Amy Wonkka: [00:00:00] Welcome to SLP Nerd Cast. I'm Kate. And I'm Amy. And we appreciate you tuning in. In our podcast, we will review and provide commentary on resources, literature, and discussed issues related to the field of speech language pathology. You can use 

Kate Grandbois: this podcast for ASHA Professional Development. For more information about us and certification maintenance hours, go to our website, www.slpnerdcast.com.

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Amy Wonkka: to teach us. Just a quick disclaimer, the contents of this episode are not meant to replace clinical advice.

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Kate Grandbois: Before we get started in today's episode's, financial and Non-Financial Disclosures, um, I am the owner and founder of Grand Wa Therapy and Consulting, LLC and co-founder of SLP Nerd Cast.

Amy Wonka is an employee of a public school system and co-founder of [00:02:00] SLP Nerd Cast. Uh, we are both members of ASHA's six 12 and both serve on the a a C advisory group from Massachusetts Advocates for Children. I am a member of the Berkshire Association for Behavior Analysis and Therapy, mass, a BA, the Association for Behavior Analysis International and the corresponding Speech Language Pathology and Applied Behavior Analysis special Interest group.

Okay, so I have a question for you. 

Amy Wonkka: Yeah. 

Kate Grandbois: Do you get nervous when we read that 

Amy Wonkka: a little bit? 

Kate Grandbois: This is, I think our 15th, 16th recording maybe. Yeah. And I still. Get nervous when we read this intro 

Amy Wonkka: because it's like the scripted thing. Is that 

Kate Grandbois: weird? 

Amy Wonkka: Well, it's 'cause you don't wanna, I mean, for me, I, I don't wanna screw it up.

Kate Grandbois: I don't wanna mess, I don't wanna mess it up. It's like if, 'cause I don't know what will happen. The script police gonna come after us, I guess. We'll, we would just have to do it over and that would be annoying. I don't know. Trying to think about what contingencies are participating [00:03:00] in my anxiety. Moving on, Amy, what are we talking about today?

Amy Wonkka: Well, today we are talking about private practice. 

Kate Grandbois: So we have already done an episode on private practice, but this one is slightly different because we are going to be reviewing documentation, logistics, and staffing. And our first episode, for those of you who haven't listened, was related to liability concerns and financial issues.

Um, in that episode we talked about the difference between incorporating or being a sole proprietor or being a DBA. Um, we reviewed budgets. Um, con budget considerations and taxes. So if you haven't listened to that episode, we definitely recommend it. Um, today's episode stands alone. I would say. You don't have to listen to the other episode first, but we will be referring back to that episode a little bit.

In terms of, um, budgetary, everything is related to the budget. The budget comes first basically in any [00:04:00] business. So, um, if you are interested in any of those items, feel free to go check it out. I think it was episode four. 

Amy Wonkka: It was, it was an earlier episode. 

Kate Grandbois: Yeah, it was episode four. Go to the website, 

Amy Wonkka: find it.

Kate Grandbois: Yeah, it's on our website. People can find it. It's up there. 

Amy Wonkka: So why, why are we talking more about private practice when we've already talked about it one time? 

Kate Grandbois: Well, actually we had a couple of listeners, um, reach out and ask some follow up questions related to private practice that we didn't cover in that episode and we figured it would be a good opportunity to just share more detail.

Thank, for those of you who don't know. Um, I have been a private practice owner for about 10 years or so. I've been in private practice and I've done a whole variety of things in private practice. I have done, um, brick and mortar where I had an office. I've done consulting, I've done home [00:05:00] visits, I've taken insurance, I've done private pay, I've done, um, private practice by myself.

I've done private practice with employees, um, ish. So, um, I have some knowledge to share. And I didn't share this disclaimer in the last episode until like halfway through, 'cause I forgot. But I am remembering this time that the disclaimer for this episode is that I am not an accountant and I am not an attorney.

Amy, are you an accountant or an attorney? 

Amy Wonkka: I am most certainly not an accountant, nor am I an attorney, nor have I ever had a private practice, um, where I have managed any of these things. I, I had seen a few private clients way, way back in the day. Um, and the rules and regulations around owning a private practice have really changed since 

Kate Grandbois: then.

They have, 

Amy Wonkka: uh, so. Kate Pete is my go-to for all of this type of information, for when I entertain a thought of doing some private practice work, and then I remember all of the different parts that are [00:06:00] included. Uh, so I think this is gonna be really interesting for me, just looking through the notes, seeing your so glad 

Kate Grandbois: am I gonna teach you something for the, for the, that's a rare, rare opportunity.

It's usually the other way around. How many people have I worked with over the years where I ask me a question, I say, ah, that's a good question. Lemme ask my friend Amy. And this is the only, this is the only area where I can shine. So I'm, I'm gonna, I'm gonna take advantage of it. 

Amy Wonkka: You have a lot of friend, but this is definitely one of them.

I know, I know really very little about this. So I'm excited to learn about all of these different components that go along. You know, with the budgetary and, and legal pieces that we talked about in the last podcast, 

Kate Grandbois: and sort of piggy, you know, just going back to that disclaimer, all of the information that we are gonna share today is based on, um, experience.

This is just a, I, I feel like I'm, I'm not old enough to call myself an experienced person, but I'll, I will say that this is all based on my experience owning and [00:07:00] running a private practice. Um. For the last 10 years. So there are going to be some things that we cover that are very specific, especially to the state where you live.

And I always, always al well, we both always encourage people to reach out to an accountant, reach out to an attorney. Um, we covered this a little bit in the other episode. It is worth the money to pay an attorney or an accountant for a one hour consult, just to have a point of reference and make sure that you're doing some things in basic compliance.

Um, none of the information in this, in this episode is legal advice or accounting advice. We always, always, always recommend that you talk to your local expert. Now that that is out of the way, let's review our learning objectives for the day. 

Amy Wonkka: And this information will help you have formulated questions and a plan for when you do meet with your legal and financial expert.

Yes. So having this background information is going to be very helpful for when you reach that point in time because you will have. [00:08:00] A, a background walking in. 

Kate Grandbois: Totally. And, um, we can talk about this a little bit as we go through, but one of the best ways to use an accountant, an attorney is to draft your own documents, draft your own policies, and then pay for their time just to review them.

You don't have to pay them to come up with these things for you. Mm-hmm. 

Announcer: Um, 

Kate Grandbois: so hopefully you can take the information from, um, this episode to sort of craft your own set of, of documents and policies and procedures. Um, okay. Learning objectives. Amy, you wanna read 'em for us? 

Amy Wonkka: Yes. Yeah. So our learning objectives today, first we're going to identify the required and recommended components of documentation in private practice.

Um, we're next, we'll talk about the logistical considerations and some possible solutions. And last, we're going to identify issues related to hiring employees and staffing. 

Kate Grandbois: Yes. And, um, I think we're also going to maybe talk [00:09:00] a little bit about the structure of staffing and maybe do a little bit of a shameless plug for, um, a future episode on mentorship and how important that is when you have staff.

