Building a Strong Mental Health Private Practice

How To Grow Your Private Mental Health Practice in 2021 (‘Building a Strong TMS Practice’ Webinar Transcript)

Note: This content was originally discussed in a webinar. Find the Full Webinar recording here: https://gentem.com/lp/building-a-strong-tms-practice-in-2021/

Hi, everyone. Welcome. My name is Omar Khateeb. I’m the director of growth at Gentem Health, and Dr. Khaled Bowarshi joins me.  We will go into some key topics for growing a successful private mental health practice. These are topics that anybody in mental health or private practice can take and put into implementation for a successful 2021.

Let me tell you a bit about Gentem. We are a full platform from end-to-end when it comes to revenue cycle management and billing. We have a very simple mission, which is to simplify and accelerate an increased reimbursement.

Private practice medical practices never have to worry about revenue again. And that way, they can focus on patients. We were founded by a Stanford educated physician and a former Facebook software engineer. And our company’s vision is that we want to help revive the private medical practice and help providers remain independent.

Let me tell you a bit about our guest speaker. Dr. Khaled Bowarshi graduated from medical school in 2010 and did his residency at West Virginia University of Charleston in two specialties. One in internal medicine and one in psychiatry. He chose this combined training in medicine psychiatry to understand the direct connection to mental and physical health. There are only about 10 of these intense, integrated residency programs in the United States and altogether they produce about 20 dual training physicians. We’re speaking to somebody with a unique set of expertise and unique private practice. So this makes doctrines such as integrative training unique, but most importantly, this helps him see unique circumstances for his patients. During his various years of experience, he’s won multiple awards across multiple leadership positions. He received the outstanding educator award for excellence in clinical teaching. He also served as the chief resident position for both medicine and psychiatry and categorical psychiatry, taking both leadership positions at once. After he finished residency training, he worked in a staff position for the same hospital. He then served as a clinical instructor for medicine, psychiatry, clinical training, training other physicians, and teaching medical students. Finally, after doing his fellowship in TMS training at Duke University in 2019, he started his Florida TMS practice shortly after bringing the most advanced TMS technology to Wesley Chapel in the Tampa Bay, Florida area. He’s currently double board-certified in internal medicine and psychiatry and is a member of the American Psychiatric Association and Clinical TMS Society. Dr. Khaled Bowarshi the floor’s yours.

My God. I’m blushing. I know that our audience are looking into or interested in private practice, and that’s basically what matters. I finished residency in 2016, and I currently own and operate my mental health practice, which you guys could relate to if you were thinking about opening a private practice.

You don’t have to wait forever. You can do it as soon as you could. I probably would have done it, you know, sooner if I wasn’t, waiting for my immigration status to become a permanent resident of the United States of America. If I were able to get that done a little bit earlier, I would have done it.

So, I was hoping you could relate to this part a little bit because you don’t need to wait. If you’re thinking about it, then this is a time to kind of give it a thought and see if you can go ahead and start.

So our agenda today, number one, I want to tell you why this is important. Most of the participants today are in behavioral health. If you were in general medical practice as well, a lot of this could apply to you, but most of us are in behavioral health. So we want to understand why, particularly for behavioral health, we have such a need. So we need to know why it’s important.

Number two, we need to know how to start. How to get there, once you started, and then I might talk to you about the five pillars of successful private mental health practice. So that’s generally what I’m going to go through today. Any conflict of interest? No, thankfully, and that’s part of why some of you might be interested in private factors because you can speak your mind and do what you think is right.

I don’t get paid by anybody except for my own practice. So, if I mentioned a manufacturer of TMS device over the other or something like that, or I’m talking about Gentem today, I have zero shares or financial incentive from Gentem. I like what they’re doing, and I’m willing to share my positive experience with them, with anyone else.

And I want to, to kind of pause here with a conflict of interest. It’s very important whenever you’re taking advice, especially when you’re starting in private practice, who has given you that advice and why. So if you are hiring a person to coach you through things, this is good, but if you, or if you are getting free advice like the swan, or you’re kind of listening to other people to experience them, this is also good.

If you’re taking advice from somebody who could have a conflict of interest, you just need to be aware of it. If you’re taking advice from a certain TMS manufacturer or a medical devices manufacturer, you want to have that in the back of your mind. If I am getting the advice from so-and-so, there might be a conflict of interest that would help you be a more educated consumer of social advice. So this is an important factor. I said this is another reason to be in private practice because you can speak your mind. You are going to see me speaking my mind a lot today.

Interested In Starting A Private Mental Health Practice? Why It’s Important.

Why is it important to start a private mental health practice? I think the main reason why it’s important is because of the current healthcare crisis. You can’t find two people who would not agree that we have a healthcare crisis in the United States of America. Particularly when it comes to the delivery of healthcare, the cost of healthcare, you can see that every election, whether it’s on the local level or national level, they would use the card of healthcare crisis.

One of the agendas is the spending of healthcare money. It is on the rise. We are spending too much money. We don’t get the same value that other countries get. We don’t get the same value that we could get if we improve our healthcare system.

We know that large healthcare institutions are the leading spenders. That’s where most of our money is spent on. This takes you back to; maybe we need to take ownership with the healthcare system again, like me and you, the average doctor, Joe, and the average Joe.

So we need to take, take control again. You know, we need to provide the best care that we think is the best for our patients. As long as we’re leaving it for, you know, investors and the MBAs and healthcare system and insurance companies and stuff like that, the more that the expenses are going to grow larger and larger.

Less delivery of care to the patient increases the gap between revenue and spending and makes more profit. So I think, and I think many economists think, the same way that, small businesses are what’s going to save the economy. I think that private TMS practices are going to save the healthcare system at some point.

So you might want to think about that. When you’re considering the bigger picture, I don’t know why I put this slide in here, but I was kind of trying to demonstrate some of the ironies, the irony of our healthcare system. That piece of news struck me when it came out on the news. Envision, which is a large multi-physician group, basically, it’s a physician group that, that stocks multiple hospitals in the US, mainly HCA facilities, you know, but anyway, they got into a legal dispute with the United and that piece of news. I’m going to leave it for your interpretation. According to the press release, Envision accuses United of reducing reimbursement for doctors while reporting record profits including more than six billion in the second quarter of 2020.

So we know that with COVID-19 patients, we’re not going to like, for their routine medical care as often. A lot of insurances have made more profits, for the second quarter, in this situation, they made significant, more profit, but that did not stop them from trying to cut payments to physicians.

I don’t know which side to take. I’m not going to take Envision’s side when they also charge three times the physician fees than a small TMS practice. So if you are a small TMS practice that gets a third of what’s Envision was billing, I just want you to take a moment and observe this fact here to know how big a crisis this is.

There are multiple players in there trying to make as much profit as possible from the healthcare system rather than focusing on the patient. And rather than them focusing on the person who delivers healthcare which is the physician, right? So the physician is a leader in that healthcare system. It should not be the investor. It should not be the MBAs and stuff like that.

The Solution Is Your Own Private Mental Health Practice

The immediate solution is to take the initiative and have your own private mental health practice. Nobody can give you an order any more. Well, you still have to adhere and do what’s right for your patients. I’m not saying anything like not doing the best thing. You will still do the best thing for your patients, but you are taking leadership, right? You take leadership for your own patients, so you’re setting an example. So we know why it’s important because of the healthcare crisis.

