I knew that psych was something I wanted to do,
but believe it or not, back in 2003, you typically
went into med -surg as soon as you got out of
school. So I did work med -surg for about a year
and a half before I started doing inpatient psych.
I knew in school that someday I wanted to open
a private practice, but did not have any idea
how to even. jumpstart that. We had to move into
a new a new practice and now we have well over
3 ,000 patients. We lost a lot of money on billing
which is that's another thing too. How you grew
from like no patients to a thousand patients.
We hired a marketing team. They take care of
all of our social media. They're fantastic. The
truth is we're in Tennessee and we're probably
one of the most restricted states. When we first
opened, just to make some extra money through
NP Hub. So every once in a while, I'll get one
through there that, you know, pays. But if it's
word of mouth, I don't charge them. Welcome to
another week of no prior auth. This week, I'm
talking to Angie Janicek. Angie is a DNP board
-certified psychiatric mental health nurse practitioner
and the co -owner of Premier Psychiatric Services
in Goodlettsville, Tennessee, just north of Nashville.
She became a CNA in 2001, got her ADN in 2003,
spent the next 16 years working inpatient psych
and raising four kids, including twins, before
going back for her BSN, then her MSN, then her
DNP from Frontier Nursing University. Her husband,
John, they've known each other since they were
13, is the practice CFO. Her co -owner's wife
is the practice manager. She runs a Spravato
clinic for treatment -resistant depression. She
specializes in ADHD in women, and her office
dog, Murphy, is officially listed as CEO on the
company website. If you've ever worried you waited
too long to build the career you actually wanted,
Angie's story is going to wreck that excuse.
Let's get into it. Hi, Angie. Hi. How are you,
Lindsay? I'm doing well. How are you? I'm doing
well. It's a good day. Thanks for being on. I
appreciate it. For sure. For sure. Yeah. Really
excited to be here. You are my first guest who
I've never met via video before our episode.
It's like we've been acquaintances for a while
now. So I'm really excited about this one. I've
been wanting to get to know you more for a while,
and I think your story is going to really inspire
Psych NPs. So just start out telling us a little
bit about yourself as far as... At what point
you decided that you wanted to have a private
practice and kind of what got you started down
this career path to begin with? Yeah, I fell
in love with psych in nursing school. That rotation
was. just eye -opening for me. I really fell
in love with it. So I knew that psych was something
I wanted to do. But believe it or not, back in
2003, you typically went into med -surg as soon
as you got out of school. So I did work med -surg
for about a year and a half before I started
doing inpatient psych. And my first psych unit
was a military unit which I absolutely loved
and it just kind of progressed from there to
different units to you know the really acute
units to more of like a mood and stress I worked
in intake for a while and then I ultimately before
I went back to school landed in the emergency
department as the behavioral health assessment
nurse. So I would see patients when they would
come in really acute, having a psych issue, and
then I would assess them and then kind of go
from there. Do I think they meet criteria for
inpatient admission? If I did think they did,
then I would reach out to the psych NP or the
psychiatrist at that time. And that's when I
learned, it was that job where I learned that
there was such a thing as a psych NP. I did not
know until a few years ago. Yeah. Oh, really?
Okay. So just a couple of years ago, you kind
of realized what that role was. Probably back
in 2020 is when I learned that, you know, I had
a friend that said, you should go back to school
for your MP. I was like, I have no desire. And
he said, you could be a psych MP. I was like,
what? I mean, that's fascinating to me because
you had been working in psych for how long at
that point? I had been working in psych since.
like 2004, 2005. But the hospital that I work
for, a big company that we usually refer to with
letters and big corporation. And they, at that
time for inpatient, all they had was psychiatrists.
They didn't have any psych MPs at that time.
They did not get psych MPs until about a year
before I graduated. And they had one. And I was
already in school. When I met her and became
friends with her. So she was the first psych
NP at this particular freestanding hospital.
They didn't have them. Right. Yeah. I always
wonder, like, because I'm from Ohio and I had
never heard of the role of a psych NP until I
moved to Arizona and got a job at Arizona State
University. So it's just like, I wonder. how
long it would have taken for me to become acquainted,
to become aware of the role if I had stayed in
Ohio longer, you know? So that's, that's just
fascinating. So what year did you start your
private practice? I started it in 2024. And that's
kind of an interesting story in itself because
by 2024, there were four. nurse practitioners
and one PA working at the hospital. They just
took it and ran with it. And so I'd been there
a little bit of time. I'd been there a couple
of years. I was like the second one they had
hired on. And I started meeting some of these
NPs that they were bringing in and became really
good friends with them. One of them being my
current business partner, Trey. And I knew in
school that someday I wanted to open a private
practice, but did not have any idea how to even
jumpstart that. So I had several of the other
NPs come to me and say, do you want to start
a private practice? And I thought about it for
a long time and then ultimately called my current
business partner, Trey, and said, listen, no
knock to anyone else, but why don't we, you know,
I loved everybody that was, you know, asking
about it, but I knew Trey. Trey's a great businessman.
