Taking the Leap Together: Liz Horn on Launching a Speech Therapy Practice During COVID

Liz Horn and her business partner Kayla Mashoff didn't sit down with a spreadsheet and a five-year plan. They were hanging out over Christmas break with their grad school friends, talking about how families in their area had almost nowhere to turn for private practice speech therapy. A few months later, Willow Tree Speech Therapy existed.

Then COVID hit.

Liz is a school-based SLP, a clinical supervisor at SIUE, and a mom of two. She and Kayla opened Willow Tree in Waterloo, Illinois, just south of St. Louis, during what turned out to be one of the strangest years in recent memory. Their story is less about scaling fast and more about something harder to teach: finding the courage to start, and having the right person beside you when things get messy.

The Confidence Problem Nobody Talks About

Liz is honest about what almost stopped her. It wasn't money or logistics. It was doubt.

"I don't think I would have had the confidence or the drive to even consider opening a private practice if it wasn't for being a supervisor at SIUE," she says. Going back to the university clinic to supervise graduate students gave her a perspective shift. Watching first-year clinicians walk into sessions loaded down with materials, nervous and eager, reminded her how far she'd actually come.

"It really became full circle for me. Kayla and I sat back and said, maybe we can do this. Maybe we do know enough."

That moment of recognition is something a lot of speech therapists can relate to. Years of clinical experience, specialty knowledge, daily problem-solving, and still that voice in the back of your head saying you're not ready. Liz's advice? You know more than you think you do.

Insurance Credentialing: The Part That Makes You Want to Cry

Liz and Kayla knew from the start they wanted to accept insurance. Liz's own son had been through speech therapy, and insurance made it possible for their family to get the services they needed. They wanted to give other families that same access.

So they filed for their PLLC, got their paperwork together by mid-February, and dove into insurance credentialing. Then everything shut down.

COVID slowed the already-glacial credentialing process to a crawl. Some insurers took months to respond. Others told them the panel was full, which Liz found hard to believe given how few speech therapists were actually available in their area. As of the recording, they'd gotten through with Blue Cross Blue Shield and Tricare, were close with Cigna, and were still waiting on Aetna and UnitedHealthcare.

The credentialing paperwork itself was its own kind of nightmare. Forms designed for physicians, not speech pathologists, with fields that didn't apply and requirements that didn't make sense. Liz spent hours on hold, read every blog she could find, and leaned on Kayla to tag in when frustration hit a wall.

"There were some days I had to say to Kayla, I've been on hold for an hour and a half and I'm just so frustrated I'm hanging up."

Having a partner for exactly those moments made the difference.

Learning to Bill Without Losing Your Mind

Once clients started coming in, Liz and Kayla had to figure out billing. They used Availity, the free clearinghouse tool, and found it worked well enough to get claims through. Blue Cross Blue Shield, their most-used payer, turned out to be straightforward to work with.

But straightforward doesn't mean simple. Two clients with the same insurance can have completely different co-pays, deductibles, and coverage levels. Every new client meant a new set of variables to sort through.

Liz's approach was refreshingly practical: call the insurance company and ask. "I would often joke with the insurance agents on the phone and say, I have a master's degree but it is not in this." The reps walked her through questions she didn't know she had, and over time, the calls got shorter and the process got faster.

She's quick to note that she wouldn't have gotten through it alone. Having a partner to split the learning curve, to laugh with when it got ridiculous, and to take over when one of them needed a break, that was everything.

A Personal Mission Behind the Business

What drives Willow Tree isn't a business plan. It's personal.

Liz's youngest son, Sammy, had one vowel sound until he was nearly 20 months old. As a speech therapist, Liz sat on the other side of the standardized assessment while his clinician flipped further and further back through the Rossetti, watching the age-equivalent scores drop below the six-to-nine month range. She asked the therapist to stop because she was about to cry.

Sammy is doing well now, two years old and his language is taking off. But that experience gave Liz something no textbook could: the ability to sit across from a parent and genuinely say, "I know what this feels like."

"I know what it's like to be the parent on the other side of that table. And I know what it's like to be the therapist on the other side of the table."

That empathy is baked into how Willow Tree operates. It's also why Liz and Kayla's long-term vision goes beyond speech. They want to build a clinic that houses OT, PT, and speech under one roof, a one-stop resource for families who are currently driving all over to piece together the services their kids need.

