Building an Interventional Psychiatry Practice: 8 Strategic Decisions

When you're building a practice around interventional psychiatry – TMS, SPRAVATO®, ketamine – eight strategic decisions shape everything downstream. 

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The 8 decisions at a glance

1. Wedge or service line? Whether interventional is your whole practice or an addition changes every decision below.
2. Which modality first? Capital, cash flow timing, and patient flow point most new practices toward TMS or cash-pay ketamine — then layering the rest.
3. How much runway? 12+ months of personal financial runway, plus a bridge income strategy, because leases and payer negotiations run long.
4. Sequence the pre-launch work. Every week of credentialing done while still employed is a week you don't burn runway.
5. EHR selection. Every day that passes using an EHR you regret makes it harder to fix
6. In-house or outsourced? Outsource billing, credentialing, marketing, and accounting to interventional specialists; keep clinical care in-house.
7. Build the pipeline before you open. Word-of-mouth and referral relationships take months to develop — start before the device arrives.
8. Design for scale from day one. Make every foundational decision as if you'll have 5 providers and 2 locations in 5 years.

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These questions ran through a recent Psychiatry Collective roundtable hosted by Dr. Brittany Albright (Founder and Medical Director of Sweetgrass Psychiatry) and Dr. Will Sauvé (CMO of Osmind). The clinicians in the room had arrived at interventional psychiatry from different directions – some built interventional-first, others layered it onto established general psychiatry. Below you’ll find a summary of hard-earned learnings from solo providers to interventional practices who’ve scaled to multiple states.

Why do you want to offer interventional treatments? 

First, know your ‘why.’ You've seen what these treatments can do for patients, and now you're figuring out how to build the foundations to offer them. That's what this guide is for. You can build a cash-pay ketamine-only clinic, or scale with insurance-backed treatments like Spravato and TMS.

Jake Carrico, who grew Stella from one Jacksonville clinic into a multi-state platform, frames it as the difference between a job you own and an asset you can grow and sell, and the two call for opposite choices on insurance, infrastructure, and staffing.
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‍Should interventional be your wedge, or a service line you add later?

When ketamine, Spravato, or TMS is your only offering, you make different calls about location, marketing, EHR, and staffing than when it's an addition to an established general psychiatry patient base.

The roundtable spanned both paths. David, a child/adolescent and adult psychiatrist, relocated from the Bay Area to launch an interventional practice from scratch in Louisville. 

Mary, a rural Virginia PMHNP, took the other route: she built a general practice around perinatal psychiatry first, then added TMS and Spravato and is now exploring VNS, all within her first three years. 

For an interventional-first launch, patient acquisition has to target people seeking these modalities specifically, but many patients don’t know to google ‘TMS’ for example, until they’ve tried other options.

Jake advises in most cases to build a medication-management panel first, add Spravato second (it rides Janssen's direct-to-consumer awareness and converts from your internal panel), then add TMS once that panel exists to fill the chair, and treat cash-pay ketamine as optionality you layer in whenever. 

In Jake’s experience, practices that go straight to interventional and skip medication management struggle to fill chairs. That doesn't mean interventional-first can't work—David is building exactly that in Louisville. But an interventional-first launch has to solve patient acquisition the hard way. Having an existing panel does a lot of referral work.

The decision principle: Interventional-first practices are higher-capital, higher-risk, but often higher-reward. They require more pre-launch planning than adding a modality to an existing base. Neither path is automatically right, but they're genuinely different decisions, and the rest of this post flags where they diverge. If you’re set on adding a specific modality, our TMS guide and Spravato guide show you the playbooks.

Which interventionoal modality should you launch with, and in what order do you add others?

The roundtable participants were running two to four modalities each. None launched with all of them at once. Three factors drive the sequencing.

Capital intensity. TMS devices range from $50,000 to $180,000 upfront, though subscription models like Ampa now run roughly $3,000/month. Spravato has lower upfront capital but ongoing REMS, storage, and inventory complexity. Cash-pay ketamine has the lowest infrastructure barrier. 

Cash flow timing. Cash-pay ketamine generates revenue quickly. Insurance-billed TMS and Spravato take months to credential, run prior authorizations, and collect. New practices under runway pressure often start with whatever converts to revenue fastest.