It's not just about supervision, it's about creating a culture where people can learn and grow. And all more brains are always better than one brain. I, no one will ever convince me otherwise. I, um, but yeah. Shameless plug for a future episode. Okay. So, um, first learning objective 

Amy Wonkka: documentation, take it away.

What, what do, what do I need to do and how is it different? 

Kate Grandbois: Documentation seems so boring, doesn't it? But the thing about private practice is that if you don't have your, the right documentation, you can get in a whole heap of trouble. So you 

Announcer: really trouble that. Right, right, 

Kate Grandbois: right. I feel like a lot of people are, are motivated to just avoid, motivated to have, you know, learn more about documentation just to avoid, um.

You know, any of these issues that could come up. So we're gonna talk about, um, [00:10:00] documentation, the recommended components of documentation, and then the required components of documentation. There are so many different pieces of documentation and private practice. There's the intake paperwork that you give your families and your clients.

There's how you document your billing. It's really overwhelming. Um, we're gonna have a handful of free downloads on our website, as well as a couple of super, super cheap little startup packagey things that, um, are available that we hope are helpful to sort of get things up and going in terms of, um. The discussion in terms of, you know, reviewing these different kinds of documentation, I thought it made sense to review clinical documentation first.

When I say clinical documentation, I mean your, um, you know, the notes that you're writing after each session, evaluations, any doc, any piece of documentation where you're really talking about your therapeutic activities and what was involved in your clinical work. So we know [00:11:00] that clinicians have to take data.

Another shameless plug to our episode about data collection. Uh, that was episode three. Data collection is really, really important. Um, so we all know that we need to take data, data. We all know that we need to document our work. It's in our code of ethics, but the level of documentation that is required varies widely by setting.

Wouldn't you agree? 

Amy Wonkka: I completely agree. I mean, having, just thinking about the difference between when you're in a school-based environment versus an outpatient environment, you know, I think a lot of that for me. In the different environments where I've worked, I think a lot of it's tied to the funding source.

And different funding sources sort of require different types of documentation for reimburse reimbursement. Um, but every, every place has their own kind of set rules about what they, what they like, and what are the minimum and kind of recommended criteria for documentation. 

Kate Grandbois: Right? And if you're working in a setting where you can get away with a soap note.

That's sort of [00:12:00] your like scribbled. I remember when I was in one of my graduate school placements, my supervisor at the time literally scribbled something on a scrap of paper and like shoved it in a, in a folder. And I was like, what the hell is that? That's not, in my mind it was like, not documentation that probably wasn't very, wasn't very good practice on her part.

But, you know, documentation really can vary when you're in private practice. I would definitely recommend that documentation stay on the, in that spectrum of like, you know, your very casual soap note to your very, very structured, highly detailed note. You definitely wanna be on the more highly structured, detailed end of that spectrum.

Um, and that's for a couple of different reasons. Um, I found this great article by I'm gonna Complete, we always, I feel like I always botch the, the names, but it's, I think Nick, Nick, JNIK, JEH, and Carol. Or maybe it's Swedish and it's the J makes a y sound. Not sure. Anyway, there's this great article, the link will be up on [00:13:00] our website, Nick j and Carol, from um, 2010.

And it was published in Perspectives on Voice and Voice Disorders, which is random because the article didn't really talk about voice and voice disorders that much. It was really primarily related to private practice. Um, this article is really, really awesome. If you read nothing else related to this episode, definitely download this article.

If you're an Azure or a member, it should be a, it is available to you in this article. They really make the point that in private practice clinical documentation needs to be detailed enough where it will stand alone as a legal document. So if you have a, if you have a problem or you get sued or something happens, you have your documentation to back you up.

Amy Wonkka: Well, and this is where I feel like a lot of the things that you are doing and that we'll talk about throughout, throughout this podcast today. Are about anticipating problems before they happen, 

Kate Grandbois: right? CYA? 

Amy Wonkka: Yeah. Yeah. 

Kate Grandbois: Do you know what that stands for? 

Amy Wonkka: I do, I know it. [00:14:00] I'm not, I'm not gonna 

Kate Grandbois: cover your beep.

Beep. Yeah. I'm not gonna curse on this one. I curse on one of the last ones. I'm gonna be so clean because I'm so clean. I'm so innocent. Anyway, moving on. So, CYA is the big takeaway for all of private practice, as far as I'm concerned. It's like one of my biggest things. And in terms of clinical documentation and this article, which I thought was very helpful, every, you need to look at, think about each clinical document, being able to stand alone as a legal document.

You can get audited, especially if you're receiving payments from Medicare. So without going down a whole hole, a whole like, you know, tangent, um, there is. Something called the Recovery Audit Contractor Program, which is essentially a program that runs at the government level to audit private practices and correct omen, incorrect overpayment to practitioners.

Um, and [00:15:00] it basically means if you take Medicare funding, you can go and have your practice audited and, and it can cause a whole host of problems. So if you, for some reason take Medicare, you should look into that and make sure that your documentation is really, really, really tight. I don't know many private practitioners who take Medicare, but that is just like a, a tiny little side note.

Um, at the end of the day, your documentation always needs, can always be used in any dispute, even if you are not being audited. So any kind of dispute, a billing dispute, disputes about clinical decision making, um, and this article in, um, perspectives on voice and voice disorders. From 2010, they make really, really valid points about the quality of clinical documentation in private practice and what it needs to include.

And I'm gonna read these points. So number one, documentation should accurately and completely describe the procedures that were used. [00:16:00] Number two, they have to be dated and signed. Sort of a no brainer number, but you can't do a soap note. You have to date it and you have to sign it. Number three, they should be error free and understandable to any reader.

Now this is a really important one I think, because if you are having a dispute with a client or a former client or the teacher of a former client and you've used a whole bunch of technical jargon that is, could end up leading to problems. So I think that that was, um, a really good. Point. And the second point that I'll make about using jargon or use making your note understandable is that if you use insurance and you get audited or reviewed or something gets denied, most people who are reviewing the case or the claim are not speech pathologists.

Most of the time there will be a nurse or other medical practitioner who's reviewing your documentation and might not be up to terms with the jargon. So make sure that your documentation is error free and understandable to any reader. 

Amy Wonkka: And in looking through your notes, preparing [00:17:00] for this episode, I thought that this was a very interesting geese because I would, I think my tendency would be in the other direction, right?

I'm, I'm trying to totally be clear about all the things I did. I'm gonna use all my fancy speech language pathology terms so people understand this is real and warranted. Um, so I think that that, that's a really interesting point for me, that it should be. Easily understandable to a non speech language pathologist.

Kate Grandbois: Definitely. Um, and there, there, which that sort of leads into their fourth point was that documentation should support, should support the need for skilled services and be related to the diagnosis. So your document really does have to reflect why you are, why the individual is participating in services.

That means you probably need to make sure you have the diagnosis written on your document, even if you are in, you know, in private, even if you're not accepting insurance, because the family could be submitting that as a super bill to their insurance to be reimbursed. [00:18:00] Um, and finally, and I thought this was such a good point that I, I actually have the quote and it's up from page 33 in this article.

If it was not documented, it was not done, it was not said, it did not happen. That is so important. If you have any concerns about anything that has happened in your session, document, document, document, how many times in a, in a work setting have you passed the buck to your boss? You know, let me ask my administrator.