Just Try It

Liz and Kayla have been seeing clients for about three months as of this conversation. They're at around ten clients, still small, still growing. Liz is full-time in the schools. Kayla went part-time in her district to free up two weekdays for daytime sessions, many of them at daycares. They've split their caseload by strength: Kayla gravitates toward the birth-to-three and pre-K crowd, while Liz prefers elementary-age kids.

Neither of them is ready to quit their school jobs, and they're fine with that. This started as a passion project to fill a gap in their community, and that's exactly what it still is.

Liz's parting advice is simple: "Take the leap of faith. You're not going to regret it. You know so much more than you think you know." Find a friend to do it with. Don't be afraid to ask questions. And remember that insurance is hard for everyone, not just you.

Juggling a growing caseload alongside a full-time job means your systems have to work. ClinicNote is a HIPAA-compliant EMR built for private practices and university clinics, handling documentation, scheduling, and billing in one place so you can spend more time with the families who need you. See how ClinicNote works.

Transcript

Kadie: You are listening to Clinic Chats, the speech therapist private practice podcast, a podcast full of personal journeys where we not only talk about success stories, but also real life struggles of small business startups. Clinic Chats is sponsored by ClinicNote, a HIPAA compliant, cloud-based EMR platform used specifically by private practice owners and university clinics. I'm your host, Kadie Jackstadt, and thank you for joining me today.

Kadie: Today I'd like to welcome and introduce Liz Horn, who's a speech pathologist who just recently in 2020 opened up Willow Tree Speech Therapy, which is located in Waterloo, Illinois. Hi, Liz. How are you?

Liz: Hi, Kadie. Thanks for having me on today. I'm doing well.

Kadie: I can't wait to get started because we've kind of been in touch this past year as you've gotten started, and it's fresh on your mind. So I can't wait to hear all the nitty gritty about all the hard work that goes into starting a business.

Liz: Oh, there definitely has been a lot of work. But before I get too far, I have to say that I have the most amazing partner to do it with. So my partner, Kayla Mashoff, has done so much work, and we would not be here at all without all the time that she has put into it as well.

Kadie: Yes. That is so nice to have someone to piggyback ideas off of, split all of that initial work and time. So I'm sure that's been super helpful.

Liz: It has. It's been huge.

Kadie: So tell me a little bit about when Kayla and yourself began brainstorming about this private practice.

Liz: Well, you know what? It was just kind of a normal Christmas break day last year when my group of friends got together. Now I have to say that we all went to graduate school together. We've all been incredibly close since then. And it's so crucial to have those resources and those peers that you can go to and say, help me with this. I'm not sure where to go from here.

Liz: But we were just chatting, and we were talking about a need for private practice, specifically in the area where Kayla and I live, and looking for those extra resources for families in home therapy. And we really, we had heard of just a couple, but nothing big. And near us is St. Louis. We are on the Illinois side of South County St. Louis. So we knew that there were some places over there. There were places in O'Fallon, Edwardsville. But we just really wanted to be able to open something closer for our families in that area that needed the assistance.

Kadie: And you all were in the school. Were each of you in different districts thinking, I have nowhere to refer these kids out if they want extra services?

Liz: Kayla and I are also school-based speech therapists. So right now our private practice is growing. And we're excited to watch it grow over the upcoming months and years. But we also do still service our kiddos in the schools. Based on our location, we're not completely close to where our private practice is. It's more of our home location.

Liz: So Kayla had some moms that she was friends with that would ask her, hey, we know you're a speech therapist and we're just looking for resources and advice and services. Is there any way that you can help us? So it just kind of stemmed from that need of recognizing that there were families out there looking for speech and asking ourselves, what can we do to help and solve this need?

Kadie: Right, right. You know, I also know that now you guys are supervising in the SIUE Speech and Hearing Clinic, right?

Liz: Yes, yes. It's kind of funny how it becomes full circle. You know, I don't know that I would have had the confidence or the drive to even consider opening a private practice if it wasn't for that addition of being a supervisor at SIUE as well. This is my second year supervising in the clinic. And I have to say, it is just the most amazing job. Having the opportunity to go back where everything started and where it all began.

