facilities to do testing for them. Then that just made me feel better to know that that was there just in case.
Dr. Sharp: Of course. I’m glad you brought that up. I know that’s been a big part of your practice over the years. I want to highlight that because people think it’s either I take insurance or I go all cash payments, but these contracts, if you can get a contract, there are a [00:31:00] number of contracts with different entities that pay at or above market rate, and it’s pretty easy to do the billing, and it’s simple.
Dr. Annie: Oh, it’s wonderful. I had one residential contract when we first started. And that was what made me feel comfortable taking the leap into private practice from a state gig. It’s very wonderful, and not something I think that we think about a lot because we’re not business-minded maybe. We have six now.
Dr. Sharp: I was going to say, what kinds of contracts have you sought out?
Dr. Annie: So, the one that I accidentally got was through just a friend of mine who is retired from other types of psychology work and she has just been testing for a residential. And so she introduced me there. That was the first one I got. Then I got a second residential because of the first one. [00:32:00] Then we got a third residential. It’s very interesting. If you know local residential treatment centers or other kinds of things for children, group homes, things like that, if you go on their websites, often you’ll see something that looks like they’re looking for something with testing, but it’s never a clear ad. That’s what I found anyway.
So I cold-called one and just said, Hey, I’m not looking for a full-time job, but I’m a psychologist. I specialize in testing. That was kind of a neat way to do it too. So kind of networking and knowing that this was a service they offered and then asking if they needed more people just being a little obnoxious was helpful.
So, that’s how we got these residential treatment facilities. And then, we ended up getting some contracts with school districts. We did some of that. [00:33:00] This might be a little too much in the weeds, but we also, on Dr. Jeremy Sharp’s advice, by the way, got a relationship going with a local training program. And so we started being… that’s brand new… so we started working with the local school. And that got us hooked up with another contract, which is working pretty closely with their law school to do some educational testing for cases that they’re doing educational advocacy work for.
All of that kind of culminated into my last contract, which we’re trying really hard to work at now, which is with county mental health. They don’t have a psychologist. And in many parts of the country, I think that that’s a problem. So county mental health agencies either can’t afford or can’t hire or can’t find psychologists. So they’re looking for some help in that area too. So if you just kind of pop in and do some testing and pop back out, it can be a good income stream.
Dr. Sharp: Sure. [00:34:00] Well, I want to point out, I don’t know if this is your experience, but for me, there’s a trade-off where like maybe the rates in the contract are slightly lower than your out-of-pocket rates, but it’s guaranteed and it’s easy and you’re not filing claims and calling and all that nonsense that goes along with insurance sometimes.
Dr. Annie: Right. That’s probably the most important part to point out about that work is that it took all the leg work out of the hard part about getting reimbursed. Juvenile Justice is another great place to look for contracts. We work with them too. All we have to do is an invoice and it’s so much easier. And there is a trade-off and it’s definitely lower than a private pay rate, but it is so worth it. And another wonderful way to bring services to kids who may not otherwise get services because they’re getting it covered through another agency.
Dr. Sharp: Well, I wonder, [00:35:00] is that the place where we start to dovetail with this access question? I’m curious how you worked through that for yourself in this decision to go off of insurance panels, like how were you thinking about access during that process?
Dr. Annie: My original dream was that we could stay on Medicaid, but in the state of Virginia, Medicaid is all managed. And so in order to take Medicaid, I had to also be on Blue Cross Blue Shield or whatever. So that was kind of heartbreaking. I talked a lot to my mentor who said to think about how we’re providing access through services like the residentials and Juvenile Justice and all that stuff. And that was helpful. And it helped me feel better. And I do like that because you also get a lot of autonomy with testing through those kinds of contracts.
And so [00:36:00] they may be wondering if a child has autism, but they’re certainly not going to get upset if you also look at a learning disability because you think that that’s happening too. And that can bring a whole world of access to kiddos. So I do like that. But still, it didn’t feel like enough. And so, we started exploring the idea of pro bono services. That’s actually how we try to cross the access barrier right now is through pro bono testing.
