From Handoff to Home Health Empire: Malia Vigil on Taking Over a Practice Without a Playbook

"If you're serious, I really need to start thinking about it."

That was the early morning phone call that changed everything for Malia Vigil. The SLP she'd been contracting with was burning out, and Malia had half-jokingly offered to take over. Turns out, both of them knew it wasn't really a joke. Within months, Malia was navigating Medicaid enrollment, managed care contracts, NPI transfers, and credentialing for seven therapists she'd just inherited, all while carrying her own full caseload.

Her practice, We Need to Talk and More, LLC, is a home health pediatric therapy agency in Albuquerque, New Mexico. And her story is a masterclass in what happens when opportunity shows up before you feel ready.

You Don't Always Start from Scratch

Most private practice stories begin the same way: someone quits their day job, files the LLC, and starts seeing two or three clients on the side. Malia's path was different. She inherited an established home health agency with PT, OT, and speech therapy services already running. Three occupational therapists and four SLPs, all independent contractors, came along with it.

That sounds like a head start. And it was, in the sense that she had clients from day one. But taking over an existing practice doesn't mean you skip the hard parts. Malia still had to build her business from the ground up: new managed care organization contracts, new Medicaid enrollment, new NPI, new credentialing for every single therapist under her agency. The clients were waiting, but the paperwork didn't care.

"It was starting from square one with everything. It's lucky that you had clients, but when they're waiting and you're trying to rush these things through, I'm sure that was stressful."

Her husband sat down with her and the outgoing owner's husband in late 2017 to map out the transition. By early 2018, she was deep in the credentialing process. And here's what made it work: the outgoing agency kept billing and seeing clients until Malia's infrastructure was fully in place. No gap in care. No panicked families.

The Credentialing Bottleneck Nobody Warns You About

If you've never dealt with insurance credentialing for independent contractors, here's the reality: it takes a minimum of six weeks on the fast end, and Malia has heard other practice owners report timelines of six to nine months. That's six to nine months before a new therapist can see insured clients and get paid.

Some therapists simply can't wait that long for a paycheck. And Malia gets it. But she doesn't know any way around it. She does all the credentialing paperwork herself, and the more she does it, the more efficient she gets. Still, it's one of the biggest barriers to growth for her agency. She's been desperately trying to find another OT, and they're nearly impossible to recruit in her market.

The wait lists in Albuquerque tell the story. Every practice has one. Some have stopped taking names entirely because they can't give families any realistic timeline for when services might start. It's a supply problem, not a demand one.

Paying Therapists When Insurance Won't Pay You

Running a practice built on independent contractors means Malia's cash flow depends on insurance reimbursements, and those don't always come on time. She learned that the hard way.

One insurance company updated their software at the start of the year and simply stopped paying for three months. Malia had been covering her therapists out of pocket the whole time. When her reserves started running low, she had to have the conversation nobody wants to have: "I've done this three months. My reserves are getting low, and I just can't continue unless they figure it out."

She also took a $2,500 hit on a recoupment after paying a therapist for services that insurance later clawed back. She calls it an expensive lesson. She'd already paid the therapist, so the loss was entirely hers.

"That was the only one where we've kind of had to take a hold on until we can figure things out, or you can continue to see them, but I can't pay you until I get paid."

Her advice is practical: start with a financial cushion, and don't pretend the money will always flow smoothly. One of her billing insurances pays quickly enough to create a buffer. That buffer has saved her more than once.

Paper Calendars, Excel Spreadsheets, and 84 Days Left

Malia's operation runs on Excel spreadsheets her biller set up, paper soap notes turned in monthly, and a paper calendar she still keeps by hand. Her daughter helps with admin, tracking unit balances on spreadsheets so therapists can see how many authorized units remain. Therapists turn in their soap notes, billing, and invoices by the fifth of the month to get paid on schedule.

She hasn't invested in an EMR system yet. Things have been rolling well enough without one, she says, but she recognizes the need is growing. As the practice scales and she prepares to open a brick-and-mortar clinic in November 2019, the paper-and-spreadsheet approach has a ceiling.

And here's the timeline that puts it all in perspective: at the time of recording, Malia had 84 days until she could retire from the school district. Not that she was counting. After years of balancing school contracts (homebound medically fragile kids, assistive technology, deaf and hard of hearing populations) with building her private practice through 16-hour days and long weekends, the finish line was finally in sight.

Find Your One Person and Stop Scrolling

Malia's advice for new practice owners isn't about business plans or therapy documentation software. It's about people.

Find one person you trust. Not a Facebook group with thousands of opinions that send you into a spiral of "I don't do that, should I be doing that?" Find one colleague who isn't your competitor, who you can text at odd hours, who will research a question and come back with a real answer.

For Malia, that's a fellow practice owner in Santa Fe. They share questions, compare notes, and keep each other grounded when social media makes everything feel like a crisis.

"If you can find just a small, close group of people that you can trust and ask and then make your decisions based on that."

She set expectations with her contractors early, too. A PowerPoint presentation at onboarding. Clear boundaries. Written rules they can always reference. And when problems come up, she handles them one issue at a time. No drama. Just business.

Running a growing home health practice on spreadsheets and paper files works, until it doesn't. ClinicNote is a HIPAA-compliant EMR built for private practices and university clinics, handling documentation, scheduling, and billing in one place so you can focus on the families who need you. See how ClinicNote works.

Transcript

Kadie: You are listening to Clinic Chats, the speech therapist's 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 on the podcast, I am joined by Malia Vigil, the owner of We Need to Talk and More, LLC. Hi, Malia. How are you?

Malia: Good morning. I'm good. Thank you.

Kadie: I was just taking a quick look at your practice website, and I'm excited to learn a little bit more about the speech language pathology as well as the OT aspect that you have created in your practice. So before we dive into what the practice is today, can I get a quick background about your experience and how you came to wanting to go into private practice?

Malia: I started way back, way back in the day, and I'd always been really interested in the medical setting. And we had figured out that that just wasn't going to work for our little family. So I jumped into the schools as an independent contractor. So that started my experience of independent contracting. And I always, in one way or another, maintained that independent contracting.

Malia: After that first year in the schools, it was great. I learned a lot, but it wasn't exactly what I wanted. So I was a contractor. So I got booted by the gal who I had taken her place because she was on maternity leave. So I went back to square one and I was able to piece together part-time school and a part-time clinic position. At the time, we lived about 30 miles south in this little village. And during that time, you actually looked in the newspaper for jobs. And I was lucky enough to find one at the clinic. And that's where I really started to like the clinic work.

Malia: And then fast forward many years, I was working with a woman that I was contracting with and life had thrown her some curve balls. And she was like, I don't know how much longer I can keep this up. And I said, well, when you're ready, I'll just jump in and take over for you. You know, just kind of joking. But I think we both kind of looked at each other and went, you know, that might work. And a little while later, I got a very early morning call. And she said, if you're serious, I really need to start thinking about it. And that was the start of it.

Kadie: Wow. And so did she have a fully established brick and mortar practice? Or what did her model that you took over look like?

Malia: So she has, it was always home health, home therapy with pediatrics. And she had PT, OT and speech. And so she did not have, and still does not have a brick and mortar. So I was lucky. I started my practice with a base clientele and have been able to add and grow since that time.

Kadie: Yes. And did she have multiple contractors that you kind of took on at that time?

Malia: Yes. I assumed three occupational therapists and four SLPs.

Kadie: Nice. And then since that time, I've been desperately trying to find another occupational therapist, but those guys are like, they're hard to find. And I've added four more speech and language pathologists.

Malia: Wow. So you've definitely had some growth as well.

Kadie: Yes, we are. We are growing. We are definitely growing.

Kadie: And what's the timeline? When did you end up taking over?

Malia: November of 2019 will mark when I started billing for all of the therapists one year. My husband and myself and her husband sat down in, I think, like November, December 2017 and just looked at what it was all going to take to start transitioning. And then in the beginning of 2018, I started with getting all of the managed care organization contracts and shifting over to the NPI too and the Medicaid enrollment for my business and all of the business. And then when all of that was in place I started with the credentialing of all the therapists underneath my business and the contract.

Kadie: Wow. So even though the caseload was established, you still went through the entire sort of business organization processes.

Malia: Yes. It was starting from square one with everything.

Kadie: It's lucky that you had clients, but when they're waiting and you're trying to rush these things through, I'm sure that was stressful.

Malia: It was. And it actually went really smoothly because they continued to see the clients underneath the first agency until we were really ready just to assume all of the billing under mine. And I had everything. It, as nerve wracking as it was, it went really smoothly.

Kadie: Yeah. And to kind of have a mentor in these clients that everyone was familiar with their insurance. And, you know, I'm sure you got some assistance, which is really ideal.

Malia: Oh, I still, she's a physical therapist actually. And so I still see her often and I still pick her brain and shoot out panic texts and have long conversations. She has been, I have really been lucky. She has been unbelievably helpful.

Kadie: That is so great. And you mentioned your husband was involved on some of this.

Malia: If I would release some control, I think he would be a lot more involved. But it's just been such a whirlwind that I've really been primarily the one driving the bus. And now that I think I have a pretty good hold on things, we're starting to work together because it's just been some really long nights and weekends. And he does all of my IT. He is my computer guy. He does help quite a bit.

Kadie: That is so nice. It really is. Do you still do strictly home health or home visits?

Malia: Yes. And we are going to be opening a clinic in November.

Kadie: Oh, wow. And have you been handling all of the scheduling, billing, or do you have someone else's help with these things?

Malia: All of my therapists are independent contractors. So I do all of the intake. And then once the clients are ready to go, I let the clients know that whatever therapist will be contacting them and then all of the therapists make their own schedules.

Kadie: Oh, that's a great way to do it. So here you go. Here's the client.

Malia: Exactly. It works out really well. I kind of love that you're just saying, I have your therapist. You all can work this out.

Kadie: Yeah, I do all the groundwork at the beginning and then they get going and I let the families know, you know, anytime you have any questions about the insurance or anything like that, that I am the person to go to. So the therapists, I've hopefully taken that burden off of them and they can just go in and do the therapy.

Malia: Right.

Kadie: The billing, my biller is the same biller that the other agency used. So that also was a really nice, smooth transition. She really had already her database set up for most of those clients' information. So that was really easy as well.

Kadie: Oh, that's so nice. Do therapists turn in daily soap notes, reports, all of that to you in a certain manner? Or are they responsible for keeping records?

Malia: My daughter also helps me. She has been working for therapists, other therapists forever. And so she actually has a lot of the administrative knowledge. And she sets up an Excel spreadsheet with the unit balance. And she keeps track of that for the clients or for the therapists. So they can pull up in their folder how many units they have left. And at the end of the month, everybody turns in their soap notes and their billing and their invoice. If they turn it in by the fifth of the month, then I pay by a certain date. And any time after that, it's like 15 days after they turn it in.

Kadie: Oh, okay. Yeah. That's a little bit unique. So really the therapists turn it into you monthly. And so are you then billing clients monthly?

Malia: We bill, I turn in all of my Excel spreadsheets that the biller set up. So as my therapists turn in their invoices, I fill out the Excel spreadsheets that the biller set up for me. And then I turn them into her and she does the billing.

Kadie: Oh, that's kind of nice to only have to come back to it one time a month. I'm sure it's a lengthy process at that point, but at least it's not on your mind every day or every week.

Malia: The first week of the month is a little busy because I also have to finish all my therapy notes and things like that. I try to follow the same rules that I have established for my therapists so that it keeps me up, all my notes and reports and things like that up to date as well, because I have had a tendency in the past to be a little lazy on that. So I try to follow the same rules.

Kadie: Yeah, there you go. And I hope you don't mind me asking, but I imagine some other therapists would be interested as well. Whenever you took over the established practice, was this something like a favor for her because she was just done or was this an investment?

Malia: There was no investment when the agency traded hands. So the one that I took over from has the biggest heart in the world. I think she would continue. And I know she continues to see clients without pay when the insurance has lapsed or something has happened just because she's just not going to let kids go without services. I think it was really weighing heavy on her mind that who was going to see these kids if she didn't have anyone to pass them off to. So it worked out really well that she had somebody to continue to see the kids and the continuity of care was maintained.

Kadie: Yeah. I could see that that's probably the way a situation like that would typically go. I can't speak to experience that I've ever heard of someone actually having to purchase a practice. I'm not sure if that is something that happens or not, really.

Malia: I have seen questions like that pop up on some of the Facebook groups, and I guess I don't really know how that would work either. The kids have to be seen someplace. So they're going to go somewhere to get services no matter what. I think maybe if you have a brick and mortar, that might be a little bit different.

Kadie: True. Yes, that's a good point. And do you all do much advertising at this point or has it just organically grown?

Malia: It has organically grown through size and word of mouth. Once there's a new kid in town, boy, the word spreads quickly because we have such, everybody has wait lists. And, you know, I'm not even sure that I can call it a wait list anymore because I can't give families an indication of when or how long they're going to be waiting, when they're going to get services or how long they're going to be waiting.

Kadie: Oh, wow.

Malia: It's just, yeah, everyone in, there's not too many practices in our city that don't have wait lists. And some people are just not even taking names anymore.

Kadie: Oh, my goodness. Yeah, that's hard for families. But, I mean, good that you have clientele.

Malia: It is. Yeah, it's good for us. And, you know, it's hard because sometimes it's hard to say no and you end up working late long hours. So really finding therapists has been the bigger challenge, not finding clients.

Kadie: Yes. Finding therapists, especially OTs. If there are any OTs out there...

Malia: And the other, you know, the credentialing piece is hard. It takes so long to get the therapist credentialed that some of them just can't wait that long. And I don't know, that's another thing. I'm not sure how other people are doing it. But to get somebody credentialed is a pretty lengthy process. And I've got a couple therapists right now that we're still waiting for the Blue Shield credentialing. And there's another, Presbyterian here in our state, that has a little bit faster, but some of the people, when you tell them how long it's going to take before they get a paycheck, just can't wait that long.

Kadie: Right. But I don't know any other way around it. You kind of have to do it.

Malia: Do you do all that paperwork yourself or hire out for credentialing?

Kadie: I do it all myself.

Malia: Oh, that's a big process. That's for sure.

Kadie: It is. And the more you do it, it gets a little bit easier each time.

Kadie: Yeah. What has the timeline been like for getting one independent contractor through each insurance that you take? What do you think that is from start to finish?

Malia: I would say that the quickest that we've gotten it done is six weeks.

Kadie: Okay. That's not awful, but yeah, some people just can't wait. It's not, it has, and I've heard other people, again, on the Facebook groups, that will say, you know, I tell the therapist three to six months and some are saying six to nine months. And, you know, I just don't know how people can wait that long. And then I see people, you know, things like, well, we billed underneath our NPI, and I've called ASHA and they said, oh no, never do that. So I'm not, I just try to do the best I can with the research that I have and make the decisions that I'm most comfortable with.

Kadie: Exactly. And some of the paperwork for new clients, I'm sure, was also inherited from the previous establishment. What does the intake process look like for a new client as far as paperwork?

Malia: We have a case history form, a permission to eval and treat, the HIPAA privacy, an attendance policy, and if they're private pay or insurance, a financial responsibility.

Kadie: Is all of this sent online or do the therapists all take these hard copies?

Malia: The families can download them from the website. Or the therapist will take them out to the families.

Kadie: Yes, that's extensive. And so do you have this office with all of the hard copies and file folders in your home?

Malia: Yes, I do. I do.

Kadie: Well, that'll be nice in November. You can switch it over to the office.

Malia: Yes, it will. We're trying to be as paperless as possible, but I haven't really found a foolproof way to do that.

Kadie: Right, right. Have you invested in an EMR system or just not quite in the budget yet?

Malia: I have not yet. It is something that I have looked at. But things have been rolling pretty well the way they are. As we're growing, I do think that that will be a need in the future.

Kadie: Yeah, it's hard to make that transition. And maybe you're the same. I do like things in my hand. So I can see that that's hard when you don't have those files to kind of weed through.

Malia: I do. I still keep a paper calendar. I am kind of old school. I do a lot. I keep lots of notebooks and I write myself lots of actual notes on paper and lists on paper.

Kadie: I'm with you. I agree. It's nice to get it down where you can tangibly hold it.

Malia: Yes.

Kadie: Over the years, I know the private practice ownership is relatively new, but it's interesting that you have two perspectives, being an independent contractor and an owner now. What do you think would be good advice for those who are ready to hire independent contractors?

Malia: I have always just maintained a friendly relationship with all the therapists. I've established the boundaries. When I took over, we had a meeting and I had a PowerPoint that we went through and it had what I was going to do for them and what my expectations were from them. And kind of set the ground rules right when we get started.

Malia: When I hire on a new independent contractor, I send them that PowerPoint so that they can go through it. Everything is clear on what the expectations are so that we can always go back to, well, if I have questions, I can say, well, remember, I explained that in the PowerPoint. When we first hired on, I have at least, it's like a little, I guess, mini training onboarding. There's questions they've been addressed in the beginning. And if something else comes up, then we just take it one issue at a time.

Malia: The biggest thing that we've come across is insurances and not getting paid and then having to work that out with the therapist with, all right, I've kind of, not kind of, I have paid three months and not gotten reimbursed. So now we need to, if you want to continue to see the client, I can't pay you until I get paid.

Kadie: Yeah. Have they been understanding in those situations or does it often lead to an unfortunate discharge of a client?

Malia: They are very understanding. And we have had to have one instance actually in the year, just one instance of a discharge of a client, or just wait until things are figured out. And the family was very, very understanding, but it was a pricey learning experience on my side.

Malia: And so I had to kind of pull back and just tell the therapist, I can't continue to pay you and I'm not getting paid. And I had a $2,500 recoupment. And I, again, I took that one as an expensive lesson because I had already paid the therapist all that.

Kadie: Oh man. Yeah.

Malia: So that was the only one where we've kind of had to take a hold on until we can figure things out, or you can continue to see them, but I can't pay you until I get paid.

Kadie: I imagine that is quite a challenge, making sure you have the reserves to always pay your employees. And then at some point having to say this doesn't make sense anymore.

Malia: One of the insurances here pays pretty quickly. So I always have a little bit of a cushion and I was able to start with a little bit of a cushion, which was really helpful because that was my biggest fear of not being able to pay the therapist. I was never going to be in that situation.

Malia: So I was lucky to have a little bit of a cushion because at the beginning of this year, there was a glitch with the one insurance that does pay quickly and they had updated their software and we didn't get paid for three months. At that point, I had to tell the therapists, okay, you guys, I've done this three months. My reserves are getting low and I just can't continue on unless they figure it out. Well, then they figured it out. I got paid for those three months. It all seems to be figured out now, but that has been one of the scariest things is being able to pay the therapists. And then if I don't get paid for that month, you know, we're already two weeks into the next month and trying to figure out why that was a non-payment and how do we fix that before going forward and continuing to see that client.

Kadie: Oh yeah, exactly. And have you still maintained a full caseload? Are you juggling a few clients?

Malia: I have a full caseload.

Kadie: Oh, wow.

Malia: Yeah. I misjudged. So I have been in the schools in some capacity this whole time. So I am now three days out of school. And then I do the private kiddos, my private practice, two days a week, plus in the afternoons. And then most of the administrative stuff I do either in the evenings. I do have a block on Friday mornings where I try to do my phone calls and faxing.

Kadie: Are your children grown? How are you doing this?

Malia: They are. We started the business. I was definitely not prepared for the amount of work it was going to take. And my husband was like, oh my gosh, it's like you're in graduate school again. Because it was like 16 hour days and I would get up early, early in the morning. And so those days have kind of, the days have slowed down.

Kadie: Do you see yourself always contracting with the school or do you think that that will slowly go to the wayside?

Malia: I have 84 days until I am done with the schools.

Kadie: Oh, not that you're counting down or anything?

Malia: No, not that I'm counting down. I'll be able to retire officially in July. The great thing about the school district here is it lends a lot of opportunity. I was able to, like I said, I really liked the medical setting. So I was able to do the homebound population, which were the medically fragile kiddos and the communication kiddos. And that's really where my heart is. And then from there, I launched into 11 years of assistive technology. So I've had great experiences. And now I'm at a school for deaf and hard of hearing kids. So I've had great experiences in the schools and I wouldn't have changed it, but I am excited to let that one end and start a new experience.

Kadie: You've definitely gotten a chance to work with some really interesting populations, it sounds like.

Malia: Yeah, I wouldn't change things. It's been crazy, but you know, why not?

Kadie: Yes, really. It's been a lot of fun. It's been, you know, a lot of sleepless nights but there are plenty of kids out there that need our services.

Malia: Right. And is there any tips as far as finding a resource? I know that you've been so lucky to have your previous boss be such a great resource, but how can other people get such great insight?

Kadie: Gosh, you know, I will also say one of the other go-to resources was a gal that I met on one of the Facebook groups and she's in Santa Fe and she's doing a private practice as well. So shout out to my friend, Michelle. And she and I, we're kind of in it together. There's no competition. I ask her questions all the time. She asks me questions all the time.

Kadie: So I think if you can find that one person that you trust and that you feel good bouncing things off of, and you're not in competition with that person. I think, you know, look for that person because the Facebook groups and the social media, you know, they're hard. There's so much information out there. And I have found myself reading those comments in the posts and then panicking, like, I don't do that. Should I be doing that?

Kadie: And so I've had to be real careful with that. And so she and I have been, you know, did you see this? Yeah. What do you think? And then she does her research. I do my research. I go back to my mentors. And so I kind of keep it a small, you know, if you can find just a small close group of people that you can trust and ask and then make your decisions based on that.

Malia: That's really, really great advice. Like you said, whether it's a mentor with experience or if it's someone you're kind of taking the ride with but who's not a competitor, someone you're troubleshooting your ideas with, being open and honest with, I think that is a great idea.

Kadie: That would be my advice. And where did you say you're located? Because we're looking for an OT, right? I got to help you find an OT.

Malia: Yes, yes. I am in Albuquerque, New Mexico.

Kadie: Okay. I don't have any connections there, but maybe our listeners do.

Malia: Well, I hope so. If they do, find me, call me.

Kadie: Well, I appreciate you taking the time to join me and I wish you the best and the success to come.

Malia: Thank you. Thank you.

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.