Liz: But also I think that a lot of us as speech therapists sit here and we think, there's so much I don't know and what have I learned and how have I changed and how far has my career come? And it isn't until you can go full circle and you go back to that graduate clinician setting and you see them walk into their first sessions and you think, oh, I just love it. It's my favorite part of the semester. I just love watching them walk in. And I mean, they bring more materials to one session than I own. And I just love that.

Liz: I love watching them grow. I love watching them realize there's so much more that I'm doing and things that I'm not necessarily targeting. I'm making such an impact by just being in here with this child and working on language in general. But it really became full circle for me. And Kayla and I sat back and we said, maybe we can do this. Maybe this is something. Maybe we do know enough. And it's just recognizing and having that confidence and also taking that leap of faith.

Liz: It is definitely a leap of faith. It's one that we're excited about. It's definitely been a leap with COVID thrown in there. It has definitely provided additional challenges for us.

Kadie: Oh, yes. Starting this year, starting a business, I cannot imagine. But I will say, knowing that you are a mom of two, a full-time school SLP, a graduate program supervisor, and starting a successful private practice, I just think that clearly you're going to do it all and do it all well.

Liz: So you're too sweet.

Kadie: So I want to hear from that decision, getting your PLLC, what were the next thoughts and the next steps that you guys had to navigate?

Liz: Well, so we knew when we opened our private practice that we wanted to be able to accept insurance. So that, I think, is often private practices do not accept insurance, but we just felt that for our community and our personal experiences, that was going to be important to us. My son has gone through speech therapy, and that insurance allowed us to go where we wanted. And so we wanted to give our families that same option as well.

Liz: So we filed for our PLLC. We obtained all of the necessary paperwork maybe mid-February or so. And we started looking into insurance credentialing. And I have to say that I would have been lost without you, Kadie, and being able to bounce ideas off of you and have you point me in the right direction and just say, I am so lost. Where do I go next? Listening to your podcast, I've learned so much more about it as well, and steps that maybe we could have done differently, but at the same time, I'm not sure that we would have.

Kadie: Right, right. Exactly. There's a lot of different options. So was insurance, as always, a lengthy process, I'm sure?

Liz: Still ongoing, maybe? Yes, it absolutely is ongoing. It is very lengthy. In addition to that, we were shut down then for COVID. So everything was just kind of put on hold in general. So some of the insurance credentialing agencies, it took them much longer to get back with us, which we understood. And obviously, we weren't able to see any clients at that time since everything was shut down.

Liz: So really, it allowed us the opportunity to sit back and make sure that we had everything lined up. We had everything ready to go so that we could just make those jumps. So we are actually still on a waiting list. Some of our insurance companies have told us that they're full. And so we are supposed to check back in six months and see where they are. We're not sure that they're full of speech therapists, though, because if they are, we're not sure where they are.

Kadie: Well, and this is something I don't know if I've mentioned on here before. I believe it was Aetna or Cigna, back when I was in private practice, how I tried to get a network with one of these specific companies that first month or whatever in business. And it's like they kept saying, the panel is full. The panel is full. And I'm like, I know no one who takes these insurances.

Kadie: So it took a year of fighting and proving that the other places were either no longer in business or not servicing any clients with those insurances anymore. And finally, I think it was the week after I closed my doors that they said, you're in network.

Liz: Oh, no. Of course. Right? And I have to say, I do think you have to prove sometimes that, OK, well, Kadie Jackstadt might be on this panel, but you need to see she's not in business. So it takes fighting.

Kadie: Oh, my gosh. It takes so much fighting.

Liz: Well, I'm glad that you mentioned that, because we just took their waiting letter and decided we needed to wait.

Kadie: Well, it still might be a year. That is the problem. And some of them told us back in March, when we started filling out insurance paperwork, they said it's a minimum of six months. Sometimes it's longer than that. And then to have them come back and say you have missing information or something that isn't relevant to you as a speech therapist, but is relevant for a doctor, and understanding some of those factors and being able to differentiate what is needed and what isn't.

Liz: My goodness, I've read more blogs and I've listened to more continuing ed videos on this topic just so that I can truly understand.

Kadie: Right. Well, the first time you fill out some insurance paperwork, it's so overwhelming. So was it you? Was it Kayla? Was it a team effort? Who navigated that?