So we have a mental health crisis. In politics and public, we only talk about it when there is a mass shooting. Another couple of situations happened as well, but then a week after that, nobody talks about the mental health crisis, and nobody wants to spend money on it. And I’m going to say something hurtful for me a little bit here. When I speak about that, I think many of our audience members who listen to this that work in mental health know what I’m talking about. We spent trillions of dollars on COVID-19, right? We came up with a new methodology of vaccination in just one year. So we found a solution to the problem. We all united to fight COVID-19, which is the right thing. When we all united to find a solution for this problem, we spent money on it. We were able to tackle it, and I’m vaccinated.

Now I know a lot of the doctors are now vaccinated. I think 20% of the Florida residents are vaccinated or what have you. So within a couple of months, everybody will be vaccinated. Imagine if a fraction of this effort was put into mental health, right?

Imagine if 10% of this money is put into finding the solution for depression; suicide kills people. Depression is on the rise among our teens and our next generation coming up. So imagine if some of this money is put in there, how much better things will be in the future. So, okay. Let me go back to why mental health is important and why we need to take control of that in private mental health practice.

Mental Illnesses Are Prevalent & Difficult To Treat

It’s common, you know, mental illnesses. It has a stigma to it, right? So say people commonly want to look better, and they want cosmetic procedures and stuff like that. So you see a medical spa next to another medical spa. There is no stigma about it, right. But people do have a mental illness, but there’s a stigma to it. So not everybody is so excited about running mental health private practice. It’s difficult to treat, right? So, you do injections for lips and what have you, and things are better immediately, and you see the effect of them, but for mental health, it’s more difficult to treat mental health disorders.

Psychiatric disorders are difficult to treat compared to other things, right? So it’s common. There is a stigma to it, and it’s difficult to treat. What does that mean? It means there is a need for mental health care for the next tens of years. So this is not just like in the next five years; this is not the next ten years. This is the next 20 or 30 years before the demand and supply will equalize again. So that’s another reason why, if you were on the fence about opening your private TMS practice, maybe you should not wait. Demand is going to continue to increase over time, and you will, you’ll be needed.

Let’s, let’s take some data, right? So, about one out of five Americans have some sort of mental issue at some point in their life. So that’s going to be this year as well. Maybe, even more now with, with the COVID. I think the study from, I think it was published in JAMA, looked at depressive symptoms, and depressive symptoms were three times more during COVID.

Mental Health Care For Depression Is In Demand

Mental health issues or disabling and increase the demand for health care. The world health organization ranks depression as the number one reason for a disability in the world.

Some people now don’t like the world health organization anymore after COVID-19, but you know this piece of information is before COVID, but you might ask yourself, is it the most disabling? And the answer is yes if we’re looking at mortality, yes.

Coronary artery diseases are number one, but when you have a heart attack, you might die, you might survive it. When you survive a heart attack, you might need a cardiac, we have for a couple of weeks, maybe a month after that, but you go back to normal function. That’s number one, number two. Is that usually your old when you have a heart attack.

So coronary artery disease and cardiac issues will cause a problem when it comes to this disability for somebody who is already at retirement age with depression. Depression is hidden in significantly younger than those other illnesses. And it’s taken that person out of the workforce for more extended periods and more frequent periods, right?

Depression Can Relapse If Left Untreated

It’s a relapsing-remitting disease. You can have a depressive episode every year or every couple of years, or what have you. And when you have a depressive episode, if it goes untreated, you could be out of the workforce or out of social life, you know, or engage in with your family, spouse, and loved ones for a good while.

So it is disabling, and the economic cost of depression exceeds $210 billion annually. So that’s nothing to sneeze at. So again, if we can put some money into mental health, we should not stop. This is a good investment. This is one of those things that we can. It will pay dividends for short in the future.

So if we’re looking at depression, for example, to start somebody on an anti-depressant and expect some outcome, you need at least four weeks. Most of us think about four weeks to eight weeks before you would expect any outcome from an anti-depressant similar thing.

If you are getting somebody into psychotherapy, nobody does just one session of therapy. Today, you need 12 sessions of cognitive-behavioral therapy before you start seeing some improvement. If you had somebody on medications and psychotherapy, you were still left with about 30% of patients who have treatment-resistant depression, again, difficult to treat.

Patients Need More Than Classical Treatments For Depression

This population of patients needs something beyond just classical treatments. So all of this speaks to this principle I’m talking about, which is we need to do something about mental health. If there is one specialty that I will pick for private practice, it would be mental health.

Generally, whether you’re a therapist, whether you’re a psychiatrist, no matter what you do, that’s the one that I would pick. This is the slide that I showed you, the disability weight of depression. So severe depression has more disability weight than dying of cancer without treatment or actively having a heart attack.

Now, moderate depression might be less than a heart attack, but you know, this is how people will value it. The world health organization has specific criteria for how they put the weight of disability on something. And based on that criteria, depression is more disabling than dying of cancer or having a heart attack.

And that slide speaks to the difficulty of treating depression. So I’m just going to point with my mouse here to what we will do or the response rate if you simultaneously have anti-depressants and psychotherapy. So you have a high response rate, and you have a higher remission rate appropriately, right?

So 50% of patients will remit if they did both at the same time. But if you’re talking about anti-depressant who started the trial. The first chances of an anti-depressant have about a third of patients remitting. Still, as you progress switching somebody from one medicine to the other, the chances of responding go down significantly until you reach that third failure of anti-depressants. Your chances of responding are considerably less.

Response remission treatment outcomes for depression
This chart describes response remission treatment outcomes for depression

So, it would be best if you had a radical solution, and that’s where TMS comes to play. I am a TMS specialist, and that’s what I like to talk about the most, but this could apply to any niche of yours. So if you are somebody who treats PTSD with EMDR and you know how difficult it is to treat PTSD for patients and have mastered EMDR well, and you want to do that type of therapy for your patients.

So you probably are going to be facing a similar kind of graph where you are, where you in a particular niche. It could be helpful to slide in between and provide the value of care that you’re looking at. Okay. All right. So we know it’s important. We know what we need, we know, we are in a healthcare crisis, and we know we’re in a mental health crisis.

How Do You Start A Mental Health Practice?

How do we start a mental health practice? You know, so where is the starting point? So the start usually has to begin with a goal. You need a goal, you need something, first of all, you need something to push you to go that route because, you know, start in private, private mental health practice means a lot of fork on many headaches sometimes.

So you need someone to be, and, uh, I don’t know if I want to tell you my, you know, some personal stories or not, but I’m just going to go on a limb and tell you a little bit. Okay. So I used to work for a hospital. When I moved to the Tampa Bay area, I worked for a hospital here as an inpatient psychiatrist, and I think one of my meetings was awkward after a couple of months of practice.

And at that hospital, they had a meeting, and basically, the administrator of the hospital was talking to me about the length of stay. So I’m not sure for a psychiatrist who practices here in Florida, we have something called Baker Act, and a patient will, if a patient is severely depressed and they’re admitted under Baker Act, then you have, you have basically 72 hours of involuntary admission.

But usually, insurances will payout for seven days already. So you already have approval for seven days to treat this patient. And I was treating those patients with depression in the hospital until they are not suicidal anymore, and I will discharge them. So my average length of stay was lower than the average psychiatrist length of stay in my mind.

This is a good thing. And a lot of my colleagues in internal medicine who worked for hospitals, usually this is a good thing. If you can get you a patient treated for a certain condition faster, you basically you’re doing a better job. So in that meeting, the statement got me kind of questioning what I’m doing.

She do, you know, your length of stay at the hospital? I was like, well, teach me how what’s my length of stay in the hospital. Well, your average length of stay is 5.4 days or something. So I’m like, okay. So what’s, what’s the problem with that. And, you know, do you know the average length of stay of a psychiatrist in our area?