I'm not really sure about that. Let me double check. When you are in private practice, you are the end of the line. So if you do not document it, it did not happen. It was not said, it was not done. And I cannot hammer that point. This is A-C-I-C-Y-A moment. No question about it. 

Amy Wonkka: Yeah. And it's a huge responsibility.

Yes. So, so to identify yourself, I think most speech language [00:19:00] pathologists we are familiar with working in environments where there is this whole administrative structure that's that's supportive. You know, you're able to go to, perhaps you have middle management and then management above those people, and then management above those people, and they have 

Kate Grandbois: lawyers and attorneys, like somebody's gonna figure it out.

It's not gonna, you know, you're covered under that umbrella, but when you're standing alone, you have to make sure that your document completely encapsulates all of this, all of these things to CYA. Yeah, I'm not cursing at all. I'm doing such a good job. You're 

Amy Wonkka: doing such a good job. Good job. Anybody who 

Kate Grandbois: knows me outside of a podcast knows that that's not always the case.

Even my children would probably tell you that, which is terrible. Okay, so based on these guidelines, we've got these five guidelines from this awesome article. What does that mean? What kinds of things need to go into your clinical documentation then? Um, and I, I sort of brainstormed a little bit and came up with a list.

Um, and all of this will be, I know this is a lot of information and a lot of lists. So all of [00:20:00] this is gonna be in the handout that's available on the website. Um, and in the private practice startup packet that we have on our website, there's a sample. Um. There's a sample note that you can download. Um, so all of these things will be listed there as well.

But, um, so in the interest of CYA, you wanna make sure you have your visit number. So how many visits have you had with the individual? This is definitely related to insurance. If there is a dispute over insurance and what the benefit was, because every insurance has an, well, they have a limit to the number of visits that were authorized.

Some insurances will have a number of visits authorized in a date. So you get eight visits before June 30th and whichever one comes first. Then you have to submit for more visits. So you wanna make sure you have a record in your note of how many times you have seen that client. You wanna make sure that you have a referral number or authorization number or expiration date related to that insurance.

Sometimes families, if you're [00:21:00] doing a private pay, they're, they may be using the, your clinical documentation to get reimbursed through a third party, and they might need a place to write the authorization number or a referral number, um, or expiration dates that are relevant. What activities did you do?

This can be a description, you know, insurance deals a lot with codes. You know, you need your CPT code or whatever. You could put a CPT code on there. You could also just write. Played with bubbles. 

Announcer: Mm-hmm. 

Kate Grandbois: Or, you know, constructed a, a village out of Play-Doh and used complete sentences to describe the village or whatever.

So you have to describe exactly what your therapeutic activities were and then make sure that they are, it's clear in your documentation what the clinical purpose was. So I wouldn't just say bubbles, but maybe you say bubbles. Looking for lip rounding or bubbles. Looking for, you know, specifically targeting requests or [00:22:00] bubbles related to two word utterances.

More bubbles, big bubbles, little bubbles. Lots of bubbles. I dunno. Anything like that. Um. You wanna make sure you document instances where things maybe didn't go well. So you had a visit where the child was under the table for the entire session and you couldn't get them out, or the child was having a tantrum or, you know, I work in pediatrics when I'm coming up with lots of pediatric related examples.

But if that happens for four weeks in a row, are you doing any therapeutic activity or are you doing behavior management? Um, or if you had a situation where the entire visit was related to counseling or parent discussions about, or something, something that's happening at home and you see in your clinical documentation that that happened for four weeks in a row, does that tell you something else about other goal areas that you might need to work on with your client?

So making sure that your clinical documentation [00:23:00] captures even the things that weren't necessarily therapeutically successful. Were you, um, are there instances where you've recommended a home program? So, a home program is a use that, um, is a word that's sort of leftover from my days working in the hospital where they, where their insurance really required home programming.

Announcer: Mm-hmm. Um, 

Kate Grandbois: I think that's also sort of related to like, pt. You know, you go to PT and you get your exercises and they tell you that you have to do them at home like three days a week or it's not gonna get better. Well, it's no different in speech pathology. So you really should make sure that you have, you know, your, and I'm, I think most people do, you know, we're working on two word utterances.

Try and do this at home and then give them some permanent product. Give them a data sheet that they can take home, give them a description of different ideas, brainstorm ideas with them, and then document in your note if they came back to your session and they did home programming. If you are taking insurance, there are some insurance plans that [00:24:00] will not continue to provide reimbursement without.

Evidence of home programming. That's only happened to me once, but it did happen. Um, and, and was a long time ago. So regulations may have changed, but it's something definitely to consider. 

Amy Wonkka: I think all of these things too, you know, when you think about making a template or having some form of, you know, structure for taking your notes and putting all these things in there, I mean, a lot of these things could fit into that.

Like soap notes structure, subjective, objective assessment plan. Um, you just need more boxes. Mm-hmm. You need more. So you could, you know, you could, it, it seems to me you could put those things into that structure if that structure is what's familiar to you. You just need to make sure to put in all of these other 

Kate Grandbois: parts.

You need a prompt, you need a reminder. 

Amy Wonkka: Yeah. 

Kate Grandbois: And I'm sorry, but if you send your documentation to, to insurance for review and it's like a, a whole page of a narrative. They're not reading that. They're just not. I have dealt with enough Medicaid reviewers in my career to just have like no faith that anybody [00:25:00] is reading a long narrative.

They're looking for a table, they're looking for like a quick visual cue and they scan the page to see exactly, you know, whether or not you were in compliance with the patient or clients benefits. Um, and I think that brings me to another point about what to include in that you wanna make sure that you're documenting progress or lack of progress.

Right. And we're gonna talk about that, um, in, in a second, but. If you are documenting progress or lack of progress, you need to consider how you are gonna document that on an ongoing basis and how you're gonna communicate that to the family, um, in the hospital or outpatient setting. And in my experience, even in private practice when I contracted with insurance, a lot of insurances will require reevaluations.

So every three months you have to revisit your goals and objectives. You have to look back at your data through the note, through your weekly notes or biweekly notes or however you saw the [00:26:00] client. Make sure that you are moving towards your objectives. And then document that in a document that was really redundant.

Document that in a document and submit it to insurance to make sure that you can continue to receive funding. Insurance will not cons, will not continue to pay for visits that are not clearly therapeutic in nature. And you have to document the therapeutic effectiveness of your treatment, and you have to do that with numbers.

Amy Wonkka: And I think, you know, a related topic for another podcast is knowing that when you begin and write your goals and objectives, so making sure that you do have your timeframe in mind. You know, when you're talking about a reevaluation as somebody who has most recently been in schools, that's typically an annual, you know, you're, you're making such a 

Announcer: good point 

Amy Wonkka: that are annual.

It, it's a, it's a shift to now start writing goals and objectives that kind of need to be achievable within a timeframe set by your third party funding [00:27:00] source. So being aware of that and being mindful about the ways that you're crafting measurable and achievable goals and objectives is really important.

We're not gonna talk more about that right now, but we will in a future podcast. 