Liz: It was definitely a team effort. And there were some days that I had to say to Kayla, I am so sorry, but I have been on hold now for an hour and a half and I'm just so frustrated I'm hanging up. So having that other person that is your calm and is your, you know what, I have dealt with them so many times I'm putting your phone number on there now.

Liz: Right, right. So it has, I wouldn't have been able to do it without Kayla so I just have to give her all the credit because she is my calm and she can make me laugh and I think we can make each other laugh because you have to, otherwise there are some days that you might cry.

Kadie: I'm sure it's a great balance. What insurance companies have you gotten through with at this point?

Liz: So at this point we have gotten through with Blue Cross Blue Shield. We have gotten through with Tricare. We are just about through with Cigna. Aetna was our one that put us on the wait list so that might have been the same for you as well. We have applied for UnitedHealthcare but that was another one that told us that it would take six plus months so we're still just kind of waiting to see. Every once in a while we might get an email but then we don't hear anything for another period of time so it's just a waiting game.

Kadie: And so getting through to insurances was crucial and then were you able to begin marketing your business?

Liz: Yes we did. So again I have to give all the credit to Kayla here because she designed a fantastic website. I think I did more of the proofreading and she's the designer. So we designed our website and we pushed out a social media presence which we would like to continue to increase through different platforms as well and then we had inquiries based off of that information.

Liz: We've also worked to make some connections with local pediatricians in the area. In addition to that we've worked to connect with some of our occupational therapists that are nearby which I think is huge. Those are our colleagues. We need to have those connections. Most of our kids need multiple services so we really worked hard to build those relationships as well.

Kadie: I think all of those are crucial to have in place. Which one have you gotten referrals from the most thus far do you think?

Liz: I would probably say to be honest we've had parents find us on social media but then in addition to that we have gotten a lot from daycares.

Kadie: That's awesome so you guys went out and got your name out there.

Liz: We did and we're still getting our name out there. And I think that it is hitting the right population and it's understanding how to hit them as well. We did also join, we were really excited to find a women of Waterloo that own businesses. So we joined a group called Glow. We attended our first meeting last month but it was just a great place where women that own businesses or work at businesses could connect. And really we thought that having that resource was just fantastic that we're able to lift each other up and support each other especially during these times.

Kadie: And also getting your name out there with people who are talking and influential in the community, very big deal there. So that's awesome. So how many clients have you obtained thus far? I know you're still full-time in the school.

Liz: Yeah so we're just at a small handful right now and we've had some that have left to go back to schools. We saw some in the summer that have. So we're around 10 so we're definitely still small and growing. Again we also have to remember that we started during COVID.

Kadie: Yeah and you have to also think of, if you're splitting a caseload of 10 in the evenings that's still five clients you're putting time and effort into after school hours so that's a lot.

Liz: Well and again I'm going to give all the credit to Kayla because I am full-time in the schools and she went part-time. She did. So she is three days a week in her school district which actually left her two full days to be able to see clients during the day. So some of our clients are in daycares and we have worked with them to be able to go and see kiddos at daycare.

Liz: So they are not all fortunately at night in the evenings but rather during the day and then she's able to go service those littles. And I think we both have our strengths and she enjoys the young kids and that birth to three and that pre-K age which is where the primary portion of her career has been, working with that age group. Whereas I have had preschool but I also service students up to sixth grade so I tend to gravitate more towards the older kids, elementary age. And she does the younger ones so really we become the perfect pair then.

Kadie: Right that's awesome. Especially for the populations you like, you're going to have to see them after school hours for the most part anyway, aside from COVID, that's typically the way it would go.

Liz: Right exactly.

Kadie: Now that you have your own clients, you are in network, do you feel that learning how to bill and handle each insurance is a second job in itself?

Liz: You know I'm going to jinx myself by saying this out loud so I'll knock on all the wood next to me that I can find. But I had jokingly told Kayla at the end of the summer that so far I didn't think it was that terrible and she looked at me and I said I just jinxed us I'm really sorry.

Liz: You know I do think that being able to bill through Availity has been huge for us.

Kadie: Yeah when I first got started the free resource. Yep, yep. All of your insurances have gone through just fine through Availity?