He tells me it was 6.8 days. I’m like, okay, so where’s the problem. And then he says, we are leaving money on the table, right? Meaning that a patient could, who, you know, you’re discharged. And in five days, we could have kept them for another couple of days, and we would have made more money.

That, for me, was a little bit of a moral injury. I did not. I think, you know, in my training and my mental health practice and in what I do in life, that a financial drive will mean that somebody will change their opinion about whether they will keep a patient in a hospital or not based on whether to keep them longer or not.

So I decided I’m going to leave that job. The department year is that I was interviewing for a different psychiatric psychiatry job from leaving that job. And then, my next interview was with a very smart physician who was leading the group. And we got to a point when I was talking about, you know, how to get compensated.

And I wanted to get compensated by RVU, meaning that the more patients I treat, you know, that means that I’m doing put in more effort than the more I get paid. And that would not be a problem for the group. Well, that doctor at that time was talking about shares of revenue. And my answer to him was if I wanted to worry about shares of revenue or how to collect money from insurances and how-to, you know, sort out the payer mix and stuff like that, I would have opened my own mental health practice. And, you know, we ended the interview there, I went back home, and I was like, wait a second. Did I just listen to myself?

If I wanted to worry about things, I was saying those things I would have opened my practice. So why don’t I open my own mental health practice? Because I’m scared of dealing with, you know, billing and dealing with insurances. I got gentle now, you know, they’re doing that for me. But at that time, I was thinking, well, it’s a fear that is unreasonable.

And because it’s an unreasonable fear. And that’s how I deal with my patients in psychiatry because it’s an unreasonable fear. I have to tackle it, and then I have to try it. And if I try it and validate my fear, then it could be half a problem, you know, to kind of quit it. But if I try it and I find out that this was unreasonable fear, I broke that wall between me and went into private mental health practice.

So I went ahead and tried it. Okay. So why am I telling you all of this story while I’m telling you this? Because you probably have a reason why you’re listening to this. You did not just come across building a private mental health practice, and you just clicked on it, and you wanted to watch it now or watch it later for no reason.

Why Do You Want To Start A Private Mental Health Practice?

You’ll probably have a reason why you were fed up with this system and want to start your own private mental health practice. And you’re thinking about the solution to the problem. And the solution is obvious being your own boss, you know, building a private practice. You just need that pain point to be to a level that you will be able to put effort into building your private TMS practice.

So if, if that, if that doesn’t motivate you, then you probably don’t want to continue reading this. But I think if you are already motivated that you have a pain point already, you know that you need to do it and now let’s make a plan.

Determine Your Goals & What You Want To Achieve

Number one, make a list of your goals. So the goal is going to be two pieces. One section of the goal is your personal goal of what you want to achieve. The other one is a social goal of what the impact is that you want to leave. So for your personal goal, that’s when you go back to yourself and dig inside. What do I want to achieve? And since I’m not you, I’m not going to be speaking for you. I’m going to speak for myself in my situation.

I want you to be an expert in one niche. I want you to be specifically the guy to go to for one particular niche. I know some people say niche, some people say niche, I’m not going to get into this discussion, but you know what? I don’t. Okay. So, you know, I wanted to be the guy to go for one particular niche.

Number two. I want you to use the most advanced medical technology in what I’m doing. I’m the kind of guy who wants to use the, um, the best, uh, you know, laptops and computers and software, you know, for my business, even the phone system and stuff like that. I always look for better medical technology to solve the problem, look, technology cost us a lot of problems when it comes to depression and anxiety increasing among teens who are on social media and spending so much screen time and stuff, the least we can do is to use the same weapon, which is technology to fight against those kinds of things, depression and anxiety.

So whether this is biofeedback that you’re doing today, or TMS that you’re doing today, or other use of other technologies to kind of help with mental health, You know, that’s, that’s the right track to go to holidays. Okay. And then, last thing I wanted to practice medicine the way I see fit.

So remember that example between the administrator and me, administrators in the hospital, leaving money on the table, that should not be the case anymore. I practice medicine based on the moral and ethical standards that I have. If I see a patient whose insurance does not want to pay for TMS, I think they need it; I just do it pro bono.

I don’t have to go back and check with somebody to kind of give me the green light that I can do it not. So there was a personal set, satisfaction component that’s involved in it. Okay. So that’s my personal goal. You are going to dig inside of you and find your own personal goal.

Okay. But after you do that, you probably want to see the society that you’re in, and you want to see a social goal or an impact that you’re going to leave because, at the end of the day, you could have the best or the most satisfying job in life. But if it doesn’t leave an impact, if it doesn’t leave a message for the long term, you might find yourself a little bit deficient.

My Goal Is To Make TMS Affordable & Accessible

So a mission statement for your TMS practice is important or a mission statement for what you’re doing. And in my situation, it was making TMS accessible and affordable for everyone who needs it for you. It might be different. It might be, you know, delivering TMS to rural areas. I found my niche to be in TMS therapy. Okay, so yours could be different depending on what kind of specialty you have. This image is just to show you what TMS is. You are using an electric coil to stimulate a certain area of the brain called the dorsolateral prefrontal cortex, which is this lateral area of the forehead.

Demonstrating the TMS therapy in a private practice
Demonstration of TMS therapy in a private practice

My system is a little bit more advanced than this one. It has a navigational system as well, so it can actually track where the call is placed at all times. Okay. So we made a goal now we need to make the plan.

Make A Plan To Open Your Private Mental Health Practice

When am I going to open my mental health practice? You need to make up your mind now. Which insurances I’m going to take? Am I going to take insurance or not? I know that some therapists and you might not want to take insurances. Which area I’m going to open in? I might go into the open and underserved area.

Am I going to be opening away from my competition? Or am I going to be open? And you know, in the middle of the city, you know, and among all my competitions and what have you, and then once you make a plan and you get to that stage, you’re going to find that some of your plan points are not good. And you’re going to have to adjust your plan, right?

So you adjust your plan. There is nothing shameful without don’t stick to something that doesn’t, it doesn’t work. You test things, don’t work, switch it, and go ahead with the adjustment you have, and then you’ll learn from that experience. So if you need to add something else in the future, and you need to start from the beginning, we’re given to use your previous experiences in making the next nine more flexible.So you can adjust it over time.

So we have a goal, we have a plan. We have a goal of what we need to achieve from our private mental health practice. And we have the plan, you know, made up there when you are making your plans.

How To Have A Successful Mental Health Private Practice

You’re going to establish pillars of the main things in a business plan to follow so you can have a successful mental health private practice. So, I made the five pillars that I thought were very important in a private mental health practice. And I’m going to share it with you guys. I think the first one that I had as a pillar for private practice is quality.

Okay. So to be successful in private practice, I need to be the best. And I know that a lot of doctors are narcissist. You know, I’m going to admit that. And I know that’s what I’m going to say. It sounds like a little bit egocentric kind of thing, but, you know, I promise you, this is a very, very accurate statement being the best is not optional.

So you must be the best at what you’re doing. I was doing a directory for all the TMS practices in our area because if a patient reaches out, which is out of Florida, we want to refer them somewhere. I need to know every other practice and how they deliver their treatment. So we provide, we refer them to the most appropriate one. And when we’re making this list just in the Tampa Bay area itself, I think there were 28 TMS clinics.

That’s a huge number for something for the treatment that this new. So I can’t be average among 28. Right. I need to know everything about TMS. I need to know more about TMS and anyone else who’s providing this service in my area. So, I advise somebody who’s starting a private mental health practice.