And I knew that our friendship would allow for
us to be in practice together without arguing
or, you know, having a bunch of we just get along
really well. We're we both are really kind of
go along with things. We're both laid back. So
I knew that that would work really well. So I
called Trey and said. This is what I'm thinking
about doing. Do you want to partner with me?
And he said, absolutely. Yeah, let's do it. Okay.
And so you started out with a business partner
and you still have a business partner, right?
I still have Trey. Yep. Yes. Okay. Okay. And
what are his credentials? Trey is actually dual
certified. He's an FNP and a psych NP and he's
working on his DNP right now. Yeah. Very cool.
That's awesome. Yes. So you spent. Was it, I
think it said 16 years as like an ADN and, and
all these different healthcare roles and you
were raising four kids, right? Tell us about
what that was like. That must've been a lot.
That was a lot. Yes. I mean, especially working
12 hour shifts and having smaller kids at home.
That was really tough. We muddled through it.
And so we're. pretty competitive family. And
I'm only telling you that because it kind of
leads into what I'm about to tell you next. And
so my oldest went off to college. She went to
UT Knoxville, got into their nursing program,
which is very hard to get into. So proud of her.
And I started realizing, wait a second, my husband
has his MBA. My oldest is getting her bachelor's.
My twins are going to school in a couple of years
to get their degree. And then my youngest, he's
currently working on his degree now, his psychology
degree now. And I thought, I'm going to have
the smallest degree in this house. So I was like,
I cannot have, no, this could not happen. So
I went back to school initially just to get my
BSN. And it was then that I really decided I'm
going to get my master's. I initially, my dad
is an IT guy and he really encouraged me at that
time to maybe try to fit nursing in with IT.
And while that was a fantastic idea, I shadowed
someone that I knew and I, it just didn't really
appeal to me. So that's when I had a friend that
said, you love psych so much. Why don't you become
a psych NP? When I started looking at, you know,
programs, I thought. This is exactly what I wanted
to do. And I knew that I wanted to do that because
I wanted to be able to help patients on a deeper
level. I wanted to be able to branch out and
not just pass meds. I wanted to be able to do
a lot more in a role. And that's, I felt like
that was the way to do it. Right. Yeah. That
makes a lot of sense. And from what I understand,
your husband's the CFO, right? You have a practice
manager. We do. Yeah. So has, yeah, go ahead.
I was just going to say, so little story about
that. When we first opened, we had just a little
bit of money and a credit card. And so we were
like, what are we going to do? So we decided
to hire family because they were free at the
time. So that's kind of how that worked. You
know, we, my husband is an accountant. He's a
college professor. He teaches accounting, teaches
marketing, teaches business as his MBA. He's
really smart at that kind of stuff. And he said,
listen, I'll manage your books in the beginning.
He still doesn't, but he's your books for free.
I'll help. And then Trey's wife, Brittany said,
She actually quit her job. She's a respiratory
therapist. Oh, okay. And she was at the hospital.
I didn't realize Brittany was Trey's wife. Okay,
got it. Brittany is Trey's wife, yes. And we
knew we had to have somebody answer the phones.
So we hired her. She came in and started helping
for free. So then we added my son on board. And
that's when we started looking at paying people.
We had really picked up. We started in this small,
like little 1 ,700 square feet office. And we
grew within six months to almost 1 ,000 patients.
Like it was, it just exploded. And we were the
only group practice in the area, which that's
something too, how we decided on that. We were
the only group practice in the area. We had immediate
openings. We took insurance. And so we just exploded.
So within six months, we had to find another
location. And we came upon a location which is
like 4 ,000 square feet now. And we had to move.
Before we were even a year old, we had to move
into a new practice. And now we have well over
3 ,000 patients. And we've been open two years.
Wow. Wow. It grew huge. It sounds like it. Yeah.
One of the things that our listeners really like
to hear about, too, is kind of like how much
money did you spend getting started and on what?
And when you look back at that, like, is there
anything you do different? Yes, for sure. We
started what we had to pay first and last month's
rent, which I think at that time the rent was
like thirty five hundred dollars on the first
place. So. We gave them a total of, it was like
$7 ,000. We had to do that. We kind of pieced
that together on our own. I think we each gave
like $3 ,500, you know, to do that. And then
we immediately had to get an EHR system, which
we got, we hired Silverleaf and then IntakeQ
is what we wound up getting. And so whatever
that, I think that's like $2 ,000 maybe to start
and then for them to set it up. So we did that.
And then did you do spruce, too, or just didn't
take you? We did spruce in the beginning as well.
We did that as well, which I really like. I really
like spruce. I do, too. We've kind of moved away
from it a little bit for some reason. I don't
I don't know why, but but we we still haven't
take you still. I love it. I love it. And I actually
you still use the paperwork that they gave us.
I guess I didn't even think about we could trim
it down some because it definitely. is it's definitely
audit proof for sure. I'll give them that. But
patients complain about how much paperwork it
is. What I like about it is it tells me the story
before I meet with the patient. So I feel like
I can get right into it with the patient and
we can kind of skip all the questions because
they fill it out before they see us. And so I
feel like that gives me the story. for the most
part you know for the most part gives me the
story and then as soon as I see them we can start
right into yeah what brings you in today you
know here are my thoughts I've looked through
your chart you know that kind of stuff so that's
that's what I like about it but I didn't realize
I didn't even think about that we could probably
trim it down and I would love to do that because
patients do complain about how extensive the
paperwork is yeah Do patients self -schedule?
