Our guest host tonight, April 2, 2001 is Richard K. Adler, Ph.D., CCC-SLP. Dr. Adler is an
ASHA Fellow and President of The American Academy of Private Practice in Speech Pathology and Audiology (AAPPSPA).  Dr. Adler's private practice, Communication Improvements of Seattle, P.L.L.C., is a general practice including therapy and diagnostics for the following disorders: Articulation, voice, fluency, language disorders, TBI rehabilitation, transgendered voice and speech therapy, business communications improvement, foreign dialect and accent improvement. He will lead a chat tonight about about private practice in Speech Pathology and Audiology.

<Robin> Welcome to our chat with Richard Adler about Private Practice
<Don> Hi Richard...how are you?
<Richard Adler> Don, is that you from Ellensburg?
<Don> yep!
<misty> hey Don..............how's it going
<Robin> well, Misty and Don both have private practices...how many employees do you
    have in your practices?
<misty> too many...............20
<Robin> Misty, you have 20 employees!!!!  Wow!
<misty> don, do you find women harder to work with?
<Don> Women are not easier or harder to work with.  I think it's because I'm a guy.  Laurie
    works only with women and wants to kill one or more of them weekly.
<misty> maybe it is because I am a woman.............I think they are tougher
<Richard Adler> Alison:  Are you in private practice now?
<Alison> Yes, I am for only 2 months!
<Robin> Misty, you have twenty employees now....is the practice still focussed on
<misty> Robin,   Yes we are about 95% pediatric........primarily under 5
<Richard Adler> Alison:  Where are you in practice? Can we at AAPPSPA offer any
<Alison> I am located in CT, and I focus on doing home-based Tx, intensive
    consultation/home-program development for those who want an alternative to direct Tx
    and I just signed on as an idependent contractor contracting per diem with a SNF
<Robin> Enid, do you have any questions for Richard or our other chatters?
<Alison> Do you have a website?
<Richard Adler> Alison:  Check out www.aappspa.org and consider joining us
<Alison> Great!  Thanks!  I need all the support I can get as I start out...
<misty> Enid...........do you have a private practice?
<Alison> As a private practitioner how have you built a clientele?
<misty> word of mouth...................
<Richard Adler> Alison:  By marketing to professionals, schools, etc. and by word of
    mouth. I also offer free inservices to SNF's, schools, etc.
<Don> word of mouth and hustling doctors!
<Enid> I have worked in schools for ~15 years and am thinking of going private
<Don> That would be great!!
<misty> where do you live?
<Enid> Philly area
<Richard Adler> Enid:  I am president of the American Academy of Private Practice;
    Can I offer any help?
<Richard Adler> Enid:  My first taste of private practice was when I lived in Cherry Hill,
<Enid> Well, I'm just starting to think about all involved, insurance, zoning, fees,
<Richard Adler> Enid:  Go to www.aappspa.org or you can email me at
    drspeech@nwlink.com to help with questions and info
<Enid> I'm west of Philly, Delaware County, off Main Line
<misty> Enid...........it is a big undertaking.............but aappspa is a great organization to
    be involved with when/if you take the 'plunge'
<Richard Adler> Enid:  At the Nov. ASHA conference, we usually offer a short course in
    starting a practice
<misty> come on down to florida in early may
<misty> our spring conference will give you lots of info about starting and growing a
<Richard Adler> Our spring conference is in Delray Beach, FL May 3-6.  You can  meet
    many of us in practice and we can nurture you.
<Alison> What is a great piece of advice you can give anyone starting out?  I'm sure you
    have many!
<Enid> I'm getting tired of the constraints of schools.
<misty> don't blame you there................
<Alison> Enid, I left the schools for that same reason.
<misty> one piece of advice
<Richard Adler> Alison:  Don't be afraid.  But think about your clinical background and
    your business background.  Narrow the areas to start in and go for it.