You already have a little bit of a disadvantage when it comes to timeline compared to somebody else who’s already opened or the next hospital next to you, or next healthcare system, that’s open next to you. So how do you distinguish yourself from them? You need to know everything about your specialty, about your particular niche.

Mental Health Patients Deserve The Best Therapy Services

No one else should know more than you do about the treatments for mental health patients. Okay. Well, except researchers in academic centers and stuff like that, but in private practices, you need to know the most. Okay. You also need to choose the best option for your patients when it comes to quality. So one, you are the best quality as a, as a provider, you know, so, you know, you’re confident that you have learned everything that you need to learn and you know everything about what you provide them with others provide number two, when you’re making choices, whether location of your clinic, the kind of treatment, the machine you’re delivering your treatment with the way that the treatment is delivered, the number of sessions that are being delivered.

You always need to make sure that you’re doing the best interest of your patient. Now focus on that a little bit. I did not say that. What makes you money? I did not say what makes the mental health practice survive? Like what’s the point of surviving a practice when you’re not providing the best quality of care, right?

Choose The Best Treatment Option For Your Patient

You need to provide the best mental health treatment option for your patients and be in private practice to do this. So I gave you an example already of somebody who might not have insurance, and they qualify for TMS, and they came to your door. What are you going to do? If you decide you were going to do it pro bono, do it.

Example. If somebody had insurance and they’re going through TMS and TMS costs a few thousand dollars, because it’s 36 sessions of treatments and in the middle of the treatment, they lost their insurance, right? So the best thing for the patient is that you don’t stop their treatment. You just continue because otherwise, they will relapse into their depression, but they don’t have the money.

So do the right thing. And in this situation, go ahead and do the right thing to increase your own morale. You’re on ethical standards. It would be reflected on your staff. It would be reflected on your patient as well. And that would be the best thing to be done. Then quality is not something that you can negotiate.

You have to always keep it up, continued education. So some newer setup or stimulation has come into TMS. You need to be on top of it. You need to learn about it. You know, stuff like that. And you need to teach your staff.

Improve The Quality Of Treatments

Lastly, I would say quality, you know, how hospitals develop quality improvement initiatives and stuff like that? Well, here’s the good news in private mental health practice. It’s effortless to implement, see something, not say something, see something, go ahead and do something. Right. You know, you can fix things immediately in private practice. All right. I’m not going to give you examples because it’s going to be specific to TMS, which, you know, usually, when I find that we can improve something with, with adding the camera or add an, you know, a wifi system, you know, for some of the devices and what have you, we do it the next day. It just a matter of getting, ordering something and getting shipped, and then doing it the next day.

Expanding Your Private Mental Health Practice

You know, so you’re going to start with a few patients, and then you’re going to expand your mental health practice over time. So expand, but be smart about it. Meaning that you don’t drop the quality because you are seeing more patients.

Don’t end up being the psychiatrist who is, you know, higher-end, you know, 500 practitioners and he has no clue what they’re doing, you know, and how they’re practicing medicine. Right. So if you ended up expanding, go ahead and do it, but keep the quality the same or even increase it.

Always Provide Excellent Services For Your Patients

Do more of what you’re excellent at rather than adding other things that you’re not good at. In our field of TMS, a lot of doctors will add ketamine practice, you know, because the same patient who has treatment-resistant depression might not respond to TMS.

So they might qualify for Esketamine or ketamine. I think it’s appropriate, but still, focus on one thing first and master it before you spend time on that other thing. Okay. All right.

Choose The Best Technology & Software For Your Mental Health Practice

I think you need to use the best technology available to use in your mental health  practice. So choose the best EHR, choose the best billing system, you know, choose, I put a sentence down there that if your builder sends you a sheet of paper for like, you know, giving you like, you know, real receivable and what have you fired them yesterday? You know, you already too late, you know, why, why is even your biller using a paper system?

Like it doesn’t make any sense nowadays, right? There are much more advanced technology to do billing and automate all of that. That you, you will be in stone ages. If you’re, if you’re still using paper and old systems, it’s not only HR and billing, your phone system should be also advanced. You know, your patients should have an easy access to send you their insurance card in a text message to your main phone line, for example, That is very, very convenient for a lot of it and still HIPAA compliant and what have you and all those kinds of things. So always look for the best technology, and implement it whenever possible.

Increase The Public Awareness Of Your Private Practice

So you could be the best doctor, you know, by the way, awareness means marketing your private practice. I know that doctors have are sensitive. You know, we’re allergic to the word marketing because it seems it sounds misleading, which is not the case.

You know, marketing is everywhere in our lives, even in medical care. And that’s, what’s why your patient comes to you and they ask you, Oh, Hey doctor, can you add Vyvanse? Can you give me Trintellix? Why? Because the commercial on TV told them, talk to your doctor about Trintellix. Telex can help with depression and whatever.

So somebody is already doing marketing. If you don’t want to do it, don’t worry about it. You’re still going to be a victim of it. If you think that you’re a victim of market and somebody is already doing it, so you better take initiative of that. And change the name from marketing to awareness because that’s what it is.

And awareness is one of our duties as a physician. So you could be the best doctor, but if patients don’t know that you’re a good doctor in the area, then they are not going to find you. Okay. And work on your reputation as a doctor, before you even start your mental health practice. So, I think I read some statistic that was looking at what makes patient decide that they’re going to come see a doctor about washy versus they want to go see doctor Jill.

Okay. So they decide first based on their insurance. Unfortunately, you know, this doctor is, is this doctor in my network with my insurance? Or are they not out of network for my insurance? Number two is that they will look into reviews. They would want to see your reputation. So putting your mind that you are looking at your reputation as a practice and as a doctor.

Patients Will Market Your Therapy Services

From the day or the first phone call, you have to kind of draw out the patient’s therapy journey from the beginning to the end. From the very first phone call you want to think about what the patient is going to say at the end of it, from the very first phone call, technically, every patient who comes to your mental health practice is an ambassador for your practice.

They’re going to talk about you, whether positively or negatively. You can’t avoid that. Whether they are talking to one person who is their spouse or their family member or talking to a thousand people, writing a review somewhere will happen. So each one of them, each one of your patients, is going to help in use spreading awareness about mental health.

So keep that in mind in every interaction that you have. And I’m going to kind of take you on a side, talk a little bit here when it comes to reputation to kind of bring the bill parts a little bit into this, you know, so we kind of bring our attention a little bit into this discussion. I read one of the, of the, of the statistics of what would make a patient leave a negative review for a doctrine.

And it seems that two of the main reasons, rarely it’s the doctor himself, right? But to two of the main reasons, one is the staff, particularly the front office staff, right. You know, that person who’s taken the copays or who is, you know, checking that patient and checking them out. The one who’s answering the phone, rescheduling scheduling following up on patients, why they showed up.

Why did not show up if they’re rude or if they’re not, you know, very compassionate and empathic with patients, again, especially in mental health where our patients need that part of things, then it might be, it might be a little bit of an issue and you might get negative reviews in this regard. Number two is your back office, which has billing, right?

Billing Patients For Therapy

When errors in billing happen, your therapy patients will only review to kind of get their revenge. So, they will write some review about that mental health practice. That could be hurtful. Then why am I saying this now, when we’re talking, when we’re getting to the point of talking about billing and stuff of the sort, because you want to decrease the interactions that are related to billing to the list, to the least number of interactions.

You don’t want to have to send a bill to an insurance company and get a rejection because when you get a refusal to the office, the patient is going to get the letter of rejection as well. And then they’re going to call your office and they’re going to ask, Hey, what’s going to happen? Am I going to be liable for this, for this bill?