We turned off self -scheduling a while back.
We like for them to call and get scheduled because
a lot of times they're looking for something
specific. Like I specialize in ADHD, so they
don't necessarily know that. And then so when
they call, we can ask them, what are you looking
for? What are you wanting treated? And then they
know which provider to put them with. Yeah. Okay,
that makes sense. So you started out with an
in -person space. What played into that decision?
Because I know that's something too that people
are sometimes on the fence about. And sometimes
they sign a lease prematurely, they feel like,
before they have enough income coming in. But
sometimes they have to because of an insurance
requirement or state law. And I'm just curious,
yeah, how you guys made that decision. That's
a great question. We really did want the space.
There was a group of about five of us that were
really, really close. We all had the same mentor,
which is our current medical director and psychiatrist.
So we all had him as the mentor. And our initial
thought was, we want to open this practice with
our friends. Won't that be fun? You know, we're
going to work with our friends. It's going to
be so much fun. There was a lot that came with
that that we didn't think about. And if I love
having them all here, I do. If I could go back
and start again, I would just have it be myself,
Trey, and then Dr. Sastry, our psychiatrist,
and build from there. Right. And so we started
as a group practice. And it was a little accidental.
Like when Trey and I said, we're opening this
practice, everybody said, we want to come with
you. And we're like, sure. The more, the merrier.
We didn't think about, you've got to fill up
everybody's schedule. You know, you've got to,
you don't think about, or I didn't think about
that stuff in the beginning. And that was really
tough to do because, you know, everything that
Trey was coming in for Trey and I. was going
right back into the practice. But anything that
another provider brought in, they got a cut of
that. And so they had to fill me up. They had
to fill Trey up first because that was the money
that was paying the bills, you know, as things
went. Yeah. So you and Trey probably didn't get
paid for a while. For a long time. That's another
thing I don't think that we know is that for
Up until recently, we weren't taking any money.
It was all going right back into the practice
because then we turned around eight months later
and got a second building still having a lease
on the first building. And so all of that, all
that we were bringing in had to go right back
into the practice. And so it's still even now
not. consistent. I mean, there are weeks we take
more weeks, we take less. And a lot of that's
just because we have such a big practice, a big
group practice that because now we have two therapists
on staff, we have two admin. Now we are getting
ready to hire a third one. We lost a lot of money
on billing, which is that's another thing too.
Yeah. Okay. Yeah. I'm curious about like. credentialing,
how you got credentialed. Yeah. And any billing
tips for people, because that's a huge, huge
thing, right? It's like, do we do billing ourself?
Do we outsource it? Who do we hire? Can we bill
psychotherapy with these 30 -minute visits? There's
just a lot of stress around those topics. So
any words of wisdom for people listening? I think
if you don't want to use Grow or Headway or Amar
or one of those, I think keep billing in -house
because outside billers do not care about your
business like you do. Nobody cares about this
business like Trey and I do. It's our baby, you
know? And so we're constantly hustling. But an
outside biller is not going to care about it.
And we've been through three billers and have
lost thousands of dollars on billers until we
finally moved it in -house. Yeah. Really? We
finally moved it into Trey's wife and my son.
They do it now. They've learned enough over three
billers to be able to do it themselves. So they
do it now. And if, you know, if there's anybody
that cares about growing this business as much
as Trey and I do, it's the two of them. So they
stay on top of billing every day. You know, they're
doing stuff constantly. They're on the phone
constantly. You know, they'll be in our office.
You know, such and such insurance lapsed. What
do you want to do? How do you want to handle
it? You know, I mean, the dream would be to have
an all cash practice and it full nine to five
Monday through Friday. But it's a lot. we decided
not to go all cash because we wanted to build
it quickly. We knew we needed money coming in
pretty quickly. Yeah. So yeah. Paid for the rent.
We had paid for the EHR and hired a billing team
to do our credentialing and our billing. And
so I think the credentialing per provider was
around $1 ,200. And keep in mind, we were sticking
this on a credit card. Right. To pay, which we've
been able to pay that off. And, you know, get
return on that. But that's a group practice that
you're credentialing as well. And when, again,
if I could, I probably have a lot of hindsight
on here, but if I could give hindsight, then
it may have been more beneficial to go with like
Grow or with Headway and do the billing for us.
Yeah. That, yeah, that's a huge question right
now, right? People are like, Do we start with
that? Do we not? I totally agree with you. If
you're trying to build quickly, taking insurance
is definitely the route to go. But I can see
the value of starting with one of those companies.
I'm not financially affiliated with any of them
or saying that all of you guys should use them
to start. But I think you need to weigh that
risk -benefit. So you didn't use any of those
companies? In the very beginning, we used Grow
and Headway just because we needed to get paid
quickly with money coming in. And we grew quickly,
too. We grew so fast. And so that wasn't the
issue. And then, you know, getting the money
to come in, it was coming in. It's just we had
a lot of overhead at that time. You know, which
going back, I would have I would have still rented
the space. I love the space that we had. We would
have just done it just three of us to start.