Dr. Sharp: How did you figure out if you could do pro bono or how much you could do? And is it truly pro bono? Like for free?
Dr. Annie: Yeah, it’s truly pro bono. We’re still increasing our numbers. So right now we’re just at one per clinician, but I will say, and maybe we went a little backward here, but within three months of making the decision to go off of [00:37:00] insurance panels, we became profitable. And very profitable very quickly. And we figured out we had enough projected profit to hire. So we hired a second clinician, and then a third. And this is all within the last year. This has all happened. It’s crazy.
Within those first three months, we were able to see, okay, we may be able to spend two days a month doing work for free because we’re okay. We don’t have to spend every minute billing for billable time. So, that was eye-opening in the first three months. Within six months, I took my first pro bono case. And then within nine months, it’s a regular thing now. And we do limit it. We do try to do only one per clinician per month for high-needs cases. [00:38:00] And it’s worked really well. But we’re working in conjunction with the local county mental health and then hopefully a grant process so that we can continue to build this access. We can do that because we’re not going broke, which is great.
Dr. Sharp: Yeah, that helps. Not going broke gives you a lot of freedom to do a lot of things.
Dr. Annie: Which is even better.
Dr. Sharp: Yeah. Well, I know people can’t see your face, but it is clear that this is so meaningful and joyful for you to be able to provide access in that way to kids. So how do you figure out who gets the pro bono evaluations?
Dr. Annie: That’s a great question. We do need to work on that process a little bit better, but right now it’s been… so I like to do networking because like I said, I’m social and weird and I [00:39:00] get lonely.
Dr. Sharp: That’s not weird.
Dr. Annie: When I have clients with therapists or I will call the therapist and make connections and all these things. And right now it’s just been word of mouth. We don’t want to put it on the website because then it becomes a whole thing. So it’s just been word of mouth for really high-needs cases that are coming from a referral source. So whether it’s a county mental health or an attorney, maybe a school district, it says, we’ve done our testing and it’s maybe not a naive case, but we partner pretty closely with them or law enforcement. So it’s the director for all right now from another provider.
Dr. Sharp: I see. And are you doing, this may be too, too detailed, but are you doing like income checks or anything to determine… Are these folks with insurance who just can’t afford it? I’m just [00:40:00] curious about the details.
Dr. Annie: Oh, sure. No, we’re not. And that’s still part of the maybe we’re just being a little lazy. Because they’re coming directly from another provider, when we gather information, we ask those questions, like why are you referring this case? And so we rely on that data to tell us. And because we know these are trustworthy resources, they’re not just a physician from down the road calling, it has pretty organically worked out, but if we get grant money to continue to expand that process, obviously we’re going to have to do more, I think, to verify that.
Dr. Sharp: Of course. That’s fantastic. Like I said, that’s a big hurdle for a lot of folks as being concerned that you wouldn’t be able to provide access to some kids, but it sounds like you’ve really found a way to do it. That’s amazing.
Dr. Annie: Thanks. [00:41:00] Related to access, a lot of people feel very strongly that people won’t pay this or they’re not going to be able to in my area or different things like that. And I felt that way as well. I felt that we had a small percentage of our population that would pay for it, but that most people wouldn’t. And I am very surprised that I’m incorrect. As long as you provide some education and alternative ideas that when faced with this question of, do I want to go with this agency that I have to pay out of pocket but then this other stuff can happen or do I want to go with this other agency where I can take insurance?
We do well with retaining our clients. And I think that part of that is related to helping them to understand the value of the service [00:42:00] and why it’s different than they might get at a different agency, but also just explaining how superbills work, helping them with a superbill process, helping them understand the use of HSA cards. We’ve had families use adoption subsidy funds getting it through… There are all kinds of things in Virginia, but there are often financial services to cover uncovered services for children who are coming out of foster care or another high-risk situation.