<Enid> Couldn't go to FL in May, can't take time off that isn't at a holiday  ;-)
<misty> Also try to keep overhead as small as possible in the beginning
<misty> now, see, Another good reason to go private
<Richard Adler> I took a job in the public schools here in Seattle while I build my new
    practice.  I can't wait to leave the schools-- too many rules.
<Alison> Has anyone found Fast Forward cert. to be beneficial?
<Enid> Good question
<Alison> I offer it in my practice, however it seems many schools are jumping on the
<misty> I spent the $$ to get certified and realized down here the market is flooded so I
    didn't pursue it........
<Richard Adler> A lot of us do Fast4Wd in our practices.  We have a networking group
    within AAPPSPA about that.
<Alison> Are you in FL, Misty?
<misty> Yes, south florida
<Richard Adler> Yes schools can do Fast4WD too
<Alison> I went to Nova Southeastern Univ to get my MS in SLP
<Alison> so I lived in So Florida for 3 years...
<misty> What took you to CT?
<Alison> I'm from CT, and I just missed it.  I was a bit too hot in FL!
<Anonymous2032> hello. I'll just watch for a bit...thinking of starting a very small
    pediatric practice this fall
<Richard Adler> 2032:  go to www.aappspa.org for some info
<misty> be careful what you wish for.............if you are good that small becomes very
<Enid> Does anyone work out of their home?
<Alison> I do!  However, I treat in other people's homes.
<misty> We do some home therapy but once you have employees it is not very cost
    efficient........on, your own, though it is great
<Robin> for those interested in pediatrics....we are having a wonderful chat in two
    weeks about oral and verbal apraxia
<misty> hey, robin............who is doing that?
<Robin> Lori Roth , SLP and Dr. Marilyn Agin, a developmental pediatrician who is also an SLP
<Anonymous2032> thanks Richard, I will.  I'm hoping to see kids in their homes or
    daycares..any advice?
<Richard Adler> I started my practice with a home office but I don't believe anyone who
    is serious should see patients in their homes unless they have a private office
    entrance.  But I started with my office in my home
<Enid> Do you charge differently, your's vs. theirs?
<Alison> Once I grow, I plan to get an office.
<Richard Adler> 2032:  Set up your office in your home and then contract with daycares
    and market yourself as a home-based practitioner who goes into folks' homes to see
    their kids
<misty> hold off on an office as long as possible.............the overhead is a killer
<Richard Adler> Enid:  Your charges are based on your overhead.  Those folks I knew
    who worked in their homes charged half of what I did.  But that was their choice.
<Alison> Richard, How does your Fast Forward networking group work?
<misty> Allison.............at our conference in Delray in May we are having a FFW talk.........
<Enid> I worked in preschools for IU for several years and plan to contact them
<Anonymous2032> I don't feel like dealing with the insurance thing yet.  Is there any
    hope for private pay?
<Richard Adler> Strictly private pay works in certain affluent areas.  Depends on your
<misty> There are several therapists in aappspa who are cash only..........they love it
<Enid> I have office space in my home with separate entrance
<Richard Adler> Enid:  That should work fine.  I know two SLP's here who do that
<Enid> Where are best places to make contacts for referals?
<misty> preschools
<misty> mom's groups
<Richard Adler> Referrals for what specific population?
<Enid> Sorry, pediatrics
<Richard Adler> I find for peds, physician's offices, schools, preschools, PTA meetings
    to offer free inservices, etc. helps a lot
<Alison> Has anyone done inservices to mom's groups?
<Tami> I had thought about doing that this summer.
<misty> I agree............at my preschools I do free screenings and the inservices
    if necessary
<Richard Adler> Also, try private schools in your area.
<misty> yes...........I did mom's groups..........depends on the areas....$$wise
<Richard Adler> I did inservices to several play groups in my area.  Worked really well
    to get referrals.
<Enid> Hadn't thought of mom/play groups
<Alison> What subjects did you inservice on in the peds areas?