Kate Grandbois: I, and I, I think it's such a good point. And this sort of brings me to our ethical obligation about offering services that are therapeutic. Um, principle one, Kay. States, individuals who hold the certificate of clinical competence shall evaluate the effectiveness of services provided technology employed and products dispensed, and they shall provide services or dispense products only when benefit can reasonably be expected.

That is so huge. I have, unfortunately, in my time, come across a handful of private practitioners who I'm sure they are in some way documenting their, the [00:28:00] progress of their clients. But you are ethically obligated to provide services where the benefit can be reasonably expected, and your documentation has to very clearly demonstrate that your services are therapeutic if you find that your services are not therapeutic.

Do you have an ethical obligation to discharge that individual from private practice or brainstorm other ways where it could be more therapeutic? This could be, you know, if you have an individual who is, has a more severe impairment or, um, you know, is, is an, is is an emergent learner or has a more complex body or complex, you know, has some complex communication needs and is not demonstrating improvements in a once a week session in your private practice.

Maybe it isn't the ethical thing to discharge them [00:29:00] based on the context, but maybe you need to do more collaboration. Maybe you need to see more, um, interaction with the school teacher to make sure that the therapeutic goals are being worked on in multiple environments. Maybe there are things that, more things that could be done at home, maybe you need to revisit your goals and objectives and your goals and objectives are not, you know, you've gotten to know the client better over a three to six month period and you've learned that, okay, that original goal was maybe a little bit of a reach.

Let's try this. You can't just keep plowing through, just waiting for time to make a magic wand. We are really ethically obligated to make sure that our services are, and this is literally, I'm reading it from our ethical code. Our only, our, our, you have to continue to provide services where the benefit can be reasonably expected.

And I know that that's a gray area and open to interpretation, um, but it's very important in private [00:30:00] practice to make sure that you have that clearly documented, not only in your weekly note or your biweekly note, but also in progress notes or reevaluations or whatever you wanna call them. 

Amy Wonkka: And I think that that's important for everybody to think about all the time, right?

And not being stuck into this very rigid structure of what service looks like. Mm-hmm. So that's, you know, when you have a client and you're continually reevaluating their goals and objectives and their progress, or lack of progress toward those goals, that should be something that's happening constantly and something that makes you consider, whether you're in private practice or not, makes you consider the appropriateness of those goals and objectives.

Whether there are things that you can do within your implementation that you could modify the way that you are, you know, providing your therapy, that that could help move toward achieving those goals and objectives and thinking about your service delivery models. You know, I think 

Kate Grandbois: that's such a good point.[00:31:00] 

Amy Wonkka: Be having been outpatient, which is kind of what I'm picturing as you're talking through all of these private practice components. One times 30 outpatient, you know, separately from the world that the individual lives in may not be the right service delivery model. That might be a service delivery model problem, not a goals and objectives problem.

Mm-hmm. So it's a nice, it's a nice kind of recheck to make sure that you're thinking about all of those variables. Thinking about service delivery models, thinking about goals and objectives, thinking about therapeutic intervention approaches. 

Kate Grandbois: And I think the other, you know, piece to piggyback onto that is that we're ethically obligated to evaluate effectiveness.

And that requires data. It requires something that is not your opinion. It cannot be, it cannot be solely subjective. You know, and remember again, just back to our podcast, our pod, our episode about data collection. Data can be [00:32:00] qualitative, but it has to be something that is an objective measurement. Of the client's progress.

Amy Wonkka: Well, and having been a relatively recent consumer of physical therapy myself, like I, I don't wanna spend, we're not old or No, not at all. I don't wanna spend 45 minutes at home doing my clamshell, you know, with the green band if I'm never gonna make it to the red band. Right. I, I mean, like, I'm going in, I'm doing my, my 45 minute session with my pt.

I'm paying for that. I have my little home exercise. I take 'em home, do my clamshells, um, you know, and, and if, if I were never making progress, that that's a waste of everybody's time. And it's, you know, a use of my money that I would rather allocate elsewhere. Uh, so, and that's 

Kate Grandbois: resources, 

Amy Wonkka: right? 

Kate Grandbois: Right. And, you know, we're, we're ethically obligated to make sure that we're in, in providing effective service, that the families that we're serving are using their resources [00:33:00] effectively.

And that just goes back to your comment about service delivery. You know, is a consultation with the classroom teacher a better use of your time? Right. Or is that a better service delivery model in private practice? I think there's a lot of different ways that you can look at that, but sort of zooming back out again, thinking about documentation and clinical documentation, we've reviewed a lot of the different components.

I think the bottom line is that it, it definitely needs to be on the more detailed end of that spectrum, um, and be able to stand alone as a legal document and be written to the funding source. 

Amy Wonkka: Right. There's, there are specific things that you have to include, it sounds like, 

Kate Grandbois: ethically and, yes. 

Amy Wonkka: Yeah. So 

Kate Grandbois: definitely the list.

Amy Wonkka: Right, 

Kate Grandbois: right. Okay. Um, moving on to hipaa, HIPAA's always so fun. So there are additional requirements related to hipaa. Um, so if you are accepting insurance, HIPAA is, you are considered a covered entity and you must abide by hipaa. What we [00:34:00] already reviewed in the first private practice episode that our ethical code, you know, puts paramount the privacy and security of our patients and their patients and clients and their data.

We are required that we give informed consent, all of these kinds of things. So Azure really does say even if you are not accepting insurance, you really should be in compliance with hipaa. Um, we have more links about HIPAA requirements that are on our website based on, um, uh, the, uh, health and the Department of Health and Human Services.

Um. But when you are in private practice, based on whether or not you take insurance, we really are required not only to comply with HIPAA in terms of patient security and pri patient privacy and security of their information, but we're required to give them a pri a privacy policy notice. Privacy. We are required to inform them of their rights under the HIPAA [00:35:00] law.

Now I have a, um, we have a page on our website that gives you more, um, the link to the Health and Human Services, the, the Department of Health and Human Services page. And it gives more options for me. It gives more information about meeting these requirements, but I'm gonna read directly from that page.

The HIPAA privacy rule requires health plans and covered healthcare providers. That's us to develop and distribute a notice. That provides a clear and user-friendly explanation of individuals' rights with respect to their personal health information and the privacy practices of health plans and healthcare providers.

So you're required to share with your cli, with your clients and patients, what their rights are under the HIPAA law, what you do with their health information and what you do to go to make sure that that health information is protected. The hhs.gov um, website has a link where you can generate your own [00:36:00] HIPAA privacy policy, and then it can, it gives you, um.

So once you have your HIPAA privacy policy, you have to give your client a piece of paper that acknowledges that you gave them the pr, the policy. I'm stumbling over my words here really aggressively, but basically everybody's done this. When they go to the doctor, you, it's not necessarily the consent for information, but you acknowledge that you, you sign a piece of paper that says, you gave me the HIPAA privacy notice.