So we really explore with our clients many different ways that they can cover the costs without paying out of pocket. And then we go to the paying out of pocket and then we work on payment plans and things like that. So I think you can’t just say, we’re going to go private pay and everybody’s just going to pay us. There’s a lot with client care that I think comes into with retention of our clients. So, that was helpful too. We had to figure that out.
Dr. Sharp: Oh, sure. Can you [00:43:00] speak to how you communicate that value, that component that you mentioned, why would I go to this private pay practice versus the insurance practice down the road? How are you sharing that or selling the service?
Dr. Annie: That’s a great question. It is 100% in sharing your vision with the person who answers your phone and having that person be just as excited as you are. I remember consulting with you about talking about the script for when people answer the phone and how important that first phone contact is with people.
We also started doing, which I know came from a recommendation from you, but also I’ve seen it on the Facebook page, 15 minute consultations with me for free before they book. And that’s just a wonderful way. I always say to them, I will be doing myself a disservice if I sell you something you [00:44:00] don’t need.
So I just as easily turn people away as I do book them. And I think those conversations are really helpful. And the clients feel like we’re connected to them and we’re really not going to do it if we don’t think we can do the best job. We’re also pretty small. And I think that that helps because it’s easy for us to be pretty personal. When our person who answers the phone talks to the client, if they come to me and they say, it feels like I was talking to a friend, it feels like she really understood and she wanted this to happen for me if we wanted it. I think that’s been really helpful too, but it’s a lot about that initial contact.
Dr. Sharp: Sure. It sounds like there’s a, what’s the word, culture piece in your practice that everybody’s bought in like everybody is on board and [00:45:00] I don’t know that you can… well, I think you can teach that actually to a degree. You can communicate that and hire well and make sure people share your values, but it sounds like that’s an important component.
Dr. Annie: Yeah, it certainly feels like it. Those first initial calls with clients are I think what makes people feel heard.
Dr. Sharp: Sure. Let me backtrack a little bit and just ask, how did you get off the insurance panels and how long did that take?
Dr. Annie: It’s a good question. It took 90 days approximately. I learned that the way to do so is by writing a letter. This might be too in the weeds, but honestly, it would have been really helpful if I understood this at the time, but often when you’re getting on a panel, you have some human at that insurance company that’s your contact and they’re emailing with you or your practice manager, whoever.
And I [00:46:00] had, like most of us, saved a bunch of my emails into a folder that’s labeled insurance. So I wrote the letters that I was supposed to write. And it said I want to get off the insurance. It included our EIN number and all that stuff. I’m happy to provide a copy of the letter if it would be helpful to anybody. And then I went back to those old emails that had various information, and I just emailed the people directly and said, Hey, I want to get off insurance. What do I do? And every time I got a response. It was really helpful except for one which is notoriously non-responsive in our state.
And I did call the provider number and they told me what to do, which in that case was fax a letter. So, it’s easy. It’s simple. It’s just not easy to find out how to do it.
Dr. Sharp: Right. But you found that it really did work. The 90 days [00:47:00] held true?
Dr. Annie: It did. And we were very fortunate because we were still working with our billing company and they were incredibly helpful. What they did was they would just call the insurance company and find out if we were unpanelled but I could’ve just as easily done it myself. It didn’t feel like something I needed somebody extra to do. And even with all our amazing administrative support here, I did all that myself and it was fine. I’m not very good at complicating stuff.
Dr. Sharp: Okay. That’s fair. So during those three months, what were you doing? How did you prepare? Or did you prepare? What was happening during those three months?
Dr. Annie: It was insane. It makes me laugh to think back on it. If Kim was here, she would laugh really hard and then probably fall over and run screaming. So along with [00:48:00] access to services, I couldn’t stomach the idea of, because, like many of us, I always thought I’m never going to have a waitlist. It’s going to be amazing. And of course, I had like a huge waitlist and clients booked out till eight months, whatever it was. It was really far.
