Lessons Learned When Starting a Group Practice

What one therapist who started her own group practice learned about mental healthcare billing.

By Leila Ghaznavi

Justena Kavanagh is the founder of NYC Counseling and has been on the Executive Board of the Women’s Mental Health Consortium for over a decade. I sat down with her to discuss how she made the transition from being a solo practitioner to managing a thriving group practice, and the tools she used to get there.

What inspired you to go into mental healthcare?

In my mid-to-late 20s, someone close to me remarked that, “All you do is read psych books; why don't you do that for work?” Suddenly, a light went off. It never occurred to me to work in the field that was truly my passion. Until then, it had been a hobby or a guilty pleasure. That was in 2000 and I've never looked back.

It’s wonderful that you had this revelation that mental healthcare was your calling. How does this experience inspire your philosophy of care?

My primary philosophy about what makes a good clinician is how much work a clinician has done on themself. I personally have been in various therapies for 25 years and have experienced all sorts of self growth. As a clinician, we're an instrument—and the more we can clear out our own issues, the more objective we can be with clients. Not that we are ever meant to be totally objective, or else robots could do this. However, working through one’s own challenges gives a therapist the flexibility to use those experiences when necessary while ensuring that we are not projecting our own unresolved issues or blind spots onto the client.

Also, I want to decrease stigma so mental healthcare is more accepted. In many cultures and families, and for many generations, it’s been a commonly held belief that you can overcome any mental health challenges through self-reliance, discipline and intelligence, and if you need help, you're weak or broken. In reality, therapy empowers people to make better decisions about their lives by increasing self-awareness and self-agency.

I love that approach. How does this philosophy help you set goals for each client?

I believe it works best when people figure out their own goals. I'm guilty, as probably many therapists are, of wanting more for someone than they might want for themself. I'm very ambitious with what people can do with their lives, especially in terms of meaning, fulfillment and relationships. But I don't think anyone can go places they don't want to go or, perhaps, more importantly, are not ready to go.

When people think of how far they want to go in therapy, it's kind of like going to a trainer. How fit or healthy do you want to get? You can do a little or you can do a lot. Therapists have to engage clients on what they want for themselves, which may not be entirely conscious. For example, someone may come in with: “This doesn't feel great. These coping mechanisms aren't working. I'd like to find new ones.” But they might not say, “I need to stop drinking, working too much, continuing in dysfunctional relationships to get through life.” As a therapist, I help the client peel back the layers so they can create the change in themselves that they are seeking. What do you struggle with? What do you want in life? What are your roadblocks? Are there more constructive ways to navigate difficult feelings? etc.

All humans have a wide range of emotions. And not a lot of us were raised in families or cultures or schools that helped us figure out how to navigate the more difficult feelings like anger, envy, jealousy, rage, depression, etc. Most people, when they feel those emotions, shut down or do something to get rid of the uncomfortable feelings in the short term, which might not serve them in the long term. The goal isn't to get rid of those feelings, but to figure out productive ways to get through them. The only way out is through.

How do you gauge when a client has accomplished their goals?

It’s really up to each client about when they feel that they have accomplished their goals, if their goals have shifted, if they want to take a break, etc. Many come in to work on a few specific things and as they make progress, they realize there is more they’d like to address.

It can be like climbing Mount Everest. You don’t realize how high you have climbed because there is a lot more mountain ahead of you. But when you stop and look back down you can see how far you have come and that you are handling life better than before. It’s important to remember: progress is rarely linear—some parts of life can get harder, while overall, your life is improving.

Your own career has an impressive climb to it. You started as a solo practitioner and then opened a successful group practice.  What motivated you to make that change?

It was a confluence of several factors. As an inveterate connector who loves playing therapist matchmaker, I was often sending referrals to people whom I could not see or whom I thought would be an even better fit with another clinician. I know of so many wonderful therapists and even more people who can benefit from therapy with the right therapist. There are only so many hours in a day and I wanted to reach more people (and be home at night to put my kids to bed).

Mental health is more of a vocation or a calling than a career. I've seen many people drawn to this field after other successful careers with so much life and growth experience. Expanding to a group practice was a great opportunity to help people who were earlier in their training while shifting my own career clinically.  

I always advise therapists considering expanding to a group practice to start slowly and when they have a lot of time in life, neither of which I did. When I started my group practice, it grew rapidly and I didn't have much time to dedicate to the administrative needs of an expanding business.

The administrative road has been super stressful—it is finally coming together after many years of trial and error. But clinically, it's highly gratifying when everything is working. Most clinicians love the clinical work and they don't love the administrative part of the business. The goal of a group practice is to streamline the administrative work to support optimal clinical care. Nirvana has been essential in helping me do that, especially with mental healthcare billing.

How did Nirvana help you streamline your mental healthcare billing?

When we came to Nirvana, we had a long backlog of insurance paperwork and a ton of messes to clean up. For seven years we tried to ‘accept assignment’ from insurance, but it just proved to be too complex. Nirvana helped us make the jump to courtesy billing, which is much more straightforward.  Nirvana helps ensure that our clients are reimbursed quickly and easily.

Nirvana ensures that the insurance claims are submitted quickly and correctly. I know from submitting my personal insurance that there are many hurdles to getting reimbursed in the American insurance industry.

On the client side, most people calling for therapy have never done it before, so they are not familiar with their benefits. Understandably, most people want maximum coverage and some want to go in-network, which is very challenging in NYC. People get overwhelmed and flustered, so they give up on finding care. Nirvana gets rid of the mystery around mental healthcare billing so clients know how much reimbursement to expect and the time frame for receiving it.

Now that you have been running a group practice for a while, what do you like most about it?

What I most like about a group practice is that we can offer a variety of therapists, specialties, availability and price points. The hardest part in finding a therapist for clients, especially now, is matching with one that suits both the client’s personality and requirements for time, location, and price.  

At NYC Counseling, we have a wide variety of therapists available, so when we get a referral, we can send a few options to a potential client. We want people to know that if the first therapist is not the best fit, we'll recommend another. I try to refer both in practice and outside the practice so I can give people a shortlist that’s not too overwhelming. I encourage clinicians and clients alike to check in with: where they are and what they want, what they are getting, and what they aren't getting, to make therapy as rich of an experience as possible for everyone involved.

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This interview has been edited and condensed.