18 Years of Private Practice: How Caroline Skidmore Built Skidmore Speech and Language from the Ground Up

Caroline Skidmore started her private practice three weeks after her first son was born. That was 2002. Eighteen years later, she's still running Skidmore Speech and Language Services in Bend, Oregon, with a second clinician, a cozy office that kids think she lives in, and the kind of reputation that keeps pediatricians sending referrals her way.

Her story isn't one of overnight growth or a single big break. It's a slow, disciplined build. The kind that actually lasts.

Starting From Scratch, Twice

Caroline was working at Oregon Health Sciences University when she decided not to go back after maternity leave. The clinic she'd been at was generous about it. They let clients follow her and kept referring families her way.

Then, a few weeks into her new practice, her husband got a job three hours away in Bend. She packed up and started over.

"I had to start a whole new caseload and establish my business, but it worked out."

She kept it lean. No office, no insurance billing. Just home visits, private pay, a couple days a week. She grew slowly and deliberately, only adding overhead when demand forced her hand. About two years in, families started asking if she'd bill insurance. When she made that switch, things took off fast.

The Insurance Learning Curve

Making the jump from private pay to billing insurance was steep. Caroline did what a lot of practice owners do at first: tried to handle everything herself.

"I'm sort of the person that I have a hard time delegating, so I decided I was just going to do it all and just jumped right in."

That lasted a few months. She brought in a remote biller she knew from her OHSU days, someone who could take on the heavy lifting. Eventually she moved to a practice management software platform with integrated scheduling and billing, which simplified things enough to go solo on billing again. A few years later, she hired another biller, because the work never really shrinks.

Her approach now is strategic. She handles the initial electronic billing herself, which she says is quick with the right software. Her biller takes on pre-authorizations and fights the tricky denials, the kind that require long hold times with insurance companies. It's a setup that keeps costs down while making sure nothing falls through the cracks.

She accepts five major insurers plus Medicaid. The Medicaid reimbursement, she says bluntly, "doesn't pencil out." But she keeps it because some of those kids wouldn't get services otherwise.

Work-Life Balance That Actually Works

The whole reason Caroline went into private practice was flexibility. Eighteen years in, she'll tell you it delivered.

"When they were little, I had the ability to take them to story time at the library, drop them off and pick them up from preschool. All those things that were really important to me as a mom."

She sees clients three days a week. One full day and two half days. The rest of her time goes to intake, billing, and managing client accounts. She's disciplined about structuring her days so the admin work gets done without eating into her personal time.

The morning of this interview, she got up early, did computer work, took her dogs on a two-hour hike, and then sat down to record. That's not an accident. That's 18 years of building a practice that fits around the life she wants, not the other way around.

Does work creep into evenings and weekends? Absolutely. She's always reachable by phone, even on vacation. But she's learned when to let a call go to voicemail and return it after the hike.

Building a Referral Network Through Reputation

Caroline didn't build her caseload through advertising. Word of mouth from parents carried her practice for years, especially in a town that started at 40,000 people. As Bend grew to 100,000, she built strong relationships with every pediatrician group in town. Now they send most of their speech therapy referrals her way.

Her office doesn't help with visibility. It looks like a house, tucked away from foot traffic. Kids literally think she lives there. But in a field driven by trust and results, the storefront doesn't matter. The reputation does.

She's also built something smart with her physical space. A learning specialist works right down the hall, sharing many of the same clients. Caroline has started collaborating more closely with a local OT as well, floating the idea of a co-op arrangement that would give kids access to an OT gym alongside speech services. It's the kind of interdisciplinary setup that benefits families and strengthens referral pipelines in both directions.

Hiring and Managing Staff Transitions

Caroline has navigated several employee transitions over 18 years. Her first hire started as a subcontractor doing home visits, then moved to W-2 employee status when they got an office, since the subcontractor classification no longer fit.

She used QuickBooks Payroll and worked with her accountant to set everything up properly. At-will employment contracts. All in writing.

Her longest-tenured employee stayed almost 12 years. When that clinician left to be a full-time mom, the transition was harder on families than Caroline expected. Parents were anxious about the change, even though Caroline had nine months of lead time to find a replacement.

