Starting Your Private Practice in Medicine-Psychiatry: A Complete Guide

Understanding the Unique Landscape of a Med-Psych Private Practice

A medicine-psychiatry (med psych) residency opens doors to one of the most versatile and needed niches in healthcare. As integrated care, collaborative care models, and whole-person medicine gain traction, the idea of starting a private practice as a dual-trained physician becomes increasingly attractive.

But before you think about decorating an office and opening your EHR, you need to understand the specific opportunities and constraints of a medicine psychiatry combined private practice.

Why med-psych is uniquely suited to private practice

Your dual training gives you a value proposition that is rare in both outpatient medicine and psychiatry:

• You can manage complex medical patients with significant psychiatric comorbidity (e.g., diabetes with severe depression, COPD with anxiety, heart failure with cognitive issues).
• You understand psychotropic-medication–medical disease interactions in a way that few others do.
• You can provide integrated assessment:
  • Is this cognitive decline from depression, delirium, dementia, or medications?
  • Is this fatigue from anemia, sleep apnea, hypothyroidism, depression, or all of the above?
• You have credibility with both PCPs and psychiatrists, making you a natural hub for referrals.

This combination allows you to carve out a private practice that:

• Commands higher perceived (and often actual) value
• Attracts complex, interesting cases
• Partners well with hospitals, PCPs, and behavioral health groups

Common practice models for med-psych physicians

Before thinking about furniture and business entities, get clear on your desired model. A few common configurations:

1. Integrated internal medicine + psychiatry practice

   • You bill both E/M (medicine) and psychiatric codes
   • You may do full primary care and psychiatric management for a panel of complex patients
   • Typical visit mix might include: chronic disease management, psychopharmacology, integrated consults

2. Psychiatry-heavy practice with medical oversight

   • Branded primarily as a psychiatric practice
   • You emphasize evaluation and management of patients with complex medical co-morbidity
   • You perform limited primary care (e.g., labs, vitals, metabolic monitoring), but not full-spectrum medicine

3. Consultative/curbside-style med-psych service

   • Referrals from PCPs, oncologists, cardiologists, transplant services, bariatric programs, etc.
   • You provide time-limited consults and shared care
   • Often ideal if you also maintain an academic or employed role

4. Collaborative or group practice

   • You join or co-found a multi-specialty or behavioral health group
   • You become the in-house med-psych expert
   • Infrastructure (billing, space, staffing) is partially or fully shared

5. Hybrid employment + private practice

   • Half-time hospitalist or CL psychiatrist; half-time private practice
   • Helps manage financial risk while you build your patient panel

Each model has different implications for credentialing, malpractice, billing codes, panel size, and staffing. Deciding your model early helps avoid costly pivots later.

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Clarifying Your Vision: Clinical, Lifestyle, and Financial Goals

A common mistake is to treat “starting private practice” as a binary decision. In reality, you should start by defining what you want your work and life to look like in 5–10 years—and build backward.

Clinical scope: What will you actually do?

Ask yourself:

• Will you provide full primary care, or limit to:
  • Pre-psychotropic workups
  • Metabolic monitoring
  • Focused medical consults?
• Will you accept:
  • Patients on opioids or benzodiazepines?
  • Patients with severe SUD?
  • Patients requiring frequent crisis management?
• Will you see:
  • Adolescents?
  • Geriatric populations?
  • Perinatal or reproductive psychiatry cases with medical complexity?

Write down a scope-of-practice statement of 5–7 sentences. For example:

“This practice will provide integrated internal medicine and psychiatry to adults 18 and older with complex medical and psychiatric comorbidities. I will offer primary care primarily to patients already under my psychiatric care, emphasizing chronic disease management, psychotropic safety, and care coordination. I will not provide OB care, chronic pain management with opioids, or high-intensity SUD treatment, but will collaborate with outside providers for these needs.”

