The Challenges of Private Practice
Running your own practice can be highly rewarding, but there are difficulties, as well, from starting up to maintaining.
Starting a private practice—hanging a shingle—is a dream for many licensed clinical social workers. Some enter their master’s programs with this goal already in mind, while others, after years of experience in varying roles, come to learn that private practice may be where they can be most effective and, importantly, happy as a professional.
“I think there are people who are temperamentally able to roll with bureaucracies and function really well and do great work within a bureaucracy. I am not temperamentally suited,” laughs Liz Fletcher, LCSW, when discussing why she went into private practice. Fletcher opened her practice, Big Sky Counseling, Inc, in Oklahoma in 2013.
When it’s the right fit, private practice can be an incredibly rewarding professional experience, allowing for the autonomy and flexibility that simply does not exist in other settings.
“I absolutely love being in private practice, everything about it,” says Barbara Groves, LCSW, who has a private practice in Charlottesville, Virginia. “The flexibility, the ability to write off copays for motivated single working moms and students from low-income homes. The variety of patients in racial, socioeconomic, and spiritual orientation, as well as gender and political affiliation is so rewarding to me. I feel that I make a difference every day in helping patients become more self-aware and to become enlightened stewards of their lives.”
As rewarding as private practice may be, there are certainly challenges—as with any career and business. Learning about and navigating these obstacles is key for a social worker interested in making private practice their path.
“I had no business background, no financial education,” Fletcher says. “So I went to an accountant that someone else I knew used and he said, ‘Yeah, we do this all the time for therapists.’” Her accountant, whom Fletcher still works with to this day, advised her to set up an S-Corp. From there, she had to choose a name for her practice, confirm it wasn’t used by someone else in Oklahoma, and register with the state, among a long list of other important must-dos. Private practitioners today need websites, EHRs, and more to properly run their practices.
“It’s quite the learning curve,” agrees Kendra Spielman, MSW, LICSW, owner of Unrooted Counseling, LLC in Minneapolis. “I’m someone who likes admin and behind-the-scenes work, but I remember being pretty overwhelmed with trying to figure out business logistics and taxes the first year. I think I’m finally now settling into a place of knowing what I’m doing … at least a good chunk of the time,” she says. Spielman has been in private practice part time since 2020 and full time since 2021.
Fletcher adds that today, as opposed to when she began 10 years ago, there are a number of resources available for social workers entering private practice. Practitioners can find, either locally or online, consultants and companies that specialize in assisting a private practice as it gets started. That being said, the promise of such a service isn’t always equivalent to what one gets.
Ally Barnett, an LCSW with a private practice in Burlington, Vermont, notes that while she did, in fact, hire someone to teach her how to start a private practice, “They didn’t do a great job.” She found herself needing to gather information from a variety of sources regardless.
Social workers need the capital to launch and maintain their businesses. There are costs to many facets of the practice. Some of those are unavoidable (like taxes), while others may not be necessary but are a wise investment. For instance, when Fletcher first started, she worked with a psychoanalyst weekly doing clinical consultations. “It was so, so useful,” she says. “You no longer have clinical supervision, and if you’re not in a group practice where consultation is a part of the culture, it can be very sort of ‘Oh no! Now suddenly, there’s no net.’ You’re just out there on your own.” Fletcher says that the consultations were expensive, and she also had to devote the time to drive out to the psychoanalyst each week. Nevertheless, she feels it was worth it.
Many social workers, recognizing how expensive it can be, enter private practice while continuing to work in a different setting, either part time or full time. Spielman, as noted previously, was part time in private practice for many months before becoming full time. Fletcher worked as a contractor for a Medicaid agency that provided home-based therapy services for several years after starting her practice, seeing 15 or 16 clients through the agency and 20 to 25 clients in her private practice during that time. And Barnett overlapped at a community counseling center for a period while also running her practice, though not at the onset.
While Fletcher does have a sliding scale and a few pro bono cases, she notes that her price-per-hour is based on what she needs to make to stay afloat, taking into account potential sick time and other (unpaid) leave.
And that’s just private pay.
Navigating insurance systems is its own challenge, as each insurance company is unique. “I want my services to be accessible to clients, and at the same time, insurance limitations and compensation is driving me more and more to look into transitioning to private pay,” Spielman says. “It took me a significant amount of time to be accepted into certain insurance companies’ networks, including appeal letters and references speaking to my abilities, despite the clear high need for therapy services across the country.”
“One of the new challenges is dealing with the smaller insurances who are not registered with CAQH [Council for Affordable Quality Healthcare] and Availity,” Groves adds. Both are organizations that work with providers to streamline information exchange and payment with insurance providers and other payers. “The way I work around that is that I explain this to my patients and provide them with a receipt so they can get reimbursed directly by the insurances.”