I have been made aware of my rights. We have to do the same thing with our clients. So we give them a copy of the HIPAA privacy policy and then we give them another piece of paper that where they sign that they acknowledge that they received the privacy policy. That piece of paper that you give them, that they sign, you keep it forever, might the, the right answer might not be forever, but you really need to CYA, you keep it for your records so that you can show in case of an audit or in case of a legal issue or in case of anything that you were [00:37:00] compliant with the hipaa.

That's super important. I, that was a really difficult one for me to get out there. I feel like I stumbled over my words, but hopefully that was clear. So you go ahead. 

Amy Wonkka: Is, is that privacy policy [email protected], is that something people can just do for free? Is that something you have to 

Kate Grandbois: No, it's really great.

They have a lot of really great, um, resources on their website and it's just a, a little pack. It's pretty user-friendly, little packets that you can download for free. Um, so in terms of informed consent, we need to give them our HIPAA privacy policy, the notice of acknowledgement that they, the thing that they signed, that they acknowledged that we gave them the HIPAA privacy policy.

We also have to give them a consent to release form. That is a pretty. I mean, I sort of feel like that's a no brainer. Most people are pretty familiar with that. So Amy, if you were my client, you might write on your consent form that I could talk to the teacher, I could talk to [00:38:00] your family member if you're, you know, a consenting adult, I could talk to, I don't know, other professionals who are involved in your care.

Those are the kinds of things that go on a consent to release. You need to make sure that if you have student volunteers or clinician or other clinicians in your practice, that they are listed, that they are also given, um, a consent form. So I think in private practice, having student volunteers is great because it's great experience for the student and it's free.

You, you can have somebody help you make materials, help you with the sessions. But that student also needs to sign a piece of paper that they acknowledge that they are being given access to private information, that they are not allowed to talk, that they are also being held to the HIPAA law. They are not allowed to talk about your clients in the hallway.

They're not allowed to go home and, you know, spew a bunch of private information to their roommates or [00:39:00] to their family members. Um, so you need to make sure that everybody in your practice who is interacting with the client is made aware that they are held to, um, the privacy policy of your office. You need to make sure that your clients or patients are given a use of media consent.

So how are you ever taking pictures of them? Are you using the materials that you made for your session at a conference? Are you taking videos of your session to use as teaching materials? Are you ad using it as advertising on your website or in on social media? You need to make sure that they've cl all of that information has been clearly distributed to them and that they've signed off off on it.

Telepractice, this is another huge thing that's happening right now. Telepractice requires its own consent, so how are you gonna ensure that your patient or client information is private through electronic communication? I mean, I think it's pretty obvious. Everybody knows you need to use a HIPAA or [00:40:00] FERPA compliant video channel, but outside of that, what?

What are what? Precautions are you making to make sure that nobody can hear the audio in your house? What precautions are you taking to make sure that no one else can see your screen? What precautions are you taking when you email? Are your emails encrypted? You know, electronic communication is a lot more than just a Zoom phone call that, you know, we're all so familiar with this now, but there are specific consents that should be given for telepractice.

I think most people probably know that by now, but just for the sake of saying it. Um, so those are all of the things that I could sort of come up with related to informed consent and hipaa. Um, but sadly, the list of documentation goes on, 

Amy Wonkka: goes on and on. 

Kate Grandbois: It goes on and on. CYA, there's always, there's always room to cover your bums.

I'll say bum boop. Um, incident reports. What if somebody, what if you have rented space or you were playing [00:41:00] with, you know, you were doing a home visit? And somebody cut themselves with scissors or somebody fell in your office and hit their head on a table by accident and they have a horrible bruise. What did you do?

What happened? What are the, what are the consequences? So you need to make sure that you have an incident report form. Document. Document, document is always the, you know, the. I don't know the theme of the day. Your incident form or your incident report should include the client's name, the location of the incident, who was present when it happened, um, what, what happened, a description of the incident, what you did in response to the incident, who you notified as a result of the incident.

It should have a date on it. It should have your signature on it. You could consider having the parent or guardian sign it when you review it with them, you know, so Johnny hit his head, this is what happened. [00:42:00] Um, this is what I did in response to it. Um, this is definitely an area I would highly recommend having an attorney look at it because it's clearly related to a liability.

If somebody hurt themselves while they were either, especially if you have a rented space and it was on your, you know, sort of on your watch, um, you need to make sure that the. Families are aware if there was another person there. So does that volunteer, does that student clinician, does that observing professional have consent to be a part of that session?

That was sort of related to the other section, but, um, what about home programming and data sheets? We sort of already talked about that. Um, and so that, that sort of encapsulates the, the CYAI think, component of this in terms of, um, privacy policy, HIPAA notices and incident reports. I think [00:43:00] the, one of the last things related to paperwork that I wanted to go over was intake paperwork.

So this is the drier, sort of more administrative e. Components that's less. So we've reviewed the, just to sort of recap, we've reviewed the clinical documentation piece. We've reviewed the informed consent and HIPAA privacy policy, um, the CYA of having an incident report. But now we're gonna talk about what kind of paperwork do you give your client when they're a new client into your practice?

And this is sort of touching on some of the business components and administrative components of your practice. Um, I always provide my families with a welcome letter. So if they're new to the practice, if you are, you know, you make an appointment at a dermatologist's office, you might have a lot of questions about, you know, well, do you, do you have students?

Is this a teaching hospital? Am I gonna have eight doctors in the room? You know, what should I expect when I come to your practice? Does your practice have rule rules? I have one doctor's office where they have the se [00:44:00] the signs in the waiting room that says there's no cell phones. And you just like, ignore those.

Right. Like, you just, you still pull out your phone. 

Amy Wonkka: Yeah. 

Kate Grandbois: Hey, I got told to put mine away. They were like. Don't you see the sign? They took it really seriously. I mean, that would've been nice to know in the, in the welcome letter, we strongly enforced our cell phone. I would've brought a book. I don't know.

Amy Wonkka: Um, no. You see sometimes like places that have the signs about like scents, right? Like, we're like, please don't wear perfumes and other, oh, I've never 

Kate Grandbois: seen that sign. 

Amy Wonkka: Yeah. My, like, my dermatologist maybe has a sign like that. But either way yes. Anything like that. Um, and it also is how you welcome your person.

Kate Grandbois: Yeah. Right? You want them to like have a, like a clear understanding of what to expect. Yeah. I think that's really important. Um, so yeah, intake paperwork, a welcome letter. I think it's really, really helpful to have a welcome letter. And all of these forms are included in the little thingy that we have on the, um, practice startup [00:45:00] packet that we have on our website.

Um, a client history that's sort of a no-brainer. All the consent and permissions that we talked about, the HIPAA notice, the HIPAA acknowledgement, um, consent to release information to people, consent for student volunteers or student clinicians or, you know, volunteers of any kind. And then this is a juicy, the contract, this is the part where you tell them that you charge money.

This is so uncomfortable for almost all of us, almost all of us. I, I, I think I have yet to meet someone who's like, I love telling my families that they're gonna charge, they're gonna pay me X number of dollars. This is one of the biggest questions I get is how much to charge and how do you tell people?

What you charge. And my answer is always, well, it depends. There's no clear answer about how much you charge. It's, it, it's based on region levels of expertise. Um, it varies widely. I am not going to talk about that in detail. Um, [00:46:00] but I would encourage people to, you know, do some market research in your area to see if you can get a feel for what the range is.