And so when we decided to get off panels and we sent in our letters and we had written on our calendar check, Blue Cross Blue Shield, you’ll be off on which date it was. And so every client that was scheduled, we booked into those three months. So, anybody who had already had an appointment, we moved them up and it was insane.
Dr. Sharp: Oh my gosh.
Dr. Annie: Yeah. That’s what it would’ve felt like if I sustained the practice insurance only. It was crazy. It was really uncomfortable, but it reminded me a lot of when I made the jump from this full-time state job to private practice, which for me, just because of the way my brain works, I worked my 40 hours at the State and then I would work [00:49:00] 20 more building the practice and then I could make the leap. That was what we did.
And this was advice from another person on the Facebook page that I did consult with, I keep gesturing to the wall. You can’t see my calendar. In addition to moving all the insurance cases up, we also developed a philosophy with private pay clients. We wanted to serve them as concierge as we possibly could. And that meant seeing them as soon as we could. And so we’re seeing 100 million insurance cases and then also immediately booking our private pays within a month. So it was nuts, but we survived and it was fine.
Dr. Sharp: Oh my God. Yeah, that sounds completely insane. So what was your private pay referral stream like before you got off insurance panels? Like what percentage?
Dr. Annie: 0%.
Dr. Sharp: Okay.
Dr. Annie: Yeah, we did not do [00:50:00] any private pay cases before that.
Dr. Sharp: Got you.
Dr. Annie: That’s not true. I think I might’ve done one and it was just because I don’t know why they didn’t want to use their insurance, but yeah, it was 0%. What we chose to do before sending a letter to insurance was to reach out to all of our referral sources and explain to them. I used hard data. I would call the physicians and I talked to practice managers or the physicians themselves or the therapist or whoever. Therapists were great because they really understood this stuff cause they did too.
And I said, we billed at $80,000 in the last X number of months, we recouped $22, 000, and we have tried every avenue we can think of to fix this problem. So we’re going to make this move to a different model. We want to still be able to support you if we can. If you have an urgent case, that’s really, really not going to be able to pay out of pocket and you just [00:51:00] really feel like you want to partner with us on it, let us know. So that’s the pro bono thing.
Most people did not take advantage of that. They were wonderful. They were so supportive. We followed up with a letter explaining all that stuff again, and also explaining why we felt we stood out from other practices that take insurance in our area, not just in our area. That sounds terrible. I’m not criticizing anybody, but what made us stand out, we thought.
Dr. Sharp: What were some of the things that you feel made you stand out or make you stand out included in the letter?
Dr. Annie: Probably a big part of it is these values that we keep dancing around. The desire to really understand the child as a learner and as an emotional being in the world. [00:52:00] And wanting to do whatever we need to do to deep dive and figure that part out, and partnering with parents and schools in that process. Collateral work is hugely important to us. And not just quickly assigning or not assigning a diagnosis, but more explaining all of it. I think our reports are pretty thorough. We do the backward pyramid thing, and just really try to include as many important people in that kiddo’s life as we can.
Private pay allows us to do a couple of things that are a bit a step further than you can do with insurance. So for example, I love to do in-person observations, but that’s hard to bill for, and especially when COVID restrictions started to lift them, we were able to see kids again, we’ll go to the dance class. We’ll go to T-ball, we’ll go wherever to do our [00:53:00] observations. And I think those little things are fun and they make you stand out to other providers. Maybe parents don’t realize that’s weird, but kind of little stuff like that. But the providers were amazing and they were so supportive.
And then we found that they would set the stage for us because they would explain it to their clients, and say, oh, insurance can really suck sometimes. They weren’t getting reimbursed, so they do this but do it anyway. They’re going to help you get in… The superbill thing is huge. They’re going to help you with getting as much reimbursement as you can get. And it wasn’t a problem, but it was really our partnership with referral sources. And they weren’t close personal friends. We don’t really know most of these people.