"It was just surprising to me the amount of anxiety that parents felt about that."

The new hire won everyone over quickly. But it's a reminder that in pediatric private practice, the relationship between clinician and family runs deep. Staff transitions need to be handled with care, communication, and enough runway to do it right.

Running a practice for 18 years means your systems have to work as hard as you do. ClinicNote is a HIPAA-compliant EMR built for private practices and university clinics, with integrated scheduling, documentation, and billing in one platform. Less time on admin, more time with the families you serve. See how ClinicNote works.

Transcript

Kadie: You are listening to Clinic Chats. Clinic Chats is a multidisciplinary therapy podcast that was created for students, professionals, clinic directors, and supervisors. Clinic Chats is bridging the gap between graduate programs and professionals, sharing personal journeys of the smallest of private practice startups, large and expanding practices, as well as university clinic triumphs and tribulations. We hope you'll find our podcast informative and helpful in your career endeavors. Clinic Chats is sponsored by ClinicNote, an electronic medical record company for private practice and university clinics. ClinicNote was designed to make scheduling, documentation, report writing, and billing effective, efficient, and HIPAA compliant.

Kadie: So today on the podcast, I have Caroline Skidmore, and Caroline is the owner of Skidmore Speech and Language Services. Hi, Caroline. How are you?

Caroline: I'm well. How are you?

Kadie: I'm doing pretty well also. I'm excited to hear about your business. So tell me a little bit about when you got started.

Caroline: Yeah. So I got started in private practice in 2002. It was right after my first son was born. And I realized that I wanted to have more flexibility and be able to be at home as much as possible, but also continue to practice speech therapy. So that was now my son is 18. So that was 18 years ago. And I started my practice in Portland. And a few weeks later, my husband got a job in Bend. And so I had to move everything to Bend within a few weeks of starting my practice.

Kadie: And how far apart are those areas?

Caroline: They are about three hours apart. So yeah, I had to start a whole new caseload and establish my business, but it worked out.

Kadie: Yeah. So whenever you first started, did you have a position before that that you had to resign from or what did that transition look like for you?

Caroline: Yeah. So I was working up at Oregon Health Sciences University in a clinic up there. And prior to that, I had worked for an early intervention, early childhood special education program. So I was working up at OHSU, Oregon Health Sciences University at a clinic. And when I was pregnant, I kind of towards the end there decided that I wouldn't be going back, that I'd be starting my private practice.

Caroline: And the clinic I was with was actually just really great. And they knew that there was a lot of my clients that wanted to follow me into my private practice. So the clinic was just really gracious and said, whatever clients want to follow you, we are fine with that and best of luck and we'll support you. And they ended up referring a lot of clients to me and we continued just a really good professional relationship, myself and the other clinicians at that clinic.

Kadie: Yeah. That's so nice of them. So it was kind of natural to obtain your first several clients, but then when he relocated three hours away, you had to start from scratch?

Caroline: Yeah, it was tricky. And when I started in Portland, I decided just to start really small. And at that point, when I started in Portland, I was just providing therapy in clients' homes and it was all self pay. And I only at that point, because I started working very soon or started my private practice very soon after my son was born. I think I only took off maybe three weeks he was born and then I kind of jumped back in.

Kadie: Yeah.

Caroline: Yeah. But just a couple of days a week and go to clients' homes. And then when I moved to Bend, I started that way as well, just so I didn't have to rent space and invest a lot. I just kind of started slowly. And as I grew relatively quickly, I continued to go to clients' homes and I continued to just be private pay. And then as I grew, I realized I needed an actual office. And a lot of my clients were asking if I would start billing insurance. So once that happened, everything kind of took off very, very quickly.

Kadie: Wow. So that was kind of the turning point of switching to taking insurance. You feel like you really grew at that point?

Caroline: Yeah. Yeah, I really did. And even though I tried to keep my rates competitive, but also doable for families, I felt like there was a lot of families that I could see, but that just couldn't pay privately. And again, yeah, once I started billing insurance, those referrals just came really fast and furious.

Kadie: And making that switch from private pay only to taking insurance, I'm sure that was such a learning curve. So how many years into it were you whenever you made that switch?