It definitely varies widely, and you need to put your pricing in your contract. Mm-hmm. So the things that go into a student contract or a client contract are a lot. You need to outline your policies for cancellations. Cancellations are huge, especially in the pediatric population. Are you, are you gonna have a strict.

Cancellation policy or are you gonna be more flexible because you have telepractice and you have a lot more flexibility? So if they cancel on Monday, you can probably see them Friday. Um, are you working with accent modification and adults over telepractice where if you have a cold, nah, that's not really gonna affect whether or not we can get some good therapeutic work done.

You need to have a clear outline, uh, or policy for, um, non-payment or a return check. This is like the littlest thing, right? [00:47:00] But I have been burnt. CYA it happens. You need to have a clear. Policy about what happens when there is nonpayment on account. You need to have information about your pricing and what services you offer for what prices.

So depending on your clinical area of expertise, are you offering evaluations? Are you offering consultation? Are you offering, you know, direct speech services? Are there different, is there a different pricing structure for those kinds of things? Um, we were talking a little bit before this podcast about how you charge for services.

So once upon a time it was sort of frowned upon to charge for services that had not been rendered. And by frowned upon, you mean part of our code of ethics? Yes, 

Amy Wonkka: it 

Kate Grandbois: was in our code of ethics. 

Amy Wonkka: Yeah. Back in, back in 2002, 2003, [00:48:00] it was Rule M of principle one. And it said, individuals shall not charge for services not rendered, nor shall they misrepresent services rendered, products dispensed for research and scholarly activities conducted, 

Kate Grandbois: which is very clear.

Yeah, that's very, very clear. Now we've, in rereading the code of ethics, there was not anything that was as frowned upon as clear. 

Amy Wonkka: No. And there were a couple of places where, where in my reading of it, it seems like that intent had been sort of reallocated. Um, you know, looking at principle one, section Q, individuals shall maintain timely records and accurately record and bill for services provided and products dispensed and shall not misrepresent services provided, products dispensed or research and scholarly activities conducted.

Um, you can find it again in principle three, [00:49:00] but it's not, it's not as explicit. So we would say. 

Kate Grandbois: I would say if you were interested in bundling services, so I've seen, I have seen this before where it's, you know, buy six treatment sessions and get the seventh one for free and pay upfront. Right. You, this is like, you know, when you go to like a, I feel like massage.

A massage place. Yeah. 

Amy Wonkka: Nothing like that's their thing. Yeah. 

Kate Grandbois: So if you are, if you are looking at your budget and you're looking at your business model and this is something that you wanna consider, I would definitely call the Asha Action Center before putting this into place. Oh yeah. Putting that into place, only because that was such a clear violation of our ethical code.

I don't know when, when did they change it? 10 years ago. 

Amy Wonkka: It gets revised a little bit on a regular basis. On a 

Kate Grandbois: regular basis. So I don't really even know when it changed, but it was such a clear violation at some point that I would definitely, maybe even just because, you know, CYA, I would definitely maybe even get, write the Action Center and see if you could get it in writing to make [00:50:00] sure that that was a clear.

A clear, um, you know, you got the green light on that. Um, but back to the contract. So when you're, you know, considering your pricing and what services are offered, you wanna make sure that it's unequivocally clear. Are you gonna bill the same rate for paperwork? Are you not gonna bill for paperwork? Are you gonna bill for writing time?

Are you gonna bill for IEP review? Are you gonna bill for going to a team meeting? Are you gonna bill that at a different rate? Those, all of those things have to be very clearly outlined in your contract so that if at any, just like the rest of the documentation, if there are any issues, you have a clear foundation from which to spring off of.

Amy Wonkka: And as a non, as a non-lawyer person, just somebody who's been part of contracts before, you know, the, the, I think the rule is that any ambiguity in the contract comes back on. The person who wrote the. So [00:51:00] if you don't make these things really clear in your contract, it's, that's on you, right? As the contract, 

Kate Grandbois: right?

Um, so that's, that's basically paperwork in a nutshell. Um, there are lots of ways that you can distribute this information. You can snail mail it. Now these days you can just have like a form and PDF it and send it off for somebody to e-sign. Um, if you're using electronic medical record software, like Simple Practice or one of the other ones, they have a lot of these forms built in that you can customize and then email them off and they go into a patient portal.

But that's also an expense. Um, signing up for these, um, electronic medical record platforms is something to consider in terms of your budget. You don't have to have it. You can just use Word documents. It's fine. Okay. Second, learning objective. We're really, really into this. We're gonna go through some of these.

Um, the documentation was definitely meatier than the last two learning objectives, but we will cruise through them. So logistical considerations. Logistical [00:52:00] considerations are to me, really the nuts and bolts of how you run your business on a day-to-day basis. Um, referral sources, scheduling, billing, file storage, contact information, how you make your logo, all of that kind of stuff.

So I think we've reviewed this a lot in our first episode. Mm-hmm. Related to private practice referral sources, you do not have a business if you do not have customers. This has to be your number one priority is to get customers. Your referral sources are going to be huge. I would highly recommend going directly to the people who make the referrals, doctor's, offices, other SLPs.

We are a shortage. There are not enough of us. There is work to be had. There are, at least in our area, private SLPs and private tech private practice, we refer to each other all the time. This is not a business where you're hoarding your business and not sharing it with people, at least not in [00:53:00] our geographical area.

Maybe that's different in other places in the world, but definitely reach out and network with other SLPs in your area. Go to the doctor's offices and drop off. Uh, every medical office I've ever worked in. Had a referral list and if you got flagged for a language delay, they handed you the list of local speech pathologists to call.

Yeah. Um, if you take insurance, insurance is a massive referral source because, you know, families log into their insurance and search for speech and language pathologist. I would also highly recommend registering with a Google pin. How often if you're like, Hmm, I wonder if there's pizza around here. And you go into your Google Maps and you search it and you wait for the pin to drop.

People do the same thing with speech pathology and every, every other local professional that's, and I'm pretty sure it's free. So if you don't want to, that does mean that you have a brick and mortar. If you don't wanna have an office space and you don't want your, um, personal address registered, I don't think you can do a Google pin with a PO [00:54:00] Box, but you can get a PO Box, it's not that expensive.

Um, and that way you can sort of, you can. Put your PO box on billing documents. There are some places that require an actual address. Um, so that would, might be something to look into, but I would definitely recommend getting a PO box. If you don't have a brick and mortar, um, scheduling, you need to have a HIPAA compliance scheduling system.

If you pay for an electronic medical record system, that will often be included, but you can't use a Google Calendar and have your client's names in it. That is a HIPAA violation. Don't do it unless you have G Suite and you've signed the BAA agreement and now your G Suite is HIPAA compliant. So make sure that however you are keeping track of your schedule, it is HIPAA compliant.

In terms of billing and administrative support, you could consider a billing service. Billing is a pain in the butt. In private practice, it requires, we were just having this conversation [00:55:00] before we recorded this podcast. It requires so much administrative time, especially if you have insurance to, you do your visit, you do your clinical work, you do your documentation, and then you have to file the claim.