Dr. Sharp: Sure. I’m so glad that you’re talking about this because I think this is a huge hurdle for a lot of folks in going private pay is I will disappoint my referral sources or [00:54:00] nobody will refer to me, or people are going to think I’m greedy or people are thinking I’m going to think I’m selling out or whatever it might be.
So I appreciate you articulating how you went through that process. You’ve used the word values so many times and I love that. It seems anchored. When you have clear values that resonate with others, you can do a lot. That gives you a lot of flexibility because people trust you.
Dr. Annie: Hopefully, so. I think that’s true, but it sort of stops you from maybe wanting to do the things that we always sort of picture about, you know, greed or pushing your services or doing whatever. I would say probably a list of maybe 30 referral sources, and most of them, we only get one a year. They’re just these random therapists or whatever, but we reach out to every single one of them.
There [00:55:00] was just one that was ticked off that we went to the private pay route. And once we really had to sit down because I felt bad about that. Even she came around. I was very surprised. Everything about this journey has been surprising and not what I would’ve expected hearing some of the fears that we think are real about it.
Dr. Sharp: Sure. I want to ask about any other surprises that you’ve encountered, but I want to hold that for just a second and ask just very practically when you contacted the referral sources with this announcement, was that a phone call? Was it a letter? Was it an email? Was it a fax? How did you get that information out there?
Dr. Annie: All of the above. So if it was a referral source that we work with super frequently, I called. [00:56:00] If it was somebody that we also have email contact with, we would send a follow-up email. And if it was like most of the people that we don’t speak to as much on the phone but maybe we email or fax records back and forth or whatever, we just sent a letter in the mail, an actual letter, and then an email copy of that letter and fax if they had it. So we did all of it. I remember we did it over Christmas break. We shut down for like a week and mailed letters.
Dr. Sharp: Sure. I’m going to get back to the surprises questions. What other surprises did you run into during this process, either positive or negative?
Dr. Annie: I was just astounded at the financial difference. It was [00:57:00] just mind-blowing. And it made me kind of sad, but that was one really nice surprise, and the comfort I felt in the ability to do what I love to do without worrying that I couldn’t pay myself a paycheck because that was real for us for a long time.
I was shocked. I mean it. Just shocked at how many people were willing to pay. It really was so surprising to me. And I was very surprised at the power that word of mouth has when you know you can put your time and energy into a really good product and then how far that reaches.
Another wonderful referral source that we discovered that we didn’t work with before is private schools because when you are billing insurance, often you can’t do straight LD testing or whatever. And so that became another [00:58:00] great partnership and place for referral sources. So those kinds of things really surprised me. I was really surprised at how well received we were by the local physicians and staff too. I was for sure thinking that that was going to be a nightmare. But it was great.
Dr. Sharp: Yeah. It’s really cool to hear that. Looking back, is there anything that you would have done differently or advice for somebody who might be considering taking the leap as well?
Dr. Annie: I wouldn’t do anything differently. I wouldn’t go backward and do anything differently. I know a lot of people say, I wish I had done it sooner. And my pocketbook does wish I had done it sooner because I think it would have just been a little bit less frightening to be in private practice, but I’m glad we made all those mistakes and I’m glad we took insurance for as long as we did because that allowed us to build up that referral source. If we hadn’t taken insurance, nobody would have known us.
[00:59:00] So I think that it’s an important part of making the choices, maybe knowing your audience and how long you’ve worked to build relationships in the community. To be clear, we haven’t been around very long, so it’s not like we have a 15-year relationship with these people. It’s just that it worked really well. So, that’s one part of my thought for anybody thinking of doing this is really being confident in your referral sources and knowing that you’re delivering a good product no matter who is paying for it.I think the other piece is being clear on what your purpose is, not a philosophical purpose, but if you want to move off of panels but you have this design to do whatever it is, for me, it was serve Medicaid and [01:00:00] other access issues, to figure out those ways beforehand so that you’re ready to rock. I think you can do that through brainstorming with yourself or your team, but I also think consulting can be really helpful for that. Just going back and forth with other business owners to say, how could I do this? If I really wanted to do this, how could this work financially? And get that on paper beforehand because you’ll feel more comfortable.