Barnett accepts only Medicaid insurance. She notes that if clients have out of network coverage, they can submit receipts to their insurance providers for reimbursement.
Navigating Systems and Changes
Now that the public health emergency for the pandemic officially ended on May 11, 2023, regulations around telehealth will likely change once more, varying as always depending on the insurance provider.
For example, the US Department of Health and Human Services, on its telehealth page, differentiates permanent and temporary changes for Medicare recipients regarding mental health care. The temporary changes are in place only through December 31, 2024. Now, Medicare recipients, for instance, do not have to be seen in person within six months of an initial mental health telehealth service. Nor do they have to be seen in person annually thereafter. That rule will change in 2025.
Social workers offering telehealth must then decide how they will move forward with their care. It may be that they stop accepting certain insurance plans or discontinue telehealth. The decision lies not just in how and if they will be paid for their services but also in what is possible for them as individuals and for their patients.
Fletcher’s partner, for example, is at high risk for complications not just from COVID-19 but many illnesses. “I may be sick for a week; he’s sick for six to eight weeks,” she describes. Because of this, Fletcher embraced telehealth during the pandemic and believes she’ll continue providing services virtually only, regardless of how the regulations change over time.
Finding Balance and Support
Professionals in private practice must be diligent in finding both the balance and the support they need.
For Fletcher, finding that balance started with learning when and how to say no to referrals. “Having worked in a psychiatrist’s office for a number of years, they filled me up with referrals, which is good and bad.
“I didn’t say no to any patient ever, because my thinking was, I can’t say no! I’m brand new. If I don’t bill successfully and collect, I am not going to make any money. I had this sort of scarcity/poverty mentality about it and was thinking that if I ever said no, ‘Poof!’ my business would disappear,” she remembers.
In determining how many clients can be managed at one time, practitioners then have the ability to make room for administrative responsibilities, which do still exist. Barnett says she struggled with “figuring out how to make time for all the paperwork. It’s a private practice, and now you’re on your own. You still have to do all the paperwork.” And she adds, you are the taskmaster, the motivator for getting it done. Ninety-nine percent of the time, the only person you have to answer to when it isn’t finished is you. “It’s been really hard to keep with the treatment plans that no one is asking me to do,” she says.
Nevertheless, she keeps her paperwork up to date, aware it’s both best practice and that an audit from the IRS or an insurance provider (in her case, Green Mountain Care) could take place. And in creating a system that works for her, Barnett, like other private practice social workers, is also able to ensure that she can take personal time for her friends, family, and personal interests. “That part is the best,” Barnett says.
Hand in hand with balance is support. Running a solo practice can be isolating and overwhelming. Social workers need a network of individuals who can offer not only logistical assistance but also advice and emotional support as necessary.
For some, that network is naturally in place. “Fortunately, both my partner and most of the folks in my friend group are therapists,” Spielman says. “So I’m surrounded by people navigating some of the same or similar issues of running a practice and/or caseloads. If I didn’t have this, I’m guessing I’d feel much more isolated in my work.
“I know not everyone likes to have their personal network be similar to their professional network, but for me, it works great,” she says.
For others, that support may need to be sought. Fletcher grows her network by attending continuing education events and working to integrate herself into the community. That can be a little harder now when so many events are held virtually.
Making It Your Own
For Barnett, making the practice suit her needs and goals as a social worker meant specializing. When working as an on-call crisis therapist, Barnett had to be available nearly 24/7, and it was too much. Burnt out, she began working with adults and couples in a different setting, which led to her getting a specialty in sex therapy. “I got a specialty certification in that, and now I have tons of business,” she says. “I like sex therapy because it’s a fulfilling niche with motivated clients and very little crisis. It’s also a steady stream of clients in need.”
Consciously making the decision to create a practice that meets the practitioner’s needs, as well as the clients, allows for that social worker to have even more autonomy and balance in what they do. “You can retain what is important to you. I can offer pro bono selectively. I can offer sliding fees selectively. I also do some advocacy work with reproductive justice organizations, and when they pay it’s usually a pretty small stipend. It’s stuff that I have the bandwidth to do because I’ve taken the reins of my business and made some tough decisions,” Fletcher says.
And through all those tough decisions, through the logistics of launching a business, billing privately or with insurance, and finding the support needed to keep going, social workers in private practice get to do what they love.
“I get to experience this incredibly inspiring part of human nature,” Fletcher says. “There’s a lot of really bad stuff in the world all the time, and yes, I do hear about a lot of traumatizing things. But I hear about it from people who are in the act of overcoming it. Even though they sometimes feel overcome by it, just the fact that they’re willing to share their experience with another human is so inspiring and humbling.”
— Sue Coyle, MSW, is a freelance writer and social worker in the Philadelphia suburbs.