Caroline: I think I was in about two years.

Kadie: Oh, wow.

Caroline: Yeah. And the learning curve was very steep. And what I decided to do is I decided to do it all on my own. I'm sort of the person that I have a hard time delegating, so I decided I was just going to do it all and just jumped right in. After a few months, I realized that that was a lot to handle. And so I ended up hiring a biller from Portland.

Kadie: Okay.

Caroline: Yeah, somebody I knew when I was working up at OHSU. And so she did most all of the billing for me remotely. And that was a huge, huge help. And so eventually I switched to a practice management software platform that did integrated scheduling and billing. And once I did that, I got rid of my biller and started doing it by myself again. And now a few years into doing that, I've hired another biller because I'm realizing how much work it is.

Kadie: Right, right. So now are you utilizing both the biller and the software, or is the biller taking care of all of that for you?

Caroline: I'm utilizing both. So I essentially do all the initial electronic billing, which is so easy with the platform that I use. So I do all the billing. And then actually when the EOBs come in and the checks come in, I input all of that. And how I use my biller is I try to be really strategic about it because it is an extra cost. So she bills by the hour and I have her take care of all my pre-authorizations. And then if I have something tricky where there's some sort of denial from insurance and I'm not really understanding what's happening, I'll just put her in charge of those cases. And then she spends all the time waiting on hold with insurance companies.

Kadie: Right, right. So you're really making sure you need her and that time, instead of using her for everything, you're doing it more strategically.

Caroline: Yes, yes. And I still spend quite a bit of time working on billing. And the initial electronic billing is pretty quick, but when it comes to looking through the EOBs and inputting checks and managing patient accounts and inputting co-pays and that kind of thing, it definitely takes a good chunk of my time. But I also only see clients three days a week, but Monday I do one full day and then two half days. And then the rest of the week I'm doing intake and working on inputting checks and updating client accounts.

Kadie: Yeah, I was wondering that because you mentioned when you started, it was largely about the work-life balance and spending time with your kids. So as the years have gone on, where are you with that now? And how did the work-life balance work out in private practice?

Caroline: I would say it worked out great. I definitely am always busy. I do things on the weekends and I do things in the evenings for sure. But now my kids are 18 and 16, but when they were little, I had the ability to take them to story time at the library, go to drop them off and pick them up from preschool. All those things that were really important to me as a mom. And so I had a ton of flexibility and I still do.

Caroline: A lot of the time, I actually have another clinician that works for me. And so when I'm at home working on billing or in our other office working on billing and client accounts, she's seeing patients. So the life balance continues to be great. This morning, I got up early and did some work on my computer and then I took my dogs for a two-hour hike and now I get to do this.

Kadie: Wow.

Caroline: Yeah. And I think one of the things that's helped a lot is I'm a pretty disciplined person. So I can structure my days so that I have that free time, but I also make sure I get done what needs to happen for that day.

Kadie: Right. And what about evals? You mentioned there's always so much work for every new child's intake. Does it ever take you by surprise if you're on your two-hour hike and you have to let a call go to voicemail? How do you balance that component?

Caroline: Yeah. It definitely happens where I always have my cell phone with me because a client might call or the other clinician who works for me might have a question. So I have caller ID, which is good so I know what calls to pick up and what ones can wait. Yes. There are certainly times where I'm on a hike and I can see a phone call coming in and I'm pretty sure it's either a physician wanting to make a referral or a new patient. As much as I want to answer that phone call when I'm on the hike, I'll just stop myself and say, you know what, it's going to be there in an hour when I'm done. And so yeah, a lot of the times I'll finish my hike and jump right in my car and return that call.

Kadie: Now do you all have a brick-and-mortar location or do you still go to homes?

Caroline: Oh, no. We've had an office for quite a few years. Probably, gosh, maybe my private practice now is going on 18 years. So I would say probably the last 12, 13 years we've had, maybe longer. I was only going to people's homes for maybe three years. So yeah, so 15 years we've had a building and we have two offices and so I work in one and then my other clinician, and at times I've had two clinicians, but right now that second person is on maternity leave. So just myself and one other.