And then lastly, if you’re a person like me who needs a little bit of stability and can’t just go willingly, maybe think about finding just one contract where you know you’re going to get paid so that you’ll feel better.
Dr. Sharp: Yeah, I think that’s an important point as well. It doesn’t have to be all or nothing. It’s not all insurance and or all private pay. You can do a hybrid or you can do it slowly. Like you don’t have to get off all the panels at the same time.
[01:01:00] Dr. Annie: Oh yeah. My practice manager, Kim, was realistic to me because I want it to jump off of everything at once. We were a little sub. We did it over a month, but I will say, and I mentioned this very briefly and forgot to highlight it, but we still take TRICARE because we think military families have enough to deal with. They don’t need to worry about private paying for things too.That also is reassuring because we also know, well, that’s one insurance panel that will pay even if we didn’t have the contracts and nobody else wanted to pay. So maybe keep one for a while.
Dr. Sharp: Sure. There’s so much good stuff in this conversation. I feel like we’ve covered a lot of ground and I’ve been taking a lot of notes. I hope that people are taking quite a bit away from our discussion here. And if nothing else, you’ve given some people some confidence to consider this leap. It seems like it’s working for you.
Dr. Annie: It is. It’s wonderful. [01:02:00] It’s exactly what I envisioned when I opened the place, except better.
Dr. Sharp: Amazing. That’s what you want to hear. Oh my gosh. It’s so cool to see where you have landed. I know it was a journey, but here you are. It’s really cool just to see everything you’ve got going on.
Dr. Annie: Thank you so much. And truthfully, I have to just drop my plug for you that I really could not have done any of this without your support and all of your consulting work with me over the past two and a half years. Just saying. He did not tell me to say that.
Dr. Sharp: I’m glad people can’t see us. I’m blushing. No, thank you. It’s been a joy really. And like I said, awesome to come full circle and let you share your experience with other people because I think it encompasses a lot of feelings and [01:03:00] hardships that others have gone through. I’m glad you came back. Glad you’re doing this.
Dr. Annie: Thanks.
Dr. Sharp: Yeah. So thanks for everything, Annie. We can chat about any resources that you mentioned and maybe including those in the show notes, but if folks do want to reach out to get in touch with you, one, are you open to that? And if so, what’s the best way to do that?
Dr. Annie: Absolutely. Yeah, that would be fun. I am more than willing and I will give you my email and you can share for people.
Dr. Sharp: Okay. That sounds good. All right. Thanks so much. It was great to talk to you.
Dr. Annie: Thank you too. Bye-bye.
Dr. Sharp: Thanks for listening y’all. I hope you enjoyed that conversation with Annie. I definitely did. I love talking to her. I love her energy and I think she’s doing great things in that practice. Hopefully, you’re taking some inspiration and some ideas for how to [01:04:00] incorporate more private pay and private pay adjacent services in your practice. I know a lot of us wrestle with this idea.
Thanks for listening. If you are interested in taking your practice to the next level or even getting your practice to a level, we’ve got open cohorts of the Beginner Practice Mastermind and Advanced Practice Mastermind. You can get more information for each of those at thetestingpsychologists.com/advanced and thetestingpsychologists.com/beginner. I would love to chat with you to see if either of those could be a good fit depending on where you’re at in your practice.
All right. That is all for today. Hope you’re all doing well. Getting ready for the start of the school year. That’s the theme in our house right now. By the time this is released, we might even be in school. [01:05:00] We will see. So thanks as always for listening. Love y’all. Take care.
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