This document becomes your compass for:

• Marketing
• Accepting or declining referrals
• Deciding on equipment and EHR features
• Defining staff roles

Lifestyle and workload: How do you want your weeks to feel?

Clarify:

• Hours per week you want to work clinically (e.g., 24–32 patient-facing hours)
• Preferred clinic days vs. admin days
• Whether you want evening or weekend hours
• Your on-call structure
  • Solo availability?
  • Cross-coverage with another psychiatrist or PCP?
  • Use of coverage services?

Strong med-psych candidates often underestimate:

• The admin time of running a combined practice
• Complexity of coordinating with multiple specialists
• The intensity of managing both medical and psychiatric risk

If you want a more predictable schedule, you might lean toward:

• A psychiatry-heavy, consultation-focused practice
• Limited primary care responsibilities
• Smaller panel size but higher-complexity visits

Financial goals and risk tolerance

With private practice vs employment, the trade-offs for med-psych are similar to other specialties but with some twists:

Employment advantages:

• Stable income, benefits, malpractice coverage
• Institutional infrastructure (EHR, scheduling, billing)
• Defined roles and boundaries

Private practice advantages:

• Control over clinical scope and pace
• Ability to design a truly integrated med-psych service
• Upside potential in income and equity (especially if you grow a group)

Be clear about:

• Your minimum income required in year 1–2
• Your financial runway (savings, partner income, moonlighting)
• Your tolerance for slow initial growth

Many med-psych physicians start with:

• 0.3–0.5 FTE employed role
• 0.5–0.7 FTE building their practice

This hybrid approach reduces financial stress and allows more intentional practice-building.

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Legal, Structural, and Risk Considerations for Med-Psych Practices

Once you have a clear vision, you can design the legal and structural foundation. For a combined medicine-psychiatry private practice, risk management is especially important, because you are often the “last stop” for complex patients.

Choosing your business entity

Common options in the U.S.:

• Professional Corporation (PC) or Professional Limited Liability Company (PLLC)
  • Often required for physician practices depending on your state
  • Offers liability protection for business debts and non-medical liabilities
• S-Corporation or taxed-as-S corp election
  • Frequently used for tax optimization (consult a CPA)
• Single vs. group entity
  • If you plan to bring in other med-psych, psychiatry, or primary care physicians, structure accordingly from the start

Consult:

• A healthcare attorney who understands your state’s corporate practice of medicine laws
• A CPA with experience in physician practices

Avoid generic online forms; regulatory nuances for physicians and controlled substances are too significant.

Licensing, DEA, and credentialing

For a med-psych private practice, you typically need:

• State medical license (in every state where you see patients, including telehealth)
• DEA registration (consider multiple locations if you prescribe in different sites)
• X-Waiver repeal awareness:
  • Buprenorphine can now be prescribed without the prior X-waiver, but still requires training and best-practice understanding if you plan to offer SUD care
• Board certifications (IM, psychiatry, or combined) – not legally required, but important for credentialing and marketing

For insurance-based practices:

• Credential with commercial insurers and possibly Medicare/Medicaid
• Clarify whether you will:
  • Enroll as psychiatry only
  • Enroll as internal medicine only
  • Enroll as both and submit different codes depending on visit type

This choice has implications for:

• Panel size and reimbursement
• How easily payers understand and process your claims
• Whether you can bill for same-day med and psych visits

Malpractice coverage: dual-risk considerations

You are practicing in two high-liability domains: internal medicine and psychiatry. When shopping for malpractice coverage:

• Explicitly disclose:
  • That you are dual-trained
  • Your anticipated clinical mix (percent medicine vs psychiatry)
  • Any planned procedures (e.g., joint injections, basic office procedures, TMS, ketamine/esketamine)
• Ensure:
  • Policy covers both internal medicine and psychiatry services
  • Telehealth services are covered (and across which states)
  • Coverage limits align with local standards (e.g., 1M/3M or higher)

Consider “tail coverage” needs if you’re leaving an employed job that previously covered you.