Liz: So far. It's great. And again we've taken, we're in network for other insurances but we haven't had any clients utilize all of them at this point. Most of which Blue Cross Blue Shield is heavily used in this area.

Kadie: Agreed yeah and they're pretty great to work with.

Liz: They are very easy and they'll walk you through on the phone if you have questions. I think one of the things that we had to do was swallow our pride and understand that we could ask these questions. And I would often joke with the insurance agents on the phone and say I have a master's degree but it is not in this.

Kadie: Yeah right right. They'll never see you, who cares, ask all the questions, they don't know.

Liz: Exactly and they really have been a resource. So yes you have to wait on the phone but it's worked out in our benefit.

Kadie: Exactly. And I'm sure you've started to fully understand co-pays and coinsurance and deductibles. I mean we're all familiar with those terms before directly benefiting from them for reimbursement but do you feel like all of that was a learning curve?

Liz: Oh absolutely it was and it still is a learning curve. And I think just because two clients have Blue Cross Blue Shield doesn't mean it's going to reimburse the same, doesn't mean their co-pays are the same, doesn't mean coverage is even remotely similar. So we are most definitely still navigating through that and we do it together and ask each other, hey do you remember what this means or do you remember what that resource was?

Kadie: Oh it's so fun that you have each other. I'm the weirdo who's like oh that's so fun to figure out, you know, it's just funny. It seems like you guys aren't minding it either. Some people would just dread it.

Liz: Well and I will say that if I didn't have somebody to, like I said, say you know what I'm going to cry I need you to do this. But I think having that partner is huge. But for both of us we weren't ready to make the leap full-time into doing private practice. We really wanted to assess the needs and find our niche and build clients based off of that. However, having that other person that you can ask questions to has just, I would not have done it without her. I'm not as brave as you Kadie, I don't think I could have done it alone.

Kadie: Well here's my question and it might tell you why I chose to do it alone. Are you guys nervous at all that with two people relying on this business name, I know you're being really safe as far as you haven't resigned or anything like that, but with two people trying to profit and have an income from this, do you feel like it's that much more pressure to get more clients? Because for me I was like oh 10 to 15 clients and I can almost think about quitting a job whereas for you guys it feels a little bit differently.

Liz: Yeah so that is a great question. I'll be honest with you, I absolutely with my whole heart love my school-based job. I love my kids. I work with kiddos that are in a lower socioeconomic status and I don't think I can leave them at this point in my career. I'm not and I won't.

Liz: So I think that for us it really just became more of a, this is something fun that we want to see where it takes us. Unfortunately with speech therapy we are not selling an item, we're not selling a good, we're selling a service. Or we are providing a service. So an upfront starting cost to something like this isn't like I'm stocking a store with merchandise.

Kadie: No.

Liz: No. So that really allowed us the flexibility to say, let's just try it and see because there's nothing to lose except time. But I also think that being in the schools and understanding the academic impact and how something might impact somebody academically versus a private practice service model in areas that I can work with a client longer, or I can work with them on skills that might not really be developmentally appropriate for another year or so in the school. So I think just having that freedom to make your own decisions has just been fun.

Liz: But for us right now, obviously, we want to watch our practice grow and we're really looking forward to picking up more clients as we go here. But at this point, we're just kind of rolling with it and seeing where it takes us.

Kadie: Yeah, absolutely. Well, I think the passion is clearly there for you guys. And so I just think it's going to take off and then you're going to think, what do I do? Now I have passion for my full-time job and so much going on with my private practice. But I know that'll be the case and that's a good problem to have eventually.

Liz: It is absolutely a good problem to have. You know, my youngest son really is my motivation to do a lot of this. My sweet little Sammy, who is now two and doing wonderfully, had one vowel. And he had one vowel until he was about, I would say, maybe 18 or 20 months. And it was just an open mouth vowel and we really couldn't shape anything from it.

Liz: So that was my first experience in the private practice world, was taking him to speech and being on that receiving end. And I really think that for him, I am close with his speech therapist and I've known her before I started working, before I started doing anything. But sitting there and watching her give him a standardized test as a young child, we were sitting there doing the Rossetti and she, at that time, he was about 15 months old and we didn't get anything on expressive language. So we flipped back to 12 months and we added maybe one, two things and it really wasn't much. So we flipped back.