Or what have you? And then you offer, Oh, no worry about it. We’re going to send it again. We made an error in a prior authorization number, or we made an or in so-and-so and we’ll go into submitted again. So they submit it again and then they might get another denial right now, the patient is worried again about, are they going to be billed with this or not?

Choosing A Billing Company For Your Private Practice

It’s crucial to work with a professional billing company that gets a right from the first time and gets your bills submitted as soon as possible. So patients will not have a memory issue of why they’re receiving this bill and get it right from the beginning. So that will mean the money will come back to a mental health practice as soon as possible.

And the patient will check this off of their list as soon as possible. Believe it or not, choosing a billing system and billing company that is effective helps with your reputation and helps with awareness. And we’ll put your name up while doing it in house. Sometimes could cost you an arm and a leg, not money wise, but reputation wise because yeah, you can train somebody to do billing for you, or you can do it yourself, but the chances of errors or higher and errors in billing will cost you some reputation.

Marketing Budget For A Mental Health Practice

Spend about 20% of revenue marketing your mental health practice in the first two years and 10% after that. I would still do it no matter what specialty I go to, you know, whether this is mental health or whether this is just, you know, uh, general med management, or this is general therapy, I would spend 20% of the revenue on marketing in the first couple of years, at least. The more you put in the beginning, the less you will need to put in at the end because then those patients are on your panel and you’re done with this, with this part of marketing, and they will become your marketing agents.

Right. You know, each one of those patients who are happy, they’re going to spread the message, just like how gentle has me now. Right. Okay. Happy customer was gentleman talking about them. Similar idea, take what you’re seeing today and try to implement the exact same thing, you know, for your patients. All right.

Next topic we’re going to talk about is money. Okay. So money is essential as a fuel to the vehicle of private mental health practice. It’s not the goal. Okay. So when you get into your car, you’re goal is to get from Tampa to send pizza, right? You know, you have a destination that you’re going to, the goal is not the fuel.

It’s not burning fuel. I want you to think of cash and money as the more that you have, the more comfortable you are in getting to your destination, your destination is to be happy in your life. As a provider of health care system. So what does that mean? That we need to think about money. We cannot just ignore it. You’re going to fill up the tank before you, you know, drive into your destination.

Physicians Should Never Take Loans. Do This Instead.

Never take loans. A lot of people don’t agree with that and they will take you to take smart loans and stuff like that.

A better solution if you were establishing a mental health practice and you need the cash flow to come in rather than waiting for insurances to pay you, is take advantage of the advances that Gentem offers.

Basically you submit your bills. Gentem will, based on your contracts with insurance, will find out how much reimbursement you are going to get back from insurances, and they will pay you advances ahead of time.

So you can expand your mental health practice, do whatever you want to do and stuff of the sort and, and move on in your life rather than just sitting on your hands and waiting until the money comes in.

The problem though, is that Gentem is so good about getting your money so quickly that the difference between advances and when you will get your money if you are not making advances, it’s not that long.

You know, I think are my, our average now is 20 days, you know, from the date of, uh, or from the time of submitting the bill after 20 days, you know, all of our bills are paid by insurance, which I think is a very good number. Generally, they submit the bills actually on the same day or the next day usually. If you were still kind of concerned about cash, you know, you can take this option.

Selecting A Partner For Your Private Practice

I know it’s a little bit harsh, but it’s another, one of those things that I speak my mind. So, you know, again, I’m in a private mental health practice, but I would not part partner with a non-physician.

Now. I don’t mean physician, physician. I mean, not the medical or healthcare provider, and it’s a little bit complicated in this situation. In terms of when it comes to making a decision, there is a certain ethical standard that we, physicians and healthcare providers and mental health care providers, adhere to. Business people might not do that. Okay. So if you were, if you were 50% with a partner who is, I don’t know, like a car dealership owner. He probably, or she probably would not have the same ethical standards that you do. And at some point, that’s going to show, okay. So my advice is, you know, the only partner was with healthcare providers, and your spouse does not count. You know, she can be whatever she owns, everything, you know, so now it doesn’t count.

Own The Assets In Your Private Practice

Own everything in your mental health practice, maybe except for real estate, you know, so the more you own in your practice, the better it would be. It might not apply much to private mental health practice therapy or practice med management.

But if you’re doing mental health, you’re using a very expensive machine. If you lease it from a manufacturer that still limits you for how many times you’re using their machine and won’t pay per use, you don’t control everything because every time you need to use the machine, you have to pay them.

Right. So then when you were making a decision about, do I want to add extra treatments for my patients or do I want to do right side a treatment or do I want to try, you know, a different protocol or something like that? You always, you will have to go to the manufacturer, which means that it’s taken the control out of you.

So, don’t do that on everything in your mental health practice. I actually turned down a couple of manufacturers before, just because of the fact that they would never give me a coil without, you know, doing paper use.

If you’re really interested in TMS and you’re looking at different TMS machines and stuff, go to FloridaTMSClinic.com, which is my website.

And look for the page that talks about the FDA clear TMS machines. If you Google that it will show up as the first result. And then you have an unbiased review of all the TMS manufacturers in there. That would be very helpful for you. If you were thinking about open-end TMS practice, particularly, I talked with physicians, not investors.

I talk with physicians who are interested in opening a private TMS practice, and I help them for free. Um, in case you want to talk to me one-on-one and have some kind of personal coaching in there.

Did You Know A Bad Biller Can Hurt Your Private Practice Like This?

So similar thing with cash, billing, billing, billing, If you make a mistake, if your biller is not good, the consequences are a little bit long-term. So it’s not only about a delay in a couple of months until you get your money recouped from insurances. That is money that you could have spent on expanding. That is money that you could have spent on awareness. It’s money you could have spent on hiring better staff, expanding your staff, buying another machine, you know, delivering a better quality of care. So be careful when it comes to billing.

So I’m going to tell you my own personal story with billing and, uh, this, this slide is going to be a little bit introductory to get to the next one. So I opened my mental health practice, as I told you in the beginning, I’m relatively young. I’m only. I’m not the only young, still middle-aged, 36 years old.

Right. So I finished residency in 2016. So I opened my mental health practice as soon as I was capable of doing that. I mean, and legally unable to own my own practice in the United States. Right. So that was November of 2019, but I did not count November and December because I wasn’t in network with any insurance. It was January when we started adding insurances to alert or a practice.

So. January. This is a number of encounters, right? So January we start having some patients encounters, meaning patients doing TMS sessions, right? So January we have some February word increase in March, we started picking up, right? So basically that’s when my first chair was full and I purchased a second TMS chair in here.

But you know what happened at that time? That’s when coronavirus was spiking in the country and that’s when even Tampa had to go. I know that you guys think Florida never locked down, but Tampa Bay area, we actually locked down, you know, in the second half or the last week of March. Right. And all the way into April.

So that’s when our numbers cannot decrease significantly. And I had to call. My patients who are high risk and they were already improving and hold their treatment. At that time, I still kept the patients who were severely depressed and it was essential care for them. We still stayed open and we continued treatment for them.

Okay. But back to the story here, and in terms of growth, it comes up from those numbers of one 61, and it goes to two 60 something, then 400. And then basically by July, this is when we are at our capacity. This is when we’re doing 500 sessions or 500 encounters every month. Okay. So the reason why I’m showing you this graph because what I’m showing you, billing and revenue coming to the mental health practice, I’m going to show you July and ongoing.