Then, you know, we probably could have kept the
overhead a lot less because you've got to pay
for the EHR for everybody as well. Right. So
if somebody joins you now, do you use that same
company that you got started with to get them
credentialed or? No, we have. another company
now because they were attached to billing and
credentialing and we had to let them go. And
so we have a separate just credentialing company
that if we need it, they get us credentialed.
Okay. Gotcha. Gotcha. That makes sense. So are
most of your providers, like what percentage
are in person versus telehealth? I do about 50,
50. I really like telehealth. I feel like, you
know, when they come. the patients that want
in person they can come in person i feel like
I waste time getting up, going to the lobby because
I get my own patients to get them, bring them
back. Then you chit chat for a few minutes and
then you kind of get into it. We're on telehealth.
I feel like we can log right on. How are you?
I'm doing well. How are things going with this?
You know, how are things going with this? And
I feel like I get to spend more time with them
over telehealth than I do in person because my
schedule is packed from nine to five. So it's
like. you know, constant pack. So trying to get
somebody out of the office is a lot more difficult
than telehealth. How many hours a week do you
see patients? 40 hours. Monday through Friday,
nine to five. Some Fridays, well, that's inaccurate.
Probably, you know, 35 -ish because I usually
leave early on Fridays. And I was taking Fridays
off and I've just had to open up my Friday books.
To get patients in? To get patients in, yeah.
Okay. Yeah, that's a lot of direct patient care
hours on top of running a practice. You're right.
And my follow -ups, like my stable follow -ups,
I do 15 minutes. So there's some days that it
is every 15 minutes from 9 to 5. Wow. I take
lunch from 12 to 1. So I see a lot of patients.
Do you use an AI scribe at all? I do. I use Breed.
Okay. And I actually, this is a splurge. So it's
not that I'm recommending this, but I hired a
scribe as well. So, and she's been worth every
penny. She takes all kinds of coding classes.
She keeps us completely updated. She'll tell
me. you know, you can bill a therapy code for
this appointment. Or she'll say, you cannot bill
a therapy code on this one. She knows exactly
what to tell me. Or she'll say, you can do a
99205 on this initial appointment because A,
B, and C, you know, or she'll say, you need to
go down on this one before you send it in. So
she's been fantastic. And I found her through
a Facebook group. a couple of years ago and I've
been using her for about two years. So she has
my freed login. She'll go in through that and
she'll get the transcript and then make the note
based on that. Okay. Okay. Yeah. So it's like,
it's like an asynchronous kind of setup, right?
Correct. She's not like on appointments virtually
or anything. No, no, no, no, no, no. She works
from home. I think she lives in Florida and she
works from home. Yeah. But she has started, Trey
hired her to do his stuff too. That's smart,
honestly. That's super smart because that's the
downside to using AI, right? Yeah, I know. And
I will say the hard part about seeing so many
patients is keeping up with the charting. That's
the hard part because I don't want to have to
go home and chart. I will if I have to, but I
didn't want to. And so that money. that I'm spending
for that was worth my not risking burnout to
be at home all evening charting as, as well,
because, you know, if you're doing 15 minute
appointments, you don't have time to chart in
between. Right. And so, and I, I was spending
my lunch break doing some charting. I didn't
want to do that anymore. And so same thing with
Trey, you know, he found himself getting behind.
He hired him. She hired her, hired Gina. That's
our scribe's name. Got her. She got him caught
up and it's just been the best money we've ever
spent for sure. For sure. Yeah. Okay. That's,
that's interesting. I know people are going to
be intrigued about that because I know that's
a pain point for many people. So it's like, that's.
Interesting. Was it just a random Facebook group?
And she's like, hey. Yeah, it was a random Facebook
group. And she said, does anybody know how to
hire a scribe? And she said, I do it. And so
I contacted her and she called me and we did
kind of like a little interview where she was
wanting to know what I was doing and, you know,
if I was behind and, you know, kind of told me
her rates, which I think are very, very reasonable.
And roughly, can you tell us what those are?
I don't know if it's increased, but. because
I hate to speak out of turn because I'm happy
to share her information as well. She's open
for additional. She is open for additional. Yes.
Gina Ahrens is her name. And I think when I first
started, she was, I think it was $12 for a new
eval. And then it might've been nine or $10 for
follow -ups. Oh, okay. So maybe a little less
on the follow up. So she does it for a chart.
Yes. And I'll tell you, probably for as many
patients as we see, we probably spend between
$4 ,000 and $5 ,000 a month on her. Yeah. Because
that's for all the charts she does. Yes. Worth
it though. Oh, yeah. Yeah, I might be reaching
out to Gina. Yes. And she's fantastic. She goes
to all of the, she sends herself to these coding
classes. She'll check in with you. She's taught
us so much just about what we should and shouldn't
be charting. And she will keep you on it. I do
not worry. I just welcome an audit because I
know her charting is so fantastic that I'm like,
so go ahead. look over them at some point, like
with the turnaround, that she does her part and
then you get the charts closed. Usually she's
a day behind. So if she's free today, she'll
start working on charts today. And sometimes
the next morning I come in and they're done from
the day before. Okay. But I know in the beginning
when Trey first hired her, he would change some
things and she went to him and said, You can
change things if you want, but this that you're
putting in here is going to flag insurance. And
he was like, okay, I'll leave it alone. And so,
so yeah, so she really knows her stuff. Yeah.