Liz: And as I watched her continue to flip back, when she flipped back between the six and nine-month mark, I was like, you have to stop, I'm going to start crying.

Kadie: Oh my gosh, I'm tearing up now.

Liz: He's doing wonderfully now. He turned two and has just kind of exploded, although I still am most definitely watching him. He's still very difficult to understand. So we're really anxious to see where our own personal speech journey takes us.

Liz: But I think just seeing that and recognizing that that's a need and wanting to be that person for another parent, but also having the empathy to sit back and relate and say, I know what it's like to be the parent on the other side of that table. And I know what it's like to be the therapist on the other side of the table. And just understanding that parents want the resources and want the help, and they're not really sure where to go, but you really have that knowledge and that ability to be that for somebody and really to change their life, just like Sammy's speech therapist did for us.

Kadie: Oh my gosh, that is just amazing that he has seen that much progress. So I'm just so happy for you guys. And I bet that just gives you all the motivation, like you said, to be that for other people.

Liz: It does. I joked that he had a speech therapist mommy home with him all through the COVID break, right? So it was like speech therapy 24-7. I'm just kidding. That most definitely is not the case of having multiple children.

Kadie: No, no. It's so funny how much, before kids, you tell parents, do this, this, and this. And you're thinking, how do they not work with them every single day for a half an hour?

Liz: Oh, it's impossible. Oh, absolutely. And how many parents say, they come back the next week, I just forgot. And I have to say that here I am, a speech therapist and a parent, and at the end of the day, I would go, oh, man.

Kadie: Right. Now we just need to get them to bed. That's what matters at this point. So it's going to wait till tomorrow.

Liz: Exactly. We'll just double it tomorrow. It'll be fine.

Kadie: Yeah, exactly. Will you explain where you see, what's the end goal here? I know you mentioned briefly how it's just a fun passion project right now, but what is the end goal if you had it in your ideal world?

Liz: Yeah. That's a great question. So really, Kayla and I would love to be able to expand. We would love to be able to house other therapies with us. We really just obviously want to grow that client base. But I think the end goal would be to be able to have a clinic that we could be a one-stop for our families so that they could receive OT, PT, speech all in the same area.

Liz: And in addition to this, be that resource for those parents and provide them that service that they need that maybe they aren't familiar with, which I really think is the case that many aren't familiar with some of the resources and the therapies that are available for kiddos that are young.

Kadie: Exactly. Yeah. That would be so amazing. Is there any words for those who listen, who might be in your shoes, starting out this year, 2020, what a year to get going, any words of encouragement that you'd like to share?

Liz: Yeah. You know what? It's a leap of faith and take it. You're not going to regret it. You know so much more than you think you know. Like I said, I was sitting here thinking, there's so much that I don't know. But going back to the university setting really brought my career to this point full circle. So I just would advise you to just do it. Take the leap of faith. Try it. Don't give up.

Liz: Remember, you are the professional in your area. You know how to do this. And insurance is challenging. It is not something that we took any courses in. There is no easy way around any of it. But just don't be afraid to ask questions. Don't be afraid to make those connections in your community and in your environment. And if I can really, my most important piece of advice would be to find that friend to do it with you.

Kadie: Yeah. That's awesome. Well, I'd also like to add, it's so short term. You were feeling like, okay, what do I do to get started? And it feels like yesterday, but it's like, oh, that was already six or eight months ago or something. And now look at you guys. It seems like things are going really well. So it's so short-lived.

Liz: It is. We most definitely have not been going more than maybe three-ish months that we've been able to see clients. It really wasn't until, the beginning of July. So we are new in this. We're getting faster at our billing. We're getting faster on our calls. We know what questions to ask. There are still a lot of questions we don't know to ask, but like you said, it is amazing how quickly you do learn by throwing yourself in completely.

Kadie: Exactly. Well, thank you for sharing your story and I wish you guys the best of luck with the rest of your first year in business and then the years to come.

Liz: Well, thank you so much for having me, Kadie.

Kadie: Thank you for joining me and listening to Clinic Chats, the speech therapist's private practice podcast. If you have a moment, please leave a five-star review for Clinic Chats to help other SLPs find our podcast. If you'd like to share your own personal journey through private practice, please email me kadie at clinicnote.com. That's K-A-I-D-E at clinicnote.com.