Okay. So the number of encounters is about the same, about 500 encounters every month gen chem happened in August. So I was with the, with the previous biller for all of this time, Genten happened at the end of August, maybe I think they took, they took care of the bills that came. On August 25th and beyond.

So I’m going to count September as the change, you know, since August was only a few days of office that they did, they did the thing. Okay. So July, this, the one in teal is showing you the number of encounters, right? So the number of encounters is almost all under this baseline in here, um, that you are seeing.

Can you see my cursor, uh, Omar on the screen? Yes. Okay. If you follow the point or the number of encounters is almost always around this line. Okay. So there is not that significant change in the number of encounters between July and say October or November. The one in red is actually the revenue. Okay.

And that’s where we’re getting for the practice. And you see, it’s kind of almost touching this line, not there yet. Right. And August is, as I told you, you know, gentlemen, wasn’t on until the last few days. So I’m going to count September. Notice how September we have a significant change. Then in October we have even more inquiries.

November and December were passing to the second line up here. So I’m not going to give you exact numbers, you know, for privacy of the mental health practice, but that’s that increased from one line to the other is about 15% increase in revenue. Okay. 15% increase in revenue is nothing to sneeze at. You know, that’s, that’s your money that you were putting, you know, for marketing or awareness.

This is, you know, if you, if you had an increase in payroll for your employees by 15%, Oh my God. They would be, they would be coming enthusiastic to work the next day. And what have you, so 15% is nothing, nothing to sneeze and every dollar counts when it comes in, when it comes to billing. So how did this change happen?

You know, to be honest with you, the complete answer, I don’t know. It’s probably the little small things in there, but I know where the mistakes were happening with the previous biller that none of those happened with the new biller. Okay. So. I will tell you one of the important things is, you know, adherence to the submitting the appropriate prior authorization number, for example.

So every single detail for how the bill is submitted. Is learned from the beginning, from the very beginning when Gentem came in and they were able to apply that to every single bill in a systemic way, that when you do things to systemically, you have less chances of missing them. Right. You know, it’s like a cookie cutter kind of thing.

They know that every bill has to have a prior authorization number. So it’s there from the first trial. The other part is, I think, in their system. They’ve submitted the bill the same day that we are seeing the patients. Uh, there was a slide on our portal that I might not have included in here. The bill’s average day of submitting the bill is 1.3 days, you know, meaning that either same day, which counts as one or the next day.

When submitting the bill soon, then if there are any chances of rejection or denial, they’re seen it earlier, then that will save you the chance of. Uh, late payment or what, what did they call it? Delayed payment or something like that? After a few months, insurances would not even look at your claim anymore because it has been so long.

So if you’re going to get the rejection or something like that, get in it in the beginning so early. It will help you prevent that pot. Um, another part that I found very interesting with gentlemen is that they were looking into other services that we’re providing and they were asking me why we’re not billing for it.

Right. So we, we, for example, in TMS, we’ll be doing neuro-psych testing, right? Like, you know, every 10 sessions, we will do the rating scales again for our patients. And I was submitted, you know, um, uh, for, for that bill, you know, randomly, and then when they came on or no, no, no, no, no, no, we have to do it.

Right. And why are you doing it only this number of times when you’re doing more service. So every service that you’re providing, you got a pill for. So that also contributed, so the use of modifiers or finding out, like if you provide a TMS and then you saw the patient at the same date, you might need to add a modifier in there.

So they do that, you know, pretty, pretty religiously and they kinda kind of follow up on it. So I think those small things are what makes that 15% difference. So, I don’t know. I just, I just think that this, this solved my problem. I don’t worry anymore about, about, uh, about billing. And that helps with the use of technology.

When I have a portal that I look at the portal and I see my revenue, I can look up any patient. See what’s um, uh, what, what date I was looking at and what bill and what happened with it. I have the information right there for me. Okay. This isn’t another slide. I took that as a screenshot from the portal.

It might not have been accurate as much as the previous lives that I just show you, but it shows you the changes in revenue over time and how it’s coming up over time. So it confirms the same thing. Okay. So now that you know about, you know, private mental health practice and the principles, I mean, principles of doing it.

I like this, which says the way to get started is to quit talking and begin doing by Walt Disney. Since we’re in Florida, we have to take something from Disney. I’m going to stop talking and let it open for some questions to see if I can help with anything.

Questions About Operating A Mental Health Practice

Thank you all for the attendees, for the great questions about operating a mental health practice. I’m going to try and get to them as quickly as we can. So let me start with this first one, and let me just scroll up. Cause we got quite a few, I don’t know if we’ll be able to answer all of them, but let me start with this one.

TMS Treatments Not Covered By Insurance

How often are you using TMS to treat other indications that are not covered by insurance? What is your success rate of converting patients into treatment adoptions? For example, out of 10 off-label patients, how many we’ll pay cash for TMS?

Yeah. You know, I’m not sure if you followed, you know, through my personal story of how I wanted to do the GMs, you know, that principle of, you know, converting patients to cash, cash, pain, you know, for off label users and stuff like that, or add on treatment, what some of TMS practices call it. I haven’t gotten into that.

I don’t do that. I do add on treatment, but for free. So a patient will come in with depression and anxiety. And I think the person who was talking about that has a mental health practice. And that’s the question that he’s asking me then. Yeah. So a patient will come in with depression and anxiety, and about 50% of patients with depression have combined anxiety and vice versa.

So those two come hand in hand, or the other situation would be Depression and PTSD. So a lot of PTSD patients will have depression at the same time. So the treatment that is FDA approved, um, and insurances pay for ss the stimulation with 10 Hertz stimulation on the left door. So lateral prefrontal cortex.

And that’s the one that I will do for such a patient, but I’m almost in those situations. Almost half of them will not get better in their anxiety or PTSD. They would need what we call right-sided low-frequency treatment on the right dorsal, lateral prefrontal cortex, that’s one Hertz stimulation or one Hertz treatment for about 15 to 20 minutes.

So often, the TMS practice will charge extra for that time on the, you know, on the chair for the right side of treatment. I do not do that. I just know, do it for free because I think a patient came in, came into me for complete, and I took the time for each patient for 45 minutes.

So down the road, if the patient needs more than 19 minutes on the left side, they needed the right side of treatment. Their time is already booked. So I’m making the assumption already that each patient is going to need more than just what’s if the aqueous, and that I think to speak to the point.

Number one that I talked about, which is quality and doing what’s best for the patients. And that helps me with reputation management. And that helps me with, you know, making my patients, my ambassadors. So the next time, when they’re talking with a family member, they would say, no, don’t go to, so-and-so goes to Florida TMS clinic.

They will not nickel and dime you, you know, they would, they would go there. Your insurance is paying for the left side, and you have 45 minutes on the treatment chair. If you need right-sided treatment, it would be for free. I think that’s the right thing to be done.

The principle of doing add-on treatment comes from a certain TMS manufacturer that limits you to how many times you can use the machine. And that’s why this person is asking because that’s how they establish mental health culture, which should not be the case.

I think a patient comes in, and you do all the treatments that they need at the same time.  The chance that the, he was asking him the success rate, if you are talking about the clinical success rate, the clinical success rate of, uh, left side of treatment is 58% of patients will respond.

The clinical success rate of the right side of treatment for anxiety is within the borders of 80%. So patients get calm or quicker, or the right side of therapy than they do with depression. So that’s another reason why to think about doing the right side of treatment, that standard. And another thing, there is a meta-analysis that looked at all the treatment protocols.

They found that the best one for the reason of depression is left-sided stimulation a high-frequency stimulation on the left side with primed, right side of low-frequency, meaning that you do both at the same time that had higher efficacy than actually only that side, but that was, you know, including European trials and stuff like that. So it’s not very common to do here in the United States.