And I'll share her information with you. That's
pretty cool. Yeah. So, so you guys don't have
to spend a ton of time kind of. No. Okay. I haven't
done, I can't remember the last time I had to
do a chart. Nice. Do you have a template you
like in freed? I just use the regular one that
they've got. You know, I'll either say it's a
new eval or a follow up visit. She just kind
of takes it from there. I think she probably
has. I'm sure she does have her own template
templates that she uses for the charting. But
like the, you know, the section at the bottom
of intake queue of the forms where you can kind
of put your plan or, you know, if you're going
to follow up, that kind of stuff. It's just this
long. stuff that she puts in there. If you do
psychotherapy, she does this fantastic wording
for psychotherapy. She really took it and ran
with it and has done a great job. Anytime I have
students, they'll always say your charting is
incredible. And I'm like, thank you. I didn't
do it, but thank you. Yeah. That's awesome. Oh
man. I have so many more questions for you. Cause
I'm curious about how you grew from like no patients
to a thousand patients. in six months? Like what
did you do specifically to make that happen?
So one thing that we did in the beginning that
was another cost, but we felt like was worth
it is we hired a marketing team and that runs
us about a thousand dollars a month. They take
care of all of our social media. So you still
have the same marketing team? We still have the
same marketing team. They are like handshake,
good old boy run. They're fantastic. do like
if we decide to run Google ads, which we have
run some Google ads and they handle all of that.
They handle the advertisement. Now they don't
do that. What I call kind of boots on the ground,
you know, marketing. They're more of like, they
maintain our website. They do all of our social
media, our Facebook and our Instagram for premiere.
They keep track of all of that for us. And so
that's worth it because it got to where my husband,
because He also started out managing our website
and it just got to be too much. There's a lot
of traffic through there. And so he was like,
I cannot keep up with your socials either. So
they post daily, sometimes multiple times a day.
If we want something posted, we'll just reach
out to them and just tell them, can you post
about this today? You know, that kind of stuff.
So they do a great job. Wow. You don't hear that
very often. People are like, I hired a marketing
team from the beginning and I'm still using them
and I'm happy with them. And we're happy with
them. Yes. The first time I met with the guy
that owns the company, which is Nixon Pro is
the name of that company. He said, I don't do
contracts. It's a handshake only. And that just
really sold me. You know, he's local. They knew
the area. They knew there wasn't anything in
this area like what we had. And then Trey and
I, in the beginning, we literally got in my car
and went around to different doctor's offices
and therapist offices ourselves. We did all of
that kind of boots on the ground marketing ourselves
in the beginning. We did all of that. And then
our name started getting out there and we started,
it just. The floodgates just opened with referrals
for us. That's awesome. So if you were going
to like if we were looking at a pie chart of
kind of the breakdown of where your referrals
come from, what would you say roughly as far
as like primary care versus therapist versus
Google ads? I would say now we're probably about
70, probably 60 percent from therapist. And probably
30 percent from PCPs and then maybe like 10 percent
just Google searching. Maybe a little more, you
know, that's just kind of like a rough estimate
because I get a lot from therapists and they'll
say, my therapist sent me, my therapist sent
me. So, yeah, I get a lot from the therapist's
office. OK, so do you feel like that's a direct
result of like your and Trey's kind of boots
on the ground effort? Yeah, I think so. I think
so. We started and we're getting ready to kind
of redo it. Like what we're going to do is my
son Will and Brittany are going to start going
out on Wednesdays like every other week and just
do like we did when we were brand new. Just revisit
places, see if there's any new any. Anybody new
and just same thing, just going into buildings
and offices and saying, hey, we're here. We've
got pretty much immediate openings. You know,
we can help. Just let us know what you need.
And so we just every so often that cycle. OK,
bringing in like business cards or anything like
that? We'll take business cards and we'll take
pamphlets in. I think for really big PCP offices,
Trey and I will go take them lunch ourselves
and see them that way. But like the smaller offices,
you know, Will and Brittany will go and we'll
we'll take the pamphlets and say, hey, just wanted
you to know, because I think sometimes after
a while people forget that you're there. So we
just want to. Just a quick reminder, we're here
if you need us. Yeah, absolutely. Another question
people ask is like, how do you decide when someone's
caseload is full, quote unquote? That's a good
question. I think, no, and we haven't really
thought about it, to be honest with you. I will
say this, Trey. is working. We still both cover
the hospital inpatient. So I will do it some
weekends PRN and he still does it full time.