Caroline: The great thing about our office is right down the hall is a learning specialist. So she sees a variety of kids with learning disabilities. So we share a lot of the same clients. I've started to work on reading and this learning specialist right down the hall is Orton-Gillingham certified. So she's just been a fabulous resource.

Kadie: Oh, that's so nice to be able to refer back and forth and have that connection.

Caroline: Yes, it's been great. And now I'm starting to pair up with an OT in town that I've known for years and we've just been referring to each other. And over the last few months I've been talking and just saying like, hey, we refer to each other all the time. We have so many of the same clients. Should we kind of do some sort of co-op and work together a little more closely? So that's something that might be in the future. And she's got a great OT gym and all these fun things that would be just awesome for a lot of the kids that I work with.

Kadie: Yes. And what age range do you specialize in?

Caroline: We only see kids and most of our kids, I would say, are between two and ten. Actually, we have a ton of preschoolers. We get just a lot. But I do right now have a 15-year-old on my caseload that we're working on social language. And then I also have a 25-year-old that I've known for a long time. He's a person with high-functioning autism. And I've known him for a while and now we're working on some interview skills as he's trying to get a job.

Kadie: That's great.

Caroline: Yeah, it's really fun. And like I said, we really specialize just in kids. But occasionally we'll get an adult or an older teenager.

Kadie: What would you say through the years has been your best referral source?

Caroline: I would say it's certainly parents. So word of mouth, parents has just been huge. The place I live, well, when we moved here, there was only 40,000 people. And now we're up to 100,000.

Kadie: Oh, wow.

Caroline: Yeah, it's just kind of exploding here. But it was definitely a small town when I first got here. And so that word of mouth was just huge. There's only one pediatrician group in town. And so I got a few from them, but really most of my referrals were from other families that had worked with me or were working with me. Now I'd say, I think it would probably mostly be parents, but I have a really great relationship with all the pediatricians in town. And so I get a ton of referrals from them, which has just been great. And yeah, that's a big piece of what I do because I know that we exclusively work with kids and we've been here a long time. We have a really good reputation in town. And so they send most of their patients over to us, which has been great.

Kadie: Would you say your office is like a storefront where people see the name, or is it kind of a hidden office?

Caroline: Yeah, it's definitely hidden. It's not like a storefront look at all. Actually, our office looks like it was built right when we moved into it. And so there's only four office suites and it looks like a house. So it's kind of centrally located in our town, but it looks like a house. And it's funny because a lot of the kids will think that we live there. Like they always say, yeah, we're asleep. In this one room.

Kadie: Exactly.

Caroline: Yeah. So it's great because I feel like it doesn't have that image of like a clinic or hospital. It just feels really homey in there.

Kadie: Yeah. That's actually a positive for a lot of reasons.

Caroline: Yes. Yes. But yeah, you wouldn't be walking down the street and see a sign.

Kadie: Right. Right. I see. Are there a lot of competition in the area for speech pathology providers?

Caroline: I would say yes. When I first came here, it was myself, one very small little clinic, and then just one other woman, speech pathologist, who was working out of her house like a couple days a week.

Kadie: Wow.

Caroline: And since then, we have, I mean, as the population here has exploded, the amount of speech therapy providers privately has also. So yeah, there's a lot of competition, definitely.

Kadie: Yeah. But it sounds like the area is so large at this point that there's enough to go around, hopefully.

Caroline: Yeah. Yeah. Well, I know that we all support each other, and when I can't fit somebody in my schedule because we're booked and they don't want to be on the waiting list, or even when I do put them on the waiting list, I give them the names of other private therapy practitioners so that they can get in. And I do that for the client, of course, because I want them to get into therapy as quickly as possible, and then also just to support the other private practice clinicians in town, because I feel like it's important to support each other.

Caroline: And there's a couple of private speech therapists in town that we call each other or text each other on a regular basis and ask questions about billing or tests, just to give each other that support and be a resource for each other.

Kadie: Yes, absolutely. I have not asked a podcast guest in a while about the process of having an employee, and everyone approaches it in a couple different ways. So how have you hired on, and what kind of employee is she or he?

Caroline: Yeah. So I've been really lucky with hiring and having an employee. So the first employee I hired, it took me forever. I was just, well, I still am super picky. And so the first employee, that was when I was still going house to house or going to people's homes.