<misty> general speech and language development..........you would not believe how
    dumb some people are bout what is 'normal'
<Richard Adler> Alison:  A favorite one is "Language Development Milestones" and
    "How to foster language in your child"
<Tami> Enid, couldn't you do inservices on early childhood development?
<Anonymous2032> working with special needs kids for 10 years has made me dumb
    about normals
<Enid> I think so, I've  done talks for our PTO
<Enid> 2032, I know what you mean about losing touch with normal! LOL
<misty> Christina............where are you...................
<christina> north carolina
<Tami> Enid, where are you?
<misty> And you 2032?
<Enid> Philly area
<Anonymous2032> wisconsin/minnesota border
<misty> Where in north carolina?
<Tami> Oh, thought you might be local to me.
<Tami> I'm in Oklahoma
<christina> near raleigh, town called Willow Springs
<misty> oh, christina.......how far from Asheville?
<christina> i don't know, maybe 2 or 3 hours
<Tami> I'm in Tulsa
<Tami> University of Tulsa
<Anonymous2032> does anyone have experience dealing with Medicaid?
<Richard Adler> Yes, I do. What is your question?
<christina> I work for CAP, lots of Medicaid experience
<Enid> I did medicaid in schools UGH, school district gave up on it
<Tami> Enid why did they give up on it?
<Anonymous2032> I am an "official" provider but have yet to bill them.  Do you have any
    horror stories I should know about?
<christina> I don't bill, but I know that it sucks. I have kids who have been waiting for
    therapy for a year or more
<Richard Adler> 2032:  Medicaid should be billed electronically. Paper forms are often
<Enid> Powers that be decided it was too much paperwork and not cost effective
<misty> I do lots of Medicaid billing and kids...........actually like them and it better than
    the private insurance ones
<Andi> in Georgia it usually pays more than insurance does
<Anonymous2032> what's the reimbursement rate?
<christina> all of the kids I work with are on Medicaid.
<Richard Adler> Yes, Medicaid does pay regularly if you bill correctly and honestly
<misty> guess it depends on your state.  Medicaid in Florida is guaranteed therapy
<Alison> I heard Medicaid pays more than insurance.
<christina> I'm not a slp, just a student. I work for Easter Seals with disabled children
<Tami> I'm thinking about doing some Medicaid this summer but I've been warned
    that sometimes they pay and sometimes they don't
<Richard Adler> With Medicaid, you need a doctor's order and if you bill correctly, you
    should have no problem
<Anonymous2032> I read in one of my many manuals that payment needs to be made
    in 30 days. True?
<misty> Tami..........down here the only thing you have to be careful about is that
    sometime sessions get dropped and you have to rebill
<Richard Adler> They are supposed to pay you within 30 days.  If they don't they usually
    have a reason
<misty> Payment needs to be made in 30 days?
<misty> We get paid in 10 days......direct deposited into checking....very nice
<Tami> Richard, in Oklahoma, we have to go through their case manager.  It's not
    always the SLP that fills in the info incorrectly.  At least that has been the experience
    that some of my peers have had.
<Anonymous2032> About the doctor order, if a parent calls me do I tell them to see
    their doc and request a referral?
<Richard Adler> If your money doesn't arrive in 30-45 days it is usually because they
    lost your billing or you billed incorrectly.
<Andi> the problem is when its Medicaid and insurance, and you have to bill and get
    denial from insurance first
<Richard Adler> If a patient calls you, ask them to see their doctor for a referral
<Richard Adler> And you must get their Medicaid card and other info to do billing
<christina> ok, the real reason I dropped in tonight. How is the pay in private practice?
<Andi> depends
<Alison> yes, I'd like to know too!  For me it is too soon to tell...
<Richard Adler> You  could earn only a little and you can earn quite a bit.  Depends on
    your scope of practice, contracts, marketing, etc.
<christina> Here, I've heard the average is about 41,000 starting out. Is that consistant
    across us?