So Trey will be gone to the hospital in the mornings
and then he will come here and he will see a
ton of people in the afternoon. That is getting
ready to change though, because we are getting
so, I told him, I need you here, you know, full
time. I said it. different but I basically said
I need you to be here full -time and so he has
put his notice in at the hospital and he's going
to be starting full -time next month I think
once we both get to a place where we're like
a month you know if it's like a month booked
out then at that point you know maybe that we
say you know we're not taking anybody or we need
to hire somebody because we've got a PA that
she sees adolescents online because there's such
a need for kids and adolescent, but it's not,
that's not where I'm strong. I'm not strong with
kids or adolescents. And so. she will see kids
online. And then we have another NP that does
mostly online in the afternoons as well. And
she's kind of full. She, she has stopped taking
new patients because she's just doing it in the
afternoon. So right now it's just Trey and I
taking new patients. And so we haven't really
gotten to a place where we're like, I can't take
anymore. I think the dream would be to really
grow and We can step back a little bit, just
keep the patients that we have and maybe do more
of an oversight of providers. And I don't know
really what that growth looks like. I know I.
Just I have a Florida license. I have a Kentucky
license. I have a Texas license. I just applied
for autonomy in Florida, which you can do, I
think, after 3000 hours. I just applied for that.
I haven't heard back yet and just got my day
in Florida. So we'd like to branch out telehealth
to Florida. We're right on the Kentucky border.
So that might be an area to target as well. OK,
interesting. So wait. Are you guys multi -state
or are you guys all? We're just, Premier is just
in Tennessee, but we would like to be multi -state,
which I know several of the guests that you've
had have been multi -state and I find it fascinating.
You know, like I've had so much more, so many
more questions. You know, when I listen to all
your episodes, I'm like, I have questions about
this. I just have so many questions, you know,
and we would like to. you know, be able to look
at some of the autonomous states as well, because
the truth is we're in Tennessee and we're probably
one of the most restricted states. And it's really
tough. We got really lucky. That's another thing
that I know that's been talked about before is
having to pay supervisor fees. We don't have
to because we knew that. our psychiatrist and
our mentor so well, he doesn't charge us any
fees. So we're very lucky in that. So that's
a fee that we don't have to pay right now, as
long as he's good, you know, and still with us.
But Tennessee, they've been, NPs have been fighting
for autonomy for a while. Trey and I actually
went and met with one of our senators about it.
maybe about six months ago. And we took him all
the statistics on, because I think the big thing
here is opioid abuse. And we're like, well, first
of all, we don't even prescribe opioids. So,
you know, but this is the problem with needing
the supervisor. And he told us literally, it's
a money thing. This is why it's not being passed
thing with these doctors. And so they, he did
agree to get it back on the, the board for this
year and I think the governor did a big at the
governor's state address he addressed autonomy
for nurse practitioners said that several rural
facilities were closing because they could not
find a supervising physician in Tennessee and
these people were not getting the care they needed
and that His suggestion was to give autonomy
to APRNs in the state of Tennessee. So hopefully
they'll listen to that. And that is something
that can happen, I'm hoping. But, you know, when
you're in a really restricted state, you've got
to find a supervising physician. And it is not
cheap. It is not cheap. That's what makes it
really hard. Yeah. Did you hire a lawyer? Or
have you along the way or not? Well, my sister
is an attorney, so we just picked her brain on
things. Now, she doesn't do health care law,
but she was able to help us with a lot of the
basics. Yeah. And then a lot of our I .T. stuff
and our, you know, Internet, things like that.
My dad stepped in and it was really a family
thing. You know, we had to do that. You know,
we didn't. We just didn't have it, but I am really,
we do have an attorney now that I should have
said that we do have an attorney now that if
we need him to look over contracts, we've put
him on retainer and he, he does help with stuff
like that. We've only had to use them one time.
We had a biller that was not doing what they
were supposed to do in their contract. So we
shut them out of the system and they tried to
sue us for like seven or $8 ,000 in our, we,
that's when I know that's when we retained this
attorney. And it's somebody local. And he looked
over the contract and sent him a letter and said,
this is not going to fly. And if you don't drop
this, we're going to look at a countersuit. And
we've not heard from him since. So we do have
someone on retainer right now. Yeah. Okay. Do
you hire your practitioners W -2, 1099, if you
are comfortable sharing? I am. We, they're 1099s
right now. If I could go back, I would do W -2
and just give them an hourly rate because we
were really generous, I think, in the beginning
and did a 70 -30 with them. And then we really
started losing money on the business. So we renegotiated
with them and they agreed to a 60 -40, which
was still giving them a good amount of money.
So if I could go back, I would probably just
give them a flat rate. Sometimes it muddies the
water with 1099s, especially when you take insurance,
because if they're making a certain percentage,
then sometimes you're waiting for claims to come
in. But then if claims get denied or if clawbacks
happen, then it makes it difficult to wade through
that when that happens. Yeah. Yeah. Being on
the opposite end of it, I had a job where I was
a 1099. Yeah. I didn't realize that I was going
to be like waiting to get paid. Right. So it
felt like I wasn't getting paid, but yeah, I
was, I was new to it and it wasn't really explained
that explicitly. So I was like, just kind of
like, huh, this is not loving this. So you guys
are a practice that takes students. It sounds
like. Trey and I both take students. I usually
will have, you know, a couple float through here.
And I know how hard it was. I had to pay for
preceptors. So I know how hard it is to find
preceptors. So I try not to say no to students,
but I don't want to have too many. And I want
to make sure they're getting what they need because
my appointments can move pretty quick, especially
with my really stable patients. And so I want
to make sure they're getting enough from it.