And then you have to follow the claim for the life of the claim to make sure that it gets paid out and it is such a pain in the butt. So you could consider hiring a billing service. My understanding is that billing services take a percentage of what is paid out. So it's, they're motivated to make sure that you get paid because they don't pay get paid if, if you get paid.

A lot of EMRs, electronic, electronic medical record services will have billing. Options as add-ons in case you get to a volume where you feel like you can't handle the administrative burden of doing billing. I know Simple Practice has, um, has a backend, a backend of house billing. Again, does that work with your budget?

It's, it's just another, it's just another thing of overhead. So every [00:56:00] time you add overhead, your net income, your net income shrinks and shrinks and shrinks. So it's definitely, definitely something to consider. It all comes back down to the budget. You could also consider hiring an administrator for an hourly rate.

Um, this is something I know a few people who have done. It's something I've considered doing in the past. Um. It would, you can hire them as a contractor or an hourly employee. We're gonna go through the difference between those two things in a minute. Um, but an administrator can help with some of the burdens of non-billable time.

So in private practice, you're doing all of your billable time and non-billable administrative time. And it does get to a point where if you have a certain amount of volume in terms of billable hours, that means you have all of this extra non-billable time. Sometimes it makes sense in your budget if you have a volume of this big where you should pay an administrator to do the administrative stuff because then you can bill more hours.

Mm-hmm. So if you're doing three hours a day of administrative, non-billable stuff, [00:57:00] you could hire an administrator to do that for you at a lower rate, and then spend that three hours, that's three additional hours you could bill. Those are all things to consider related to your budget, but they're administrators.

I mean, anybody who's worked in an office knows how valuable a good administrator is. 

Amy Wonkka: For sure. 

Kate Grandbois: Uh, definitely file storage has to be HIPAA compliant. Again, looking at that EMR software, um, I've heard of WebPT, simple practice. I know Microsoft Teams is really trying to compete in this space. Now everybody's using Zoom these days, but Zoom doesn't have, um, a corresponding HIPAA compliant e software.

You really, if you have, if you're just using email and keeping everything on your desktop, that's fine, but I would highly encourage you to back up your computer with a military grade encrypting software so that if it gets dropped in the toilet or in the bathtub or in the pool, [00:58:00] you don't lose your records.

Amy Wonkka: I think even with the email, if you're using email, you need to, you still need to make sure that that email is HIPAA compliant. 

Kate Grandbois: Yes. And that it's encrypted if you're sending documents back and forth, which is a service that you need to pay for. You cannot do it in Google. Don't use Gmail for your private practice 

Amy Wonkka: unless you have G Suite with the BAA 

Kate Grandbois: with the Exactly.

Unless you have G Suite, which is HIPAA compliant. Um, but 

Amy Wonkka: you hate 

Announcer: that. 

Kate Grandbois: Right, exactly. 

Announcer: Um, 

Kate Grandbois: phone and contact information. I know a lot of people who don't wanna give out their cell phone numbers. I don't blame them. You could consider using Google Voice. If you have G Suite with a BAA, um, Google Voice has a free version, free, it is not HIPAA compliant.

If someone patient calls you and leaves you a voicemail that has patient information on it, that is not HIPAA compliant, don't do it. There are other options out there if you just Google it. There are lots of other suggestions. I've used Google Voice for a while, so that's the only one that I'm, I'm aware of off the top of my head.[00:59:00] 

Onto some of the funner things. A logo, I get this question all the time. I don't know why. I think my logo is like sort of terrible too, so I'm not sure why people ask me about this. But in terms of, of graphic design and things, I, I'm not a graphic designer, but there are other resources that you can use.

Um, there are lots of licensing restrictions when you start talking about logo and, and how to make yourself present as, as a business in terms of marketing materials. So I would be very careful, but there are some third parties that you can subscribe to, to buy, buy the licensing for an image. Canva is one of them.

Um, there are again, there are, there are lots of them. I think. Um, oh, what's the name of that? Something photography. I can't remember. I'll put some links up on the website. But there is a, there's a third party called 99 Designs where if you, um, pay a fee, I can't remember. It's not. Terribly exorbitant. I think it's like a hundred or [01:00:00] $200, somewhere in that range.

You get matched. You could submit a request for what your business is, and then they do this roulette. So like five or six graphic designers will come up with a design and you get to choose, and then you go with that designer and it's all, you know, the fees are all like wrapped up in it. So there are ways out there if you don't feel like you have, I was very overwhelmed with this for a while.

Do you remember when I first made my business cards? I made, I'm gonna tell everyone this story. I'm gonna take the time and tell everyone this story. So my, when I first launched my private practice, I had, it was, it was Greater Boston Speech and Language Therapy. And I thought, okay, I'm gonna need to make a logo.

My sister had Adobe and she made this logo for me, and it was so pretty, it had all my favorite colors. It was gray and blue. And I, I just told her to use the words SLT up at the top. For speech and language therapy. So it was clear to customer, to my clients, like what I did. [01:01:00] And I showed this business card to Amy and Do you remember what you said to me?

Amy Wonkka: You did. I I think it was, it would break our it like you put a U in there. 

Kate Grandbois: No, you were like, that looks like slut. Yeah. Yeah, 

Amy Wonkka: that's what I was gonna say. 

Kate Grandbois: I was like, oh my God. And I was so, I was so bummed. I was like, you're right. And I had spent like hours designing this thing, so don't be me. Don't make a business card that says slut on it.

Go to one of these third party companies and have them make a logo for you. Um, there's lots of different options. That's, I, I don't know why I always get that question, but I do. Um, I guess it's 'cause they maybe saw my slut, my slut business card and they were like, tell me what not to do. 

Amy Wonkka: This feels like a learning experience.

Kate Grandbois: Yeah. Right. Make learn from my mistakes. CYA anyway. Um, and the, the other question I get a lot is renting space. Do I rent space or do I not rent space? So space is a huge drain on overhead, [01:02:00] massive. It's expensive, but it really depends on your volume. So your gas mileage can be tax, tax deductible, but if you're driving from house to house to house, and you at the end of the day realize that you spent three hours in your car, is the value of that three hours more over time, that billable time, that's three clients or four clients, depending on how long your sessions are that you could have seen.

And does that income outweigh the cost of the rent that you would pay? Again, all these decisions come down to your budget. One thing that I have had success with in the past is office shares. So, um, for example, I shared an office with an accu, with an Acupunc acupuncturist for a while and she had the office through two days, three days a week.

I had the office the other days a week and it was awesome. And it was, the lease was under her name and I had a sublease and it was super affordable and I had my own space and I had my own little clo like closet of materials. It was [01:03:00] fabulous. So if this is something that you're doing maybe part-time or something that you're sort of getting your toe, dipping your toes into, I would definitely consider, look, recommend looking into an office share.

Please do not buy a space. I have had that question also. 'cause then you have a mortgage and you are responsible for paying that mortgage and that is a massive, massive drain on overhead. So. Don't do that, don't buy anything. Even like huge, huge businesses don't buy their buildings. It's not a good investment.