<christina> but I got that figure off the internet, so that's why I'm asking.
<Richard Adler> My first year in 1986 I grossed 56K. Then it went upwards from there.
    Never downwards
<Enid> Seems the going rate around here is about $70/hour
<Anonymous2032> if we are doing private pay only, can we have a previously agreed
    upon policy to charge something for a no show or late cancel?
<Tami> Can you do that ethically?
<Tami> That's like charging for services never received.
<christina> regular doctors charge for late cancellations
<Robin> Tami, many places have that kind of policy
<Anonymous2032> even if the parent has agreed to this prior to the start of tx?  I'm
    thinking $25 flat charge or something.
<Tami> If they no show, and you charge them then that for services not received??
<Richard Adler> You can have a policy that 24 hours is required or else you pay.  As
    long as it is written down in your policies, you can do that.
<Tami> Oh ok.
<Richard Adler> You can't bill Medicaid for cancellations no matter when they occur
<christina> what if they have a good reason? One of my kids one time fell out of a tree
    and had to miss.
<Alison> In my neck of the woods, they are getting $100/hour
<christina> where are you alison?
<Alison> Connecticut.  Starting in private practice
<christina> starting?
<Robin> Richard, did you ever have that kind of policy in your Atlanta practice?
<Richard Adler> You can take each of these special cases individually.  But you should
    have a cancelleation policy
<Tami> $100 an hour wow.  Let me move there.
<Richard Adler> I was getting $120 an hour in atlanta.  Here in seattle, I get only $65 an
    hour.  Rates here are VERY VERY LOW
<Anonymous2032> what do you think of $75 for 45 min session in kid's home?
<Robin> I still can't get over the difference in pricing Richard!
<Alison> I'm surprised they are so low in Seattle.
<Richard Adler> $100 an hour sounds good but you have to look at your overhead and
    the competition
<Alison> Yes, it is VERY EXPENSIVE in the Northeast!
<Richard Adler> $75 an hour for 45 minutes. I charge for 1/2 hour or 1 hour. It is easier.
<christina> here (nc) there's supposedly some shortage of SLPs. Are some locations in
    more need than others?
<Tami> Christina from what I've seen on the BB yes.
<Tami> Richard,  do you have any clerical help or any other type of overhead
    experiences besides rent and materials?
<Richard Adler> Now I don't.  But in my full time practice I had in Atlanta, I had a
    secretary but I did my own billing by choice.  I also had utilities, rent, insurance, etc.
<Enid> Do people charge differently, your home/office vs. theirs?  If so, how much?
<christina> I haven't even decided on grad school! How am I ever going to decide on
    where to practice!
<Richard Adler> Charges are based on area of the country.  In Atlanta for instance,
    some SLP's charged only $80/hour and some charged $130.  Depending on the
<Alison> Enid, I think you should charge more to go to their homes, you are offering
    them an additional service
<Enid> What I mean is, difference between your office vs. child's home
<christina> should you have a specialty?
<Tami> Richard was it hard to get started?  I mean, the ideas that you have suggested,
    I've thought about doing.  I just wondered how long it took you.
<Anonymous2032> ditto allison.  Takes time to travel
<Richard Adler> Enid:  Yes you should charge for therapy and a separate charge for
    parent meetings/home programs
<Richard Adler> I started my practice in Seattle in November and I now have 6 patients.
     It is a part time practice now.  In Atlanta, it took me one year or less to get really going.
     It fell into place very well.
<Alison> Has anyone been threatened with lawsuits by parents just because they
    didn't improve as expected?
<Robin> good question, Allison
<Richard Adler> Not me.  I usually dismiss a patient if I see lack of progress.  I also
    work closely with parents so their threats don't happen. 
<christina> but if you dismiss a patient, where do they go for help?
<Tami> Good point Richard.