And so I do take students. I've got one or two
with me right now. And so sometimes they'll come
in. Sometimes I'll let them, you know, kind of
listen. If they can't make it in, then I have
a Zoom room they can come into and listen. If
the patient allows, part of the paperwork is
for student observation with our patients. And
if they check no, then no students. If they check
yes, they can listen in or sit in on the visit.
But that's part of the standard paperwork is
the student observation. Okay. Is there a certain
place that these students come from? Do you charge
for clinicals? No, I don't typically charge.
Most of the time they come from a friend. Like
a friend says, I know, or a nurse that I used
to work with. I've gotten a lot more now. Like
a nurse that I used to work with that knows what
I'm doing now will say, I've got this friend.
She needs somebody for clinicals. And of course
I'm like, sure. You know, I did sign up. Some
of them, I did sign up at one point. when we
first opened just to make some extra money through
NP hub. So every once in a while, I'll get one
through there that, you know, pays, but if, if
it's word of mouth, I don't charge them. You
know, if it's somebody I know, I don't charge
them any money. I don't, you know, I just, I
just agree to it. Yeah. How do you determine
the length of follow -up appointments and like,
How what's that conversation like in your group
practice as far as like the billing of brief
psychotherapy? Because I think that's another
one of those kind of can be, I guess, controversial
topics. People don't always agree or see eye
to eye on it. So I was just curious. So if I
do a follow up in person, it's 30 minutes. And
if we do get into some psychotherapy things,
then I will bill the 90833. I do not bill psychotherapy
for my 15 minute appointments at all. Not at
all. And so those I do not bill for. Sometimes,
you know, sometimes you just have a patient come
in person, you're scheduled for 30 minutes and
it legitimately only takes like 15 minutes, you
know, because sometimes the patient just sits
and they're like, I'm fine. Everything's good.
You know, and you try to pull information from
them and they're not going to give you anything.
Those I just bill for like 15 minutes. But if
they're here for 30 minutes and we do some psychotherapy
with it, then I will bill for the psychotherapy.
But only if I have. seen them for 30 minutes.
Do I feel that if we did some psychotherapy that
I might do it? But I'll tell you a little secret.
I do not love the psychotherapy part. I love
the medication management part. I love to hear
the good stories. I love the reason I fell in
love with psych was there's got to be a reason
that this is happening. What's the reason? And
then finding the right medication for a patient
is. what i love about it so i don't i don't get
super jazzed but i'll do psychotherapy because
sometimes it's just it it is but i don't look
for it if i build the code or if it's happened
it's happened very organically and it's on that
so yeah that makes sense that makes sense why
your follow -up visits are mostly 15 minutes
too that's right yes for sure yeah This is kind
of an interesting one, but especially having
a business partner, have you guys ever had the
conversation of like, is our goal to eventually
sell the practice? Is it to just kind of like
you mentioned earlier, maybe step back a little
bit more and do more oversight, maybe less direct
patient care hours? Like, yeah, I'm curious.
Yeah, no, it's a great question. We have talked
about at some point if it gets so huge that would
we sell it? you know, I think, and trail say
for the right price. I don't think about that
as much because, you know, we started this, this
is our baby. We love it. You know, I'm happy
every day when I get up, come to work and I love
what I do. So that's not something I'm anxious
to get rid of. We would like to grow, but I don't
want so much growth that we become like a big
chain, like something like Athena. you know,
one of those just exploded. I like, I want to
stay premier. You know, I, I would like to grow,
but not so big that we lose sight of what we
opened and why we opened it. But we do talk about
that as, as we grow, we would like to hire more
providers. step back some from direct patient
care, do more like oversight or, you know, kind
of supervision for new NPs and go that route
with it. Or we'd love to be able to get to a
place where we're saying we're not taking any
new patients. We're just going to keep what we've
got, you know, and start giving other NPs the
new patients. And so I think that is a potential
within a year, especially with Trey coming on
full time. I think that's a big potential. you
know, to happen. We get a lot of people that
we've known wanting to work here. We get a lot
of calls, you know, students wanting to work
here. And I, I'm sure it, you know, it looks
fun, like that we're all here and we're working
and it's great, but it's going to take a lot
for us. We're going to have to explode some more
before we really hire a number of NP patients
because we just need, there's nothing worse than
hiring someone and they're just sitting. you
know, for weeks at the patient load. So we're
going to have to get to a place where, you know,
we, we really are just cannot handle the senses
that we currently have before we really look
into doing that. Yeah. Okay. So from like a mentorship
or coaching perspective, it sounds like you have
that psychiatrist that has been really supportive,
but is there anything else that you've invested
in or like found for free that's been really
helpful as far as mentorship, coaching, resources?
Yes. I love NEI. I use it every day, sometimes
multiple times a day. I always recommend it to
students because they have a student rate, but
I absolutely love it. It's a daily thing for
me. I like Psychiatry Redefined. I'm actually
just working through their hormone and mental
health course. It's a three -part course because
I started to niche down a little bit with ADHD
and that kind of perimenopause, menopausal female.