Risk management in combined care

Key policies to define early:

• Controlled substances policy
  • Will you prescribe stimulants, benzodiazepines, or chronic opioids?
  • Will you manage MAT (e.g., buprenorphine)?
  • Use of PDMP checks, controlled substance agreements, pill counts, and urine drug screens
• Medical emergency protocols
  • How will you handle chest pain, suicidality, acute intoxication, or delirium?
  • Clear scripts for staff and written workflows
• After-hours coverage
  • How patients access urgent advice
  • When they must go to ED/urgent care instead of calling you
• Care coordination standards
  • When you must contact PCPs or specialists
  • What information you share, and how

Think like a consult-liaison psychiatrist and internist combined: anticipate high-risk clinical scenarios and build your practice infrastructure to manage them safely.

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Operations, Billing, and Clinical Flow in a Med-Psych Practice

Operational design will determine whether your practice feels sustainable or chaotic. For med-psych, you must support both medical workflows and psychiatric workflows under one roof.

Space and equipment

For a medicine psychiatry combined practice, consider:

• Exam room(s)
  • Adjustable exam table
  • BP cuff, pulse oximeter, scale, thermometer
  • Basic EKG machine (optional but helpful)
  • Phlebotomy equipment or arrangements with nearby labs
• Consult room(s)
  • Comfortable chairs for longer psychiatric or therapy-style visits
  • Good soundproofing and privacy
• Telehealth setup
  • High-quality camera, microphone, neutral background
  • HIPAA-compliant telehealth platform integrated into your EHR

Plan for at least one room that can flex between medical exam and psychiatric interview, with movable equipment and adjustable lighting.

EHR and practice management systems

Your EHR must support:

• Both medicine and psychiatry templates
• Integrated problem lists that don’t silo “psych” vs “medical” issues
• E/M coding support for both specialties
• Lab ordering and result integration
• Electronic prescribing of controlled substances (EPCS)

When evaluating systems, ask:

• Can you configure visit types like:
  • Integrated med-psych initial evaluation (90–120 minutes)
  • Med-focused follow-up (30–40 minutes)
  • Psych-focused follow-up (30–50 minutes)
  • Telehealth medication management (20–30 minutes)
• Does the system support:
  • Superbills and insurance claims (CMS-1500)
  • Claims with both ICD-10 medical and psychiatric codes
  • Patient portal messaging and forms

Visit structure and coding examples

Common visit patterns in a med-psych practice:

1. Integrated new patient evaluation (90–120 minutes)

   • History of present illness (medical and psychiatric)
   • Comprehensive med review, baseline labs, vitals, risk screening
   • Psychiatric history, safety assessment, diagnostic formulation

   Billing options (depending on payer rules and your credentialing):

   • High-level E/M code (e.g., 99205) with appropriate time and complexity documentation
   • Or psychiatric diagnostic evaluation (90792) if visit is primarily psychiatric, plus possible E/M if payer allows
   • Use multiple ICD-10 codes (e.g., F33.1, E11.9, I10, E78.5)

2. Psych-focused follow-up (30–45 minutes)

   • Emphasis on mood, anxiety, psychosis, ADHD, etc.
   • Brief medical check-in (side effects, vitals if in-person)
   • May include supportive or CBT elements

   Billing:

   • E/M code (e.g., 99214) +/- psychotherapy add-on (e.g., 90833) if criteria met
   • Or primary psych code depending on payer and your setup

3. Med-focused follow-up (30 minutes)

   • Diabetes, hypertension, CKD management
   • Medication reconciliations for complex polypharmacy
   • Depression/anxiety screening as part of chronic disease management

   Billing:

   • Internal medicine E/M code (e.g., 99214)
   • Capture both medical and psych diagnoses where relevant

Work closely with a billing specialist early on. Clarity on how you will represent your services to insurers will prevent denials and compliance issues.

Staffing and delegation

Even a solo practice benefits from strategic delegation:

• Medical assistant or nurse
  • Vitals, rooming, basic screening (PHQ-9, GAD-7), medication refills under protocol, vaccine administration if you offer primary care
• Administrative/virtual assistant
  • Calls, scheduling, referrals, records requests, prior auths
• Billing specialist (in-house or outsourced)
  • Claims submission, denial management, payment posting
• Collaborative clinicians (later-stage growth)
  • Psychologists, social workers, NPs/PA-Cs, other med-psych or psychiatry physicians

Given the complexity of med-psych patients, overestimate the time and support they will need. This protects your sanity and your clinical quality.

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Marketing, Referrals, and Strategic Growth for a Med-Psych Private Practice

Once the structure is in place, the next challenge is generating the right patient volume. For med-psych, the key is to clarify your niche and communicate it repeatedly.

Crafting your message

Your pitch should be understandable to:

• Patients and families
• PCPs
• Psychiatrists and therapists
• Hospital services

Avoid jargon like “consult-liaison” if your community isn’t familiar with it. Instead, emphasize:

• “Integrated care for patients with both medical and psychiatric conditions”
• “Specialized management of psychiatric medications in medically complex patients”
• “Support for patients whose mental health affects their medical disease—and vice versa”

Create a one-page summary (digital and printable) that includes:

• Who you see
• What problems you help with
• What you do not do (e.g., routine OB care, chronic pain management)
• How to refer and how to contact your office

Key referral sources

High-yield relationships for a med-psych private practice:

• Primary care physicians
  • Complex depression and anxiety in patients with multiple chronic diseases
  • Polypharmacy issues, psychotropic side effects (e.g., QTc, metabolic)
• Specialists
  • Cardiology (post-MI depression, advanced HF)
  • Oncology (cancer-related distress, delirium, complex psychopharm)
  • Neurology (cognitive changes, PNES, seizure vs psych)
  • Bariatric surgery programs
  • Transplant teams
• Psychiatrists and therapists
  • Patients whose medical issues are beyond their comfort zone
  • Metabolic and cardiovascular monitoring
  • Differential diagnosis of somatic symptoms
• Hospitals and IOP/PHP programs
  • Step-down clients needing stable, integrated outpatient follow-up

Create a referral packet (PDF + printables) with:

• Your bio and training (explicitly noting med-psych residency)
• Common clinical scenarios you handle
• Sample documentation of how you communicate back to referring providers

Branding and online presence

Patients searching for “med psych residency” or “integrated medicine and psychiatry” may already have some knowledge of your combined specialty. Leverage that in your marketing.

Your website should:

• Clearly state you are dual-trained / dual-boarded
• Emphasize evidence-based, integrated care
• Use keywords such as:
  • medicine psychiatry combined
  • med psych residency background
  • private practice vs employment (if you’re blogging for colleagues as well)
• Provide:
  • Intake forms
  • Telehealth info
  • Insurance and payment policies
  • Clear “what to expect” pages for new patients

Consider writing blog posts on:

• “How medical problems can mimic psychiatric illness”
• “Understanding metabolic side effects of psychiatric medications”
• “When to seek a dual-trained medicine-psychiatry specialist”

These position you as an expert and improve SEO.

Long-term strategy: from solo to group or specialized center

As your practice matures, you can decide whether you’re building:

• A boutique, low-volume, high-touch solo practice, or
• A multi-clinician integrated behavioral health and medicine center

Growth steps might include:

• Hiring a psychologist or therapist to expand psychotherapy options
• Bringing on a psychiatric NP or PA with your supervision
• Recruiting another med-psych physician to share complex caseload
• Adding sub-specialty services:
  • TMS
  • Ketamine/esketamine programs
  • Group visits for chronic disease + depression
  • Collaborative care contracts with primary care clinics

Each expansion requires revisiting your:

• Legal structure
• Malpractice coverage
• Policies and procedures
• Leadership and management skills

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Balancing Private Practice vs Employment Over a Career

For many med-psych physicians, the question is not whether to choose private practice vs employment once and for all, but how to blend them over time.

Common career arcs

1. Early-career employed, mid-career practice

   • First 3–5 years: Employed hospital or academic med-psych/CL role
   • Build clinical confidence and mentorship, pay down loans
   • Simultaneously learn business skills and build local referral network
   • Transition to part-time employed + part-time private practice
   • Eventually move to majority private practice if desired

2. Early private practice with safety net

   • Start a small, out-of-network practice right out of residency
   • Maintain hospitalist, ED psych, or tele-psych shifts as income floor
   • Gradually grow your panel and reduce other work

3. Long-term hybrid

   • Intentionally maintain both roles (e.g., 0.5 FTE academic CL + 0.5 FTE integrated private practice)
   • Benefits:
     • Collegiality and teaching
     • Clinical diversity
     • Financial stability
   • Requires good boundary setting and time management

Signs private practice may be a good fit for you

• You value clinical autonomy and creative problem-solving
• You enjoy systems thinking: designing workflows, policies, and integrated care processes
• You’re willing to learn the “business of medicine” or partner with those who can
• You have a strong interest in continuity care and relationships with patients and referring clinicians

Signs to proceed more cautiously

• You prefer clear structure, predictability, and limited admin responsibility
• You feel high anxiety about financial uncertainty and risk
• You strongly prefer acute, inpatient, or consult-based work over continuity care
• You are already at or above your emotional bandwidth with clinical work alone

Private practice can be deeply rewarding for med-psych physicians—but it should be an intentional choice, informed by your personality, values, and long-term vision, not simply an escape from a frustrating job.

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FAQs: Starting a Med-Psych Private Practice

1. Should I market my practice as “med-psych” or separate internal medicine and psychiatry services?
For most physicians, positioning yourself explicitly as a combined medicine-psychiatry specialist is a strength, not a liability. Many referral sources are specifically looking for integrated expertise. That said, make the benefits concrete: instead of just saying “med-psych,” explain that you offer comprehensive care for patients with both complex medical and psychiatric conditions, including safety-focused psychopharmacology and coordinated chronic disease management.

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2. Can I realistically do full primary care and full psychiatric care in one private practice?
You can, but it is resource-intensive and requires careful boundaries. Many med-psych physicians find a middle ground: they limit full primary care to a defined subset of patients (e.g., those already in psychiatric treatment with them) and focus on consultative or co-management roles for others. Start smaller in scope and expand if your bandwidth and infrastructure support it.

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3. Is it better to be in-network with insurance plans or run an out-of-network / cash-based med-psych practice?
Both models can work. An in-network practice may fill faster and increase access for complex, underserved patients—but requires more administrative overhead and lower per-visit reimbursement. An out-of-network or hybrid model allows longer visits and more flexible integrated services, but reduces affordability for some patients. Many med-psych physicians start as hybrid: in-network with a few key plans and out-of-network for others, reassessing after 12–18 months.

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4. How much business training do I need before opening my practice?
You don’t need an MBA, but you do need a working understanding of:

• Basic business entities and contracts (with professional guidance)
• Revenue cycle: how you actually get paid
• Overhead budgeting and how many patients per week you need to break even
• Marketing basics and referral building

Leverage:

• Local or online physician-entrepreneur groups
• Practice management consultants (even a few hours can save you major missteps)
• Mentorship from other psychiatrists, internists, or med-psych physicians in private practice

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Building a medicine psychiatry combined private practice is demanding but uniquely positioned to meet real-world patient needs. With thoughtful planning around scope, structure, risk, and growth—and a realistic understanding of private practice vs employment trade-offs—you can create a career that aligns with your clinical passions and your life outside medicine.