How do I open my own practice?

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What special challenges does working in your own practice bring?

Following a time-intensive training program, licensed psychotherapists possess extensive psychological skills. With the opening of their own practice, business management activities, which played little or no role in the previous training, are added to the psychological range of tasks. The challenge is to familiarize oneself with the entrepreneurial tasks and at the same time to pursue the therapeutic activities.

Due to the professional code of conduct and the associated obligations towards the general public, psychotherapeutic work is not aimed at pure profit optimization. It should be added that psychotherapists are required by § 95d SGB V to undergo regular continuing education and must complete 250 continuing education points within 5 years; failure to do so will result in fee reductions or even withdrawal of license. These points are collected on the basis of a continuing education account at the respective chamber of psychotherapists. The member is responsible for applying to the respective chamber for a certificate for the 250 points earned, which he/she then submits to the Association of Statutory Health Insurance Physicians (KV). There are further obligations towards the patient, including the duty to inform, the duty of confidentiality and the duty of documentation. In return, psychotherapists enjoy tax privileges such as exemption from value-added tax and trade tax with regard to income from therapeutic activities.

What legal framework should I be familiar with?

Anyone wishing to open their own psychotherapy practice should be familiar with the relevant legal framework. They include content-related and organizational requirements that must be observed when establishing and structuring the practice. The most important laws are the Heilberufsgesetz (Health Professions Act) of the federal state, the Psychotherapists Act (PsychTHG), competition law (UWG, HWG) as well as the civil law treatment contract (§§ 630a ff. BGB) and the psychotherapy guidelines. In addition, the professional code of conduct represents the basis of practical activity by regulating the professional conduct of psychotherapists towards their patients, colleagues, the public and partners in the health care system. Other statutes and regulations of the chamber are also to be followed.

If you have a good overview in these areas, you will have covered the most important framework for opening your own practice.

What are the forms of collaboration for joint practices?

The majority of outpatient psychotherapists work in individual practices. They may also cooperate with other psychotherapists or professional groups from the health and counseling sector in order to practice their profession, as long as this is legally permissible. As a form of cooperation, a distinction must be made between a group practice and a joint practice; these must be notified to the competent chamber.  

A joint practice is characterized by the fact that two or more practices join together and form an organizational community. The purpose of this association is the joint use and/or acquisition of premises, practice equipment and the employment of staff. The treatments, are provided by the individual practices and not within the framework of the group practice. Each practice maintains its own pratient:ing, they are independent in terms of licensure and billing. This excludes joint liability of the practices, and at the same time the duty of confidentiality between the members of the group practice must be observed. This form of cooperation is also referred to as a cost-sharing community, in which, as a rule, a joint property is formed, which represents a common asset, whereby each party can dispose of a share. From a legal point of view, a joint practice is a community under civil law (GbR), but in order to do justice to individual cooperation, details should be set out in a contract.

In contrast, the license is shared within a group practice/professional practice association, which means that, in addition to the joint use of practice rooms, equipment and staff, the medical profession is also practiced together. The group practice is a single contractual partner vis-à-vis the patients; treatment contracts are agreed between all members of the group practice and the patients. In this form of cooperation a joint liability arises, as legal forms they can either be run as a civil law partnership (GbR) or as a partnership company (PartGG). For the opening of a joint practice, an approval of the responsible licensing committee is required. Furthermore, it is possible to operate the group practice at different locations.

Should I start a private practice or a cash practice?

With the license to practice medicine, one receives the authorization to open a psychotherapeutic practice throughout Germany within the framework of freedom of establishment. Practices licensed by the Association of Statutory Health Insurance Physicians ("Kassensitze") are linked to planning areas, while private practices operate independently.

Anyone who has been involved with the panel doctors' offices knows that there is only a limited number of licenses and that the purchase prices are sometimes enormous. This aspect can be a deterrent, especially for newcomers to the profession, but the advantage of a panel seat is the security that results from billing with the KV and the high demand from patients. At the same time, the increase in controls and regulations of the KV leads to an abandonment of degrees of freedom, which is why some psychotherapists build up a second professional pillar in addition to their work in regular care. Examples of other activities are: Work in a private practice, psychodiagnostics, prevention, rehabilitation, or non-clinical activities such as supervision, teaching, coaching, marriage and family counseling or mediation. Legal and tax differences must be taken into account here.