What To Focus On Early In The Practice Development

In terms of some key steps early on from practice development, if you had two or three key areas for them to focus on, what would that be and why? If you already have an established private mental health practice and doing medical management?

I think their task is significantly easier in implementing each momentum in their own mental health practice. Technically you need to learn a it well, so you need to, you know, go, for the course at Duke or go to the course of the clinical TMS Society that is going to happen in West Palm beach.

You know of, uh, I think it’s going to be in June. To learn how to do it yourself professionally. Don’t, don’t go to the course from the manufacturers. Still, get the manufacturer’s training, but don’t depend on it, you know, do it tomorrow. Uh, and biased, uh, course, you know how to do TMS firsthand, come to somebody a little bit senior ahead of you who have been doing TMS before.

I kind of already told you that I have some doctors coming in and shadowing me on Fridays. Usually, that’s the day when I don’t see new patients, you know, I just continue with mapping and treatments and stuff. So they come in from other states, shadow me, and implement the same thing in their TMS practices and things like that.

So do that, you know, see a senior doctor, who’s doing TMS treatment, you can go visit them and see what they’re doing. And then the third thing is that once you get your TMS machine, you screen your own patients, and you see who from those are treatment-resistant, depression, meaning who for those patients have failed for anti-depressants already.

And you will find at these 20 to 30% of your current patients, or do you meet the criteria for treatment resistant depression? And those ones offer them TMS. Right? So you already have the patch of patients going and going on in this direction. So I would learn a 20, well, I would go shadow somebody else who was doing it before, get TMS machine at the practice and treat my own patients at the beginning until I’m comfortable, or then you can expand in awareness.

Should I Use An Internal Biller In My Private Mental Health Practice?

We did get a question specifically about using internal billing in a private mental health practice. So, this is a physician on the west coast, another solo practitioner. And she mentioned that she has an internal biller that does good work, but she’s wondering, is it worthwhile if she’s happy with her internal biller to use Gentium and why?

I’m going to tell you a personal story. I did not want to tell. My sister, so I, I told you I’m an IMG international medical graduate, right? Meaning that I did my medical school in a foreign country.

When I was in the medical school, in my medical school, I came to this country in my senior year of medical school. Did electives, you know, kind of trained of how the system works, joined residency here and trained in here and all those kinds of things. So then, at some point, um, I, I come from, from Damascus, Syria.

So, you know, I came before the crisis in there. I came before the crisis. So, you know, I am an immigrant by planning. Right. You know, but later on, during the crisis, my sister came here to this country. Right. And she wanted to establish herself as a career, and she did not have a career back home.

And she asked me, what should I do? Right. And in my mind, there was, you know, kind of thinking of the future of where we’re going. And I knew that we have a big problem with health, with the healthcare system and we have a big problem with money. Right. And it was so that dilemma that I was showing you between your insurances and expenses and what happiest there.

So I told my sister, I think that the future is for building, you know if you are going to choose, you know, a future or a future carrier. So if I were in your shoes, I would either choose to be a nurse. And at some point, become a nurse practitioner or something like that. If you walk into a healthcare field or if you don’t want to touch patients.

And I know my sister, doesn’t like to touch patients. Then chose a career in building and she did, and my sister is currently a biller for a private practice, you know, in the town where I consider it to me in my hometown in America, in Charleston. Okay. But she’s not my biller. Right. So I’m trying to answer that question of like, would you, would you have an in-house biller?

She would have been my beloved, you know, at any point, but I could tell her, Hey, you know what you, just to open your LLC and do my own grind, but I still did not do that one because don’t mix family and business, but we got the house. I don’t think that the person who is not incentivized to bring you the very last penny is going to do as good of a job as a company that is incentivized to bring you the last penny.

So if I pay somebody a salary, you know, if I’m paying somebody, you know, 40,000 a year, And that is saving me paying Gentem to say 60,000 a year. Okay. I’m going to look at that. And I say, Oh, I save $20,000 a year. Hey, right. But in reality, if Gentem is able to get me, not even 15%, that I was showing you a second ago if it’s able to get me 5% more, that is $50,000 more a year, not $20,000 a year.

So for that person who asked this question, doing the number and see if you are missing on revenue and whether it’s worthwhile, are you leading saving money or not saving money? So I’ll do the numbers, crunch the numbers based on the revenue that comes from your private mental health practice and see what is the percentage that a company is going to bill you and see how much you’re losing currently and switch to a billing company that knows what they’re doing and see that difference in between the two.

You might be ahead if you actually get somebody who’s not going to miss any of those, that percentage. Before Gentem, by the way, you know, before you guys, and I’m not saying that you’re not getting, I don’t have any, any financial incentive was gentle, you know, and it couldn’t happen. It could have been another awesome company that sculpts something else.

Right. You know, that’s helped me with this, but what I’m trying to say in here is that before Gentem the company that was doing my billing, she is good. You know she knows what TMS is. I unfortunately negotiated really low percentage, you know, for her, for her, the percent, how much she would make out of, the revenue and what I wasn’t really expert at that time is that lower percentage for the biller could mean low incentive for them to get for the last penny.

And that’s what happened. So she would submit the bills that are easy to get, you know, you usually have from the first pass and over a lot of bills, you know, they will come back right away, and she’s happy with them. But then, when we have denials. She’s not that motivated to get those denials done. And that’s where most of the time is spent by the builder.

So having an in house biller could get you the money that are easy to get, but the problem is going to be those tough ones to get, you know, is she going to spend the time to do it, or is she not? If you know somebody who’s really good and she works in house for, and all of a sudden, well, go ahead. You know, keep her, but if you, if you are, if you’re missing, you know, 3%, 5%, you know, if your revenue, because of that, you might be that are hiring someone who’s.

Great. Fantastic answer and explanation. And if I can just add to that, I think one thing that a lot of people are surprised to hear just because, you know, we’re, we’re a technology platform backed by a service. So we have a lot of certified revenue cycle managers and builders, but the people who actually love Gentem the most are actually the internal billing teams and billers within these private practices; just because we provide a beautiful dashboard, we’re a data-driven company. I think that the most important things that we help, the, internal revenue cycle managers and the billers at these private practices look like superstars.

And I think at the end of the day, everybody wants to feel good and, you know, I feel like they did a really good job. Yeah. The, the CEO, a few guys, I, I met with him. I think I talked with him like three times. I think that’s before, before your very last expansion, or do you guys, you know, go through kind of substantially.

But, um, you know, just, just for you guys who are listening to this might not know. And the CEO is, is, uh, a medical grads, uh, who cannot camera merged right away after medical school, into Silicon Valley and Valley Silicon Valley. And looking into technology and looking into finances at the same time when we’re talking about advances.

So, you know, he collected medical with technology with finances at the same time, which is I think the trifecta to save the healthcare system, to be quite honest with you. And I think if Denton keeps this focus on small private practices and trying to help them out over time of like, you know, how to empower private practice, it would do a good service for the health care system in general, you know, because that’s what we’re missing, you know, in private mental health practice work, what you’re missing usually is that back or back office, what is done there for billing.

So, if we can sort this out when become at the same level of, in institutions, then that would be really good. And I think Jonathan comes out well, but again, I don’t want to. I don’t want to sound too complimentary because it would sound, I have no shares with Gentem whatsoever. You guys are just doing a good job, and happy to talk about you guys and build more.

Should Physicians Accept Loans?