Caroline: So I started her as a subcontractor because she had all her own materials. I basically just, she had all her business stuff set up, and I would just give her a client and just say, this is your client, and then, of course, I would take a cut of that, but she would kind of make the majority of that.

Caroline: And then I had her on as a subcontractor not for very long because shortly after that is when I moved into an office space, and so the minute that happened, I knew I had to switch her from subcontractor to employee because she was going to be using all my materials. I was going to be doing her schedule, so clearly, she didn't fall under the guidelines for a subcontractor, so I switched her to employee.

Caroline: And that went really easy. I just, I use QuickBooks, and I use QuickBooks Payroll, and it kind of walks you right through it. I also worked with my accountant just to make sure I was doing everything correctly. I set up an at-will employee contract with her. We had that all in writing. So yeah, it was really easy, and she worked for me for 11 years, almost 12 years.

Kadie: Wow.

Caroline: Yeah, and then I also, during that time, had hired another clinician. That's the one that went on maternity leave, so she was with me for a while as well. But when the therapist who was with me for almost 12 years left, she decided just to be at home, full-time mom with her kids. And then I hired somebody else about a year ago who was fabulous and, of course, have her set up as an employee as well.

Caroline: But it was interesting. I didn't anticipate the kind of anxiety that it brought up with so many of my patients just telling them that this clinician that they had gotten to know really well and work with was going to leave to be home with her kids, and they were going to have a new clinician. And it was just surprising to me the amount of anxiety that parents felt about that.

Kadie: Yes, you'd think that they would understand that if you're hiring them, you must really trust them and like them, but I do think it's hard for them to make those changes sometimes.

Caroline: Yeah, but the good news is that the minute they started working with this new hire, and she's just amazing, and I had about nine months. My last employee gave me a nine-month notice, so I had a ton of time to find her.

Kadie: Oh, wow.

Caroline: Yeah. Yeah, so she's just fabulous, and all the parents who were really anxious about the change would send me emails, oh, my gosh, this is so great. She's just as good as the last person, and I have to say, see, I told you.

Kadie: Right, right. Well, that is a relief, I'm sure. Is there anything that is on your mind that you would like to share as just the best part of private practice or even maybe a worse part? What are your thoughts?

Caroline: Yeah, so definitely, well, I have two best parts. The first would be the flexibility. That's certainly one of the parts I really love the most. The other part I really love about private practice is the amount of improvement I can see in the kids that I work with, and their progress is just incredible because I get to see them one-on-one. I get to provide parents with carryover activities to work on at home. So that's what I really love is just seeing the amount of progress. I worked for a county program in early intervention, and it was just a little more difficult because we would see kids in groups, and the follow-up was a little more tricky. So I love those two pieces.

Caroline: The things that I don't like about private practice is I'm always working. I'm always having to answer the phone, even on vacation. I'm always having to be going at night, vacation, weekends, everything. So that's the trade-off with the flexibility piece.

Caroline: And then insurance, I can't stand working with insurance. How many do I accept? Let's see. I accept, I think, the five major ones around here. There's only two that some people have in our area that I don't accept just because they're really horrendous to work with. But I accept most insurance companies in our area. I also accept Medicaid, which is really hard for me. The reimbursement is absolutely horrendous. I mean, so that's very frustrating. And then just working with the state Medicaid program can be incredibly challenging.

Caroline: So when I kind of look at things, pencil things out, it doesn't pencil out. But I get to see a lot of kids that they wouldn't be able to access that service if I didn't bill Medicaid. It's so frustrating because you want to see them.

Kadie: I know you want to help them and see that progress. But it is hard. It is hard.

Caroline: Yeah. Yeah, it is hard. But I've also had some, like I said, it allows these kids to get private services. And recently, I started working with some Spanish-speaking families, which I love. And so that's been a great opportunity as well.

Kadie: Well, I just appreciate you taking the time to tell me about your successful business. And you have a lot of years under your belt running this by yourself. So it's obviously working.

Caroline: Yeah. Yeah, it's been great.

Kadie: Well, it was really fun to chat with you. I appreciate you having me on.

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.