<Anonymous2032> part of my reason to go into privat practice is to be able to choose the
    kids/parents I want to work with.  How do you d/c someone if you start to dread the
<Richard Adler> Many SLP's have a tendency to keep a patient on the books indefinitely
    since the money is good.  That is a bad practice to get into.  Being honest is much
    more rewarding.
<Alison> That's good to hear.  My friends tell me that's what'll happen.  I live in a very
    affluent area...
<Richard Adler> If I don't see progress, I will explain to a parent what is happening or
    what is not happening.  I will suggest a break from therapy, another therapist, the
    school or just simply tell the parent that your child is not doing well
    and not practicing.  We have to talk
<Tami> I think what Richard is saying just reminds us of our code of ethics. 
<Richard Adler> Absolutely, the Code of Ethics is a good idea to go by.  I have even
    brought that up to parents when talking about lack of progress
<Alison> great advice!
<Richard Adler> And you all should be able to choose your patient caseload and reject
    those you don't want.  When my practice was going really well, it was very wonderful
    to be able to reject a patient if I smelled trouble.
<Tami> Richard, wish I had that opportunity now.
<Tami> Sorry if I'm on my bandwagon tonight about Code of Ethics, I'm in an ethical
    difficulty with the school I work with right now.  :)
<Anonymous2032> what if I smell trouble a month into it?
<Alison> I'm terrified of ever accidentally  breaking the code of ethics.  Then your name
    gets published in the ASHA leader! Ugh!
<christina> I mentioned earlier I'm just a student, but in the little bit of work I do I've had
    trouble with parents not willing to cooperate or practice. Any ideas for that?
<Richard Adler> If parents don't want to practice or cooperate, I either call in my
    psychologist friend, have a conference with parents about what I am not seeing, and
    often suggest another route to go
<christina> what if everything is going good, but you just don't like the patient or the
<Tami> Richard do you ever refer to the schools, when you feel that the school should
    provide services.  If so do you continue to do services with the child on a private
    practice basis?
<Richard Adler> I have a chat with the parents about what I am seeing, feeling etc.  I
    am just very open and honest.  I often go back to the referring doctor for advice
<christina> Is it possible to give too much therapy? Can't a child just be overloaded?
<Enid> Christina, I think you just do what you're paid to do, be nice and keep up the
<Richard Adler> I often tell parents that I will refer to their school district. I only see the
    child in PP if I feel the child needs extra therapy.  Often I try to save parents $
<Robin> your honesty is what will make the practice grow...word of mouth
<Richard Adler> Yes, I have had parents tell me their friend referred them to me
    because I was very up front with them in all areas
<Richard Adler> Yes, too much therapy is overload.  I have had affluent parents who
    want 5 hours a week of therapy.  That is mucho overload. I don't see those kids.
<Tami> ok sounds reasonable to me.
<Enid> I saw a lot of overload in preschoolers, kids scheduled for 40 hours of
    Discreet/wk plus therapies, not good
<christina> I work with a little boy that gets 3 hours of speech, plus ot and pt. he's
    showing improvement, but I'm worried about him getting stressed
<Richard Adler> Depends on his disability and cause of his speech or language
<christina> treacher collins, paralyzed palate
<Tami> Richard, I have a parent just like that now, and requesting pp in addition to
    school.  I warned the parent about burnout but they didn't seem to get it.
<Enid> I think sometimes parents think if they throw money at the problem they've done
    their part
<Richard Adler> Sometimes parents will never get it because they don't hear certain
<Robin> well folks...it has been getting late...Richard has been chatting with us for two
<Anonymous2032> thank you richard
<christina> thanks!
<Alison> Thanks for all your advice Richard!
<Enid> Thanks, it's been helpful
<Richard Adler> Thank you to everyone.  My email is drspeech@nwlink.com  Let me
    hear from y'all
<Anonymous2032> wonderful
<Tami> Thanks a lot.
<Richard Adler> Bye Robin.  It was fun.  Thanks for asking me.  I'd be happy to do it