In comparison, psychotherapists enjoy many freedoms within a private practice. As a rule, they can treat three groups of patients: those with private insurance, those with statutory insurance if they cannot find a therapy place or if their waiting time would be an unreasonable period of more than three months, and self-payers. With regard to self-payers, there are questions about the reliability of payments and what sums they can pay in total. In addition to these three groups, it is also possible to bill for the treatment of people who are entitled to benefits. In addition, there are sometimes special contracts, for example for members of the German Federal Police or the German Armed Forces, as well as aftercare programs of the German Pension Insurance, for which the costs are reimbursed. Due to the limited patient groups, psychotherapists in private practice are dependent on word of mouth and networks with potential referrers of patients (e.g. doctors, colleagues with health insurance approval in the vicinity). In order to have sufficient demand, they should give sufficient thought to the choice of location. In this context, infrastructural connections, the clientele and the corresponding practice design must be taken into account.

Which form is chosen ultimately depends on financial possibilities and individual needs for freedom/security.

How do a half and full cash seat differ from each other?

When acquiring a health center seat that is billable to the KV under the reimbursement system, one must consider the extent to which one wishes to utilize it to capacity. These considerations can help one decide whether to acquire a half or full service contract. A half-care contract requires a weekly attendance requirement of 12.5 hours of presence, 160 minutes of telephone availability, and 50 minutes of psychotherapy consultation, not to exceed 390 hours in the quarterly profile. A whole care mandate is characterized by a weekly attendance obligation of 25 hours, 320 minutes of telephone accessibility and 100 minutes of psychotherapeutic consultation hours. In the quarterly profile, the time limit is 780 hours.

Since 2019, it is possible to reduce a full license to ¾, however, psychotherapists who want to take over the vacated ¼ panel seat must already have half of one, since a license of a ¼ seat is not possible.

In order to acquire a practice site, one has to be placed on the waiting list of the respective planning area after the license to practice medicine has been granted.

What to consider when renting the premises?

If the practice is not being taken over, suitable premises must be found in order to open the practice. When renting, care must be taken to ensure that a rental agreement for commercial premises is concluded, as rental law distinguishes between private and commercial premises. Renting premises as residential and using them commercially is prohibited. Sample rental agreements are available free of charge from some chambers of commerce and industry.

If the apartment was used as living space prior to the rental, the landlord must ensure that the relevant building authority is contacted, as changes of use relevant under building law must be taken into account. In some cases, approval and knowledge procedures are also necessary. In addition, the provisions of the state building code and, in the case of salaried employees, the provisions of the Workplace Ordinance (ArbStättV) should be observed.

The aspects described must also be taken into account if the practice rooms are located in the condominium or the owner's home. Here, above all, a strict separation of the private and professionally used premises must be demonstrated.  

The size and design of the premises is up to the psychotherapist, but according to the professional code of conduct, care must be taken to ensure that a conscientious and professional activity is carried out that upholds the reputation of the profession.

Ideally, the practice should include several rooms that are not very bright, so that there can be a waiting room, treatment rooms, toilets and an office and archive room, as well as a recreation room or (tea) kitchen for employees, if necessary. In addition, it is advisable to pay attention to accessibility.

Our conclusion

When opening your own practice, the balancing act between entrepreneurial and therapeutic activity is the greatest challenge. A good overview of the relevant legal framework and professional regulations is essential. Entering into a cooperation with colleagues or members of other professional groups should be well planned. Either a group practice or a joint practice/professional practice association is possible. Working in a panel practice differs from working in a private practice, especially in terms of billing and also in terms of duties and degrees of freedom. For half and full health insurance licenses, there are different framework conditions with regard to attendance times.

When renting the premises, aspects of tenancy law in particular should be taken into account, and the design of the practice premises should be appropriate for the profession.