Earning Potential For Assessment Focused Practitioners?

[NeuroTrope]

I left commercial insurance 5+ years ago and don't miss it one bit. Taking WC isn't perfect, but they pay well enough for assessment work I tolerate the occasional peer-to-peer. In prior states it was much more adversarial and getting psych services was like pulling teeth. Now I have some WC companies calling/begging to see their worker bc they know they need psych and/or assessment to get the case unstuck.

WC in some states like California can pay well. With voluminous records you can rack up bills up to 20k or even higher for one case.

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[PsyDr]

The WC ML fees in my experience are 1.5x-2x clinical rates, but less than straight medico legal work.

The states that do this, are trending towards "capping" rates.

WC in some states like California can pay well. With voluminous records you can rack up bills up to 20k or even higher for one case.

Median is $2k, which would be 400-500 reports per year.

For straight legal, non-WC, $20k is nothing.

 

[NeuroTrope]

Median is $2k, which would be 400-500 reports per year.

Not in California. Study the fee schedule.

For straight legal, non-WC, $20k is nothing.

Not disagreeing with you there. But that's why some practitioners can make 1mm net. Even 1.5mm is possible.

Not sure what we're arguing about anymore. Seems if you're smart and hard-working you can have a very successful assessment-based practice. Even more successful than the illustrious PsyDr seems to realize.

 

[WisNeuro]

California Code of Regulations, Title 8, Section 9795. Reasonable Level of Fees for Medical-Legal Expenses, Follow-up, Supplemental and Comprehensive Medical-Legal Evaluations and Medical-Legal Testimony.

I'll stick with my rates.

 

[AcronymAllergy]

I would agree