I think it’s good advice for physicians on topics of why you should not accept loans. Yeah. Okay. So, um, again, you know, this, this is a little bit personal for me know, not, not taken loans, because I think at some point, you will always be worried about when are you going to make it back, right. And that could limit, you know, how you would expand over time.

There’s a religious component to it that I don’t want to deal with interest generally. Okay. So that’s, that’s a personal religious component that might not apply to other businesses, but I want you to think about your mortgage, you know, for your house. Right. You know, so almost everybody has a mortgage on their house and everybody talks about, Oh, the American dream and having home ownership.

Oh, if you come to reality, the bank owns your home. If you still have a mortgage on it. Um, so it’s not really complete ownership. So to have a complete ownership of your business, of your machine, you know, for TMS or what have you, right? You need to have complete ownership, you know, then, then you call it, you call it the ownership.

Otherwise, you know, that manufacturer, if you’ve defaulted on your payments, or if you had to, you know, you, you decided that you were going, or you lost a contract with a certain insurance or you closed one mental health practice somewhere, and you’re going to open it somewhere else. And you default on your loans, then, then it might turn you into more trouble.

You will be a little bit more, less free, less free in making decisions. If you’re, if you’re taking loans, that’s a totally personal opinion. I know a lot of business people don’t agree with that. Be my guest. You know, um, a lot of, a lot of, a lot of doctors have student loans and tons of mortgages and stuff.

That’s not my style. I like to expand in what I’m comfortable with. And I see, and I see that, to be honest with you, when it comes to doing the right thing in my area at least of a mental health practice, you know, when, when I spend money on awareness, it’s money that I can dispense. Like, I don’t worry about paying this money back, right.

When I want to add, like, when we bought our third machine, we bought it. Not because we had patients for third machine, we bought it because we want to add convenience for the patient. Like if two patients wanted to be here during their lunch break, from work, and then the third one wanted to come in as well.

We don’t have a third chair. I was like, okay, we’ll buy a third chair. Right. I have the money sitting in my bank account. We’ll have a soft chair, you know, the who, who cares about that. But if I was taking a loan, I probably would not have done it. And then I did not do the best thing for the patient, which is accommodating their time.

Right. So if you’re really thinking about the quality, then having the freedom of not having loans could help with that. But I hear you, you know, business-wise, you know, people, you know, um, have different opinions. I can’t argue with that. Yeah. Oh, totally. And I think, you know, I think that’s a fantastic place to sort of wrap things up.

And one thing I do want to comment on is your slides influenced me to do a post-it on LinkedIn. I’m always asked that I go on podcasts to talk about patient marketing and how does a physician invest in it. And I think your talk highlights something important: you have to have your revenue and billing, and your cash flow streamlines your maximizing that because if you don’t have that taken care of, you technically don’t have the means to invest in marketing. Because it’s always going to feel like you’re investing too much.

How Do You Cover Two Private Mental Health Practice Clinics?

If you have two different mental health clinics, how do you cover both? Do you need to hire another doctor? I think that’s actually a really interesting question. That be the last question.

That is an excellent question and very sensitive question in the field of mental health practice. Okay. So I am going to answer it, you know, I’m going to speak my mind, right. Because again, I don’t owe it to anyone.

I’m going to speak my mind. Okay. The Medicare criteria, the CMS criteria, you know, and you have to review it in your own state, but it’s almost universal in all states that the doctor needs to be in the area. Okay. So that’s exactly the word that they use in Florida, for example, which I think is universal among all Medicare criteria, they don’t specify exactly.

What does the area mean? Does it mean the same building? Does it mean the same? It doesn’t mean the same rule because the technician is the one who’s put in the court where it needs to be. So the doctor needs to be in the mental health clinic. That is the interpretation, or that’s the intent of the law or the CMS criteria.

Now that is CMS. That’s Medicare, you know, for commercial insurances, some of them did not specify to be in the area. They just see it’s, there’s just say that it’s supervised by the physician. Okay. So. Now, do we really need a physician to be there present in the clinic when TMS is being delivered from the technical standpoint? Not, as long as you’re directly supervising patients, how do I directly supervise patients?

I have a navigation system that watches the patient with 3d cameras, and I have visual cameras on the patients, and they sign the consent for sharing that with me. And I’ll be seeing it from my room. So say if my room here in the clinic or my room isn’t another clinic, it should be there by the sink. So, but that is my interpretation of what that direct supervision is.

Okay. The clinical TMS Society gave guidelines recently stating that the PA, the doctor, does not have to be present in the clinic during the GMs session. Technically I agree with them from the clinical standpoint because there’s one risk. Two TMS, which has having a seizure. So, it happens one in 30,000 treatments.

Recently there have been post-marketing data collected all the data for seizures, and they found that it’s actually one in 89,000 treatments. So it is very, very rare to happen. I never had any, any seizure in my clinic so far, we have been doing it for about a year and we have three treatment shades. So technically, the only risk with TMS or major risks with TMS is seizure.

And if a seizure happens, what is a psychiatrist going to do? Right? Like we are not really a neurologist and even a neurologist in our patient settings there, they don’t have out of them, you know, in their cabinets. So they’re going to inject the patients with, right. This is something that you need to call nine one one anyways, and the patient will be transferred, transferred to the emergency department.

And the seizure is self-limited anyways; it stops after three minutes. So I agree with the clinical TMS society that the doctor probably does not need to be in the clinic. But they need to be involved in the supervision directly. I, that they’re always available. Is that currently the law? No, it’s not.

Okay. And so currently, if the doctor is not present, present in the clinic, it’s on their own responsibility for Medicare patients. Okay. So for Medicare patients, it’s on the patients, the doctor’s responsibility to be present in the area in the clinic. I think that Medicare, you know, CMS guidelines, aren’t going to change in the next couple of years to adhere to the guidelines that came from the clinical TMS Society, that the doctor doesn’t really need to be present in the clinic, but they need to be directly supervising what’s going on.

And I think that’s Coronavirus pandemic accelerated that a little bit because there was already some provision from Medicare about every time we say directly supervising when somebody else is delivering the service. With coronavirus who can be indirectly available by phone or via telehealth.

So Coronavirus scanning gave you this leap forward into looking into that as a change of a guideline for me. But the official answer that I have is that you have to be in the clinic by law. The future guidelines are you don’t have to be in the clinic, but you still need to supervise the therapy. And if that’s the case, then I would prefer that you have a navigation system.

And I prefer that you have cameras. We can have the patient at all times; that’s the right thing to be done. And number one, we said, you know, do the right thing for the patient. That’s the right thing to do, to be done.

Fantastic. Well, Dr. Bowarshi, we can’t thank you enough for taking the time. And of course, it’s late on the east coast and then, you know, staying past the hour. Thank you all for the wonderful attendees that joined and provided the questions again. If you love this webinar, we’re going to be sending out the live recording, and feel free to pass it on to your colleagues and peers.

Again, for all those that attended, our offer is that a free revenue cycle and billing analysis. You can see in the chat I made a mistake. I said that everyone’s getting a free billing analyst. Gentem is not sending you an analyst. We will do an analysis. So I have to correct that but thank you all for attending.

Thank you again Dr. Bowarshi, for joining us.

Everybody who asked a question, if it wasn’t answered, or if you have a follow-up question, you can send it to admin at FloridaTMSClinic.com, and I’ll do my best to answer it by tomorrow morning.

Wonderful. Thank you very much, and have a great evening. Everyone take care. Bye. Okay.


Note: This content was originally discussed in a webinar. Find the Full Webinar recording here: https://gentem.com/lp/building-a-strong-tms-practice-in-2021/

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