Um, in, from my experience, and I can't explain why, but my husband's in business and he told me not to do it, so just don't do it. Um, you could, like I said, you can consider a PO box if you wanna protect your personal address. Uh, but the decision on whether or not to rent space is really rooted in your volume and your budget.

Um, in terms of, that was pretty much everything I had for logistics. We've cruised right through that. I feel like I'm talking a mile a minute. I hope that, I hope that, [01:04:00] I hope this is understandable. Um, but learning objective number three, identifying issues related to hiring employees and staffing. So the really, the biggest thing I have to say about this is, well, I, I guess there's a couple of things that go into this.

Employees are appropriate when you have a super long wait list and when you're really interested in growing your business. 

Announcer: Mm-hmm. 

Kate Grandbois: I, I don't think that it's a great idea to like hire an employee unless you have clients to give them, because then you're responsible for an employee and you have to make, I mean, that's just bad employee employer relationships to hire someone and then not have work, work to give them, especially if they're a per diem and they have taken a job with you because they would like some income.

Right? So you really need to make sure that you have the volume to, um, consider hiring an employee now. When you hire an employee, this is a massive disclaimer. These things vary tremendously from [01:05:00] state to state. And if you're in a position where you're considering hiring an employee, I cannot say this enough, you need an accountant.

You really need, maybe you don't have someone doing your books every month, but you have pay, you should pay the money. It is worth the money to sit with an accountant for an hour or two hours and ask 'em all the questions about payroll and taxes and have them help you build a budget. That there is a budget available on our website that you can download that does not, is not related to taxes, and it doesn't have any information related to employees.

But if you are interested in a budget related to employees, please contact me. There's, I may or may not have some forms, um, or some budgets that I, that I could send you, but you have to have an, I really recommend that you have an accountant in your back pocket if hiring employees is something that you're interested in.

Amy Wonkka: And you're gonna want an attorney too, because you're gonna have a contract just like you do with your, with your clients and your patients. 

Kate Grandbois: Oh, yeah, yeah, yeah. So when you hire an employee, there are so many things that you need [01:06:00] to consider. Um, you have to give them state, you have to pay their state and federal unemployment tax.

You have to pay their payroll tax. Um, you pay them, you know, you have to do all of the math. You have to pay them a certain percentage. You have to make sure that you, it's financially viable, that they're bringing more money into your company than you're paying them. It's a super, super complicated component of running a practice, and it adds additional overhead.

You have to pay for payroll services. You have to pay for workers' comp. You have to pay for professional liability insurance. It opens a whole host of complicating factors, which is why. I would, I am not even going to sit in front of this microphone and say for two seconds that this podcast equips you to go out and hire an employee.

You really, really, really need to go find an accountant if this is something that you're interested in doing. I think the biggest thing that I can say about hiring employees and staffing, um, is that this is a question that I, I have been getting a lot, is the [01:07:00] difference between an employee and a contractor.

So, employees and contractors are two very different things. What constitutes an employee versus a contractor is designated by the Department of Health and Human Services, and it's very, very specific. And you can get into a lot of trouble for delegating someone improperly. So if you're treating them as an employee, but they're delegated as an independent contractor, that's a big no-no.

People are. More motivated, I think, to delegate people as independent contractors because it's cheaper. When you have hired someone as an independent contractor, you are not responsible for paying any of that long list of things I just read. You don't need to pay for, um, professional, for workers' comp. You don't need to pay their employment, their, you know, all of the additional federal unemployment tax and payroll taxes and all of those kinds of things.

You give them a 10 99 and then they pay their own taxes. So it's much simpler, it's much more affordable and it's much [01:08:00] more appealing to an employer, but it is not necessarily the right thing to do. 

Amy Wonkka: And if you do the wrong thing and the person is actually an employee, which a, a lot of the case, they are an employee, and I know you'll go through some of these pieces later, but, uh, if they are an employee.

Then you broke the rules. 

Kate Grandbois: Yeah. Don't break the rules. It gives gbs. 

Amy Wonkka: Yeah. CYA. It's another Yeah, 

Kate Grandbois: yeah, yeah. Just like, don't break the rules. So we have the link on our website to the Department of Health and Human Services that if you are curious about this, and you're on a point in your private practice where you're considering hiring an employee and you're wondering about some of these things, go visit this link, read through this page.

Some of the delegating factors are related to, um, the following. I'm just gonna read them quickly. 

Announcer: Mm-hmm. 

Kate Grandbois: Does the company control or have the right to control what the worker does and how the worker does the job? Does the company control the business aspects of the worker's job? Like making arrangements for [01:09:00] how they're paid, whether expenses are reimbursed, whether or not they use materials that you've provided for them.

Is there a written contract for employee benefits such as a pension plan, insurance plan, or, or a vacation pay? Will the relationship continue and is the work a key aspect of the business? These are all very complicated questions that, again, an accountant can help you navigate and you wanna make sure that you're making, um, the right decisions, all rules.

You wanna make sure that you're following all the rules and that it works with your budget. Because while hiring an employee is maybe what you're more comfortable with doing or what is what the work lends itself to based on your state, and that's what your accountant has advised you to do, you need to revisit your budget and make sure that all of those additional expenses makes sense for the direction that you want your business to grow in.

'cause if you're thinking of hiring an employee to take one client for you, is that worth it for you at the end of the year to make an extra, you know, X [01:10:00] number of dollars? Or does that really only make sense if you build it and scale it to volume? And I think those are questions that you cannot answer without an accountant and a budget in your corner.

And that is all I will say about that is end of podcast, end of episode. Um, that was a lot of information. 

Amy Wonkka: I feel like it was great. I Your eyes aren't 

Kate Grandbois: glassing over. 

Amy Wonkka: No, I, this is all, this is all content that. You know, as a, as a rules follower, the, the amount of information and the amount of variables that somebody needs to consider to do a pro private practice and do it correctly is kind of overwhelming.

It's a lot. Oh, it's very 

Kate Grandbois: overwhelming. 

Amy Wonkka: Um, so I feel like, you know, we've taught between the previous podcast in this one we've talked about a lot of different, you know, the budget is the driver, the CYA is a driver. Um, and then there are all of these different considerations that people really do need [01:11:00] to think through.

Kate Grandbois: Definitely. Um, and again, I know I said this in the other episode, but if these are, if you have questions, please reach out to me. This is a, this is something that I really enjoy doing. I really enjoy helping other speech pathologists and other professionals in general sort of explore this adventure that is private practice.

I've had such great experience over the years, um, and I hope the information in this has been helpful. And I think that wraps us up. 

Amy Wonkka: Yeah. Thanks so much for listening, guys. 

Kate Grandbois: Yeah, thank you for listening. Stay tuned for more episodes on, let's see, we had a poll. We had an Instagram poll, so we have a, a, c and a b, a coming up.

We have mentoring. Coming up we dropped little, uh, hint about a episode related to writing, measurable and objective objectives. 

Amy Wonkka: Rules and objectives. Yes, 

Kate Grandbois: measurable objectives and objectives. That made no sense. Um, and yeah, so stay tuned. Thank you for listening [01:12:00] everyone.