I see a lot of those. wanted to become you can
get certified through the course I really wanted
to become more educated on it I don't think there's
a ton out there so I was really excited to find
that course to take but trying to find you know
someone that's going to talk about hormones and
mental wellness I think there's more light coming
to it but still not enough right okay so you're
not in the fellowship you signed up for a three
-part hormone course. Correct. Yes. How far into
it are you? I am in the middle of the first,
there's three live sessions, but I joined after
the first two had already come on. So the third
one is this week. So I'm working through the
first live session now. Okay. And are you liking
it so far? Because people ask me a lot about
like trainings and education on that. I do like
it. I do. What was the price point roughly? It
was $399 for the whole course. Okay. I've looked
at the fellowship too. I know I think you're
doing the fellowship. Do you, or you're working
through it. Do you find it helpful? I do. I do
find it helpful. Yeah. I've definitely branched
out with what I recommend to patients. Sure.
Okay. And I, I'm behind on the content as per
usual with the courses I sign up for, but yeah,
I've definitely found it. helpful and kind of
given me more confidence to try some of these
integrative interventions that aren't as established,
you know, so I'm enjoying, I'm learning. That's
what I liked about it too. I was diagnosed with
ADHD when I was in grad school and that's what
prompted me to, to start taking training courses
and become. you know, trained in how to treat
ADHD. And so one of the reasons that I really
like psychiatry redefined is we're looking at
the integrative part, you know, the fun part
more instead of just, you know, handing out stimulants,
even though they are the treatment. I understand
that. I want to see better options. I want to
see, you know. And not just diet or exercise.
I want to see what supplements can we use? What,
you know, what do I need to really be honing
in on with women, especially in their late 30s,
40s, 50s, and they're having these hormonal shifts
and it's just exacerbated ADHD that they've had
to live with all these years. You know, no one's
taking them serious because sometimes they still
think that menopause is just hysteria. you know,
and, and so I really wanted to become, you know,
better educated in that area because I'm starting
to see a lot of my patients are, are kind of
in that category right now. I love that. I love
that. That's really cool. Yeah. One of the questions
that I ask at the end of the podcast, all my
guests is, um, what does the phrase no prior
auth mean to you? I think for me, You know, no
prior auth would mean maybe without, you know,
boundaries or without any kind of restrictions.
So it would be autonomy for all states, for NPs,
you know, that we're not having to ask permission.
We're not having to, you know, fall under that
guideline and that we can do what we were trained
to do, what we went to school for, what we spent
years doing, and just be able to. you know, practice
to the best of our ability to help patients because
there is such a need for that. And there's such
a shortage of supervising physicians that it
would just be autonomy for everybody. Yeah, absolutely.
I lied. I think I have one more question for
you. Go ahead. And then I'll let you go. No,
you're fine. Anything else, you know, you mentioned
like there's probably a lot in hindsight I would
do different. Anything else that you can think
of? Because that is part of. You know, this podcast's
purpose is trying to help psych NPs at different
phases of their journeys and kind of thinking
to, yeah, I had known this six months ago or
nine months ago, a year ago. This probably would
have saved me some hardship. So anything else
you can think of that our guests or our listeners
might benefit from? I think if you're currently
working a full -time job and you're nervous about
starting your own practice, then do it. Do it
slow, but just do it. Do it slow. If you need
to see patients in the evening times, not that
it's super ideal to work that long, but if you
need to start really small and see people in
the evenings and work up to that, where then
you go part -time, that's what I did. Like, I
still worked full -time with people in the evenings
until I could manage to move over full -time.
I think you just got to do it. It is scary, but
it's okay to be scared. you know, of that kind
of stuff. I think just doing it, just, just do
it. That's the best thing I know to say, just
make it happen. You can, you can. I did it at
45. I went back to school, became a nurse practitioner
and opened my own practice at, you know, 50,
49, 50 years old. So I tell people all the time,
if I can do it, anybody can do it. Yeah. Yeah.
And wait, did you go straight to private practice
when you graduated? Or did you work somewhere
else? No, I worked for two years. So I went back
to school in 2019 is when I went back to school.
And then I finished up my doctorate in 24. So
we were opening the practice. I was finishing
up my doctorate, but I had worked as an NP since
2022. So I'd been working as an NP for at least
two years at the hospital before we opened up
a practice. Okay. Because, yeah, again, people
are curious about that. Did they have experience
before they worked? I did. That's just the way
I did it. But I had hospital experience, which
we know is a very different animal than outpatient.
They're very different, very different beasts.
And the other thing I meant to say earlier, too,
was that we do get some referrals from other
practices because we handle the tough stuff.
Trey is really good at those really good acute
complex cases that other outpatients feel like
they can't handle. So we get a lot. What amount
of referrals from other psychiatric practices
because they know that we treat the tough stuff.
You guys have that reputation for like, oh, if
it's high acuity outpatient, they can handle
it. For sure. Yes. That's awesome. Well, would
love to have you on for another episode down
the road because I haven't really having fun
doing this. And I think it's really cool to see
people's journey as it kind of. unfolds so thank
you angie for taking the time and thank you for
having me today yeah all right you