Patient flow. Patients who come in for one modality often need another. 

Jake Carrico points to a natural pull from cash-pay ketamine toward Spravato: ketamine's cost ceiling and the absence of insurance coverage push patients to ask for the insurance-backed option once they've responded, so a cash ketamine program tends to seed demand for esketamine rather than competing with it.

His reasoning on why TMS comes later: You're going to have a hard time marketing yourself into a healthy TMS program unless you have a gen psych panel internally — a recurring engine where you can convert people on medications to TMS.

If you already have a general-psychiatry panel, the size of your in-house opportunity is probably larger than you think. Run the math on a panel of ~5,000: you'd expect at least 3,000 with major depression, and more than half of those are likely two-plus med trials without remission — treatment-resistant by definition. 

That's an esketamine pool of maybe 1,000–1,500 patients who qualify right now. Every one of them deserves an intervention beyond another medication trial. You can refer them out, or you can add the interventions and treat them in-house. 

And because no single intervention works for everyone, each one you offer creates real need for the others — TMS non-responders who may respond to esketamine, ketamine responders who move to insurance-covered Spravato, and so on. The modalities feed each other because none of them is 100%.

The one thing nearly everyone agreed on: the participants who tried to launch multi-modality from day one regretted it. As Jake put it, you can run them simultaneously, you just need to be really clear on what that means: there's additional risk, it's more complex, and you have to staff for it right out of the gate.

How much financial runway do you actually need?

The 2026 market reality is harsh. The Louisville psychiatrist's commercial lease pushed his planned 3–4 month opening to 6–7 months. Dr. Albright's permit process on a real estate acquisition is approaching 18 months. Both have spent months renegotiating payer contracts, with insurers offering rates as low as 59% below Medicare, and many simply ghosting renegotiation requests after Medicaid cuts.

Prior authorization timelines also vary dramatically by region. In South Carolina, insurance credentialing can take six months for new practices, with TMS prior auths running several weeks and frequent doc-to-doc requirements. 

California can be the opposite; many TMS prior auths return within 24 hours. 

Your local payer environment can shift your launch math significantly. Dr. Albright's workaround when patients qualify for multiple treatments: submit prior authorizations for TMS and Spravato simultaneously, then start with whichever clears first.

The bridge income options that held up across the group:

• Keep a W-2 role during credentialing and pre-launch
• Pairing insurance-covered standard protocols with self-pay accelerated treatments.
• ER or locum work; no patient continuity, clean exit when the practice is ready
• A high-paying gig role for a year to build launch capital

The decision principle: Plan for 12+ months of personal financial runway plus a deliberate bridge income strategy. You don’t need to ‘burn the ships’ and jump from your current job before starting your private practice. For a budgeting framework with a downloadable template, see Planning Revenue and Costs for Psychiatry Practices.

How should you sequence pre-launch work before leaving your current job?

Every week of pre-launch work completed while still employed is a week you're not burning runway. Here’s the sequence we recommend:

1. Complete CAQH and standard credentialing while still employed (see our insurance credentialing and CAQH Credentialing Guide)
2. Map every payer portal, including Spravato-specific REMS portals 
3. Identify and contract your collaborating physician early, especially for APRN- or PA-led practices
4. Complete required clinical training: TMS coursework, ketamine training, REMS certification
5. Pre-negotiate equipment financing and any specialty marketing partnerships
6. Select your EHR and schedule onboarding before resignation

The decision principle: Front-load everything that doesn't require an open practice.  Osmind handles EHR, credentialing, and insurance billing for you. See also: Building Your Private Psychiatry Practice (Pt. 1) for foundational setup that applies across psychiatry.

Why is EHR selection one of the most consequential decision for interventional practices?

Your EHR is likely the single most consequential long-term business decision you'll make. For interventional practices, three factors raise the stakes.

Procedure-side workflows are core, not edge cases. TMS session tracking, Spravato REMS automations, ketamine consent flows — these should be built-in features, not bolted on.

Manual reconciliation between documentation and billing breaks down. When 60%+ of your revenue is procedural, a biller pulling from one system and keying into another will quietly leak money.

Dr. Martha Koo—past president of the Clinical TMS Society and an Osmind medical advisor reflects, “Early TMS practices ran single devices and 37.5-minute sessions, with technicians manually swapping coils for bilateral treatments. The workflows have only grown more complex since, and the EHR is what absorbs that growth.”

Switching EHRs at 10 or 30 clinicians costs tens of thousands of dollars and months of disruption.

Documentation, credentialing, and billing belong on the same platform.

Should you hire employees or outsource to specialists?

Everyone on the roundtable agreed you should start lean. The Louisville psychiatrist is up to roughly $40,000 standing up his practice: specialist support across billing, credentialing, marketing, and accounting, plus the website, certification, and deposits that come with it.

You can hire separate specialists or one team, but either way, interventional brings more complexity than general psych practice:

• Billing complexity (90867/68/69 for TMS, G2082/G2083 or S0013 for Spravato, J3490 for ketamine) requires biller familiarity with procedure codes
• Credentialing for interventional procedures is more complex than general E&M credentialing
• Marketing for interventional needs specialists who understand the modalities, not generalists you'll spend months educating

Osmind handles all of this for you.
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There's a continuity argument for outsourcing admin work: if your single in-house biller leaves, your cash flow stops. Outsourced services are more resilient. The goal is to stay agile and avoid building fixed overhead and management layers you don't need.

The decision principle: Keep clinical and patient-facing roles in-house. Outsource billing, credentialing, marketing, web design, and accounting to 1099 specialists or These are specialists who’ve helped hundreds of interventional practices.

How to market an interventional practice?

Once you have your financial and legal foundations and website setup, you’re ready to get patients in the door. The roundtable landed on four channels participants actually used.

Clinical excellence and word-of-mouth. Patients who achieve remission after years of failed medications don't stay quiet. PCPs, therapists, and family members refer at high rates. Strong outcomes plus a clear niche drives growth. 

Boots-on-the-ground referral building. Visiting local PCP offices, joining specialty associations, building therapist relationships. Most PCPs and therapists don't know what interventional psychiatry is and why they’d refer someone to you. Read our guide: How to build a psychiatry referral network that works.

Specialty marketing firms that understand interventional. Rise4 was named by multiple participants; it grew out of a TMS clinic operator group in Texas and now markets TMS, Spravato, and ketamine specifically. The warning that came up repeatedly: don't hire a generalist marketing firm, or you'll spend all your time educating them on what you do. For positioning and marketing strategy, see How to Stand Out in a Crowded Market.

Compliance infrastructure as a prerequisite. ADA website accessibility is required to avoid lawsuit risk. Google and Meta require medical advertising certification (roughly $2,500) before they'll let you run healthcare ads. The Louisville psychiatrist's total compliant website build landed around $7,500.

The decision principle: Build your website and start marketing early. Pipeline building takes months, and the highest-leverage channels (word-of-mouth, referral relationships) are the slowest to compound. Read: 10 strategies on how to get more patients.

How to prepare to offer future psychedelic-assisted treatments, once FDA-approved?

Psychedelic-assisted therapies in late-stage FDA trials,  including COMP360 psilocybin for treatment-resistant depression—which Osmind is collaborating with Compass Pathways on to inform real-world delivery in independent practices—will arrive with REMS programs, monitoring requirements, and billing complexity that build on what's already in place for Spravato.

Practices that build infrastructure for current interventional modalities are positioned to add the next wave with less lift. To get priority access to resources as they come, take the psychedelic readiness survey.

The decision principle: Make every foundational decision as if you'll have 5 providers and 2 locations in 5 years, even if you're solo at launch. 

See The Clinical Entrepreneur Psychiatry Guide for first-hand accounts from clinicians who scaled their practices and How to Thrive in Private Psychiatry.

Where to find continual support in building your interventional psychiatry practice

Dr. Albright's closing framing was to be intentional, plan carefully, stay in learning mode, and expect failures alongside successes. The Louisville psychiatrist's story of leases and payer negotiations dragging months past plan is, unfortunately, the norm rather than the exception. 

The operators who came through it best treated the launch like a funded project with a runway and a plan, not something to bootstrap on the side while seeing a full patient load.

Conversations like this happen regularly inside the Psychiatry Collective, where clinicians from residency to multi-location group practices share what's actually working in interventional psychiatry. Join the Collective to access live events, the full recording library, and direct conversations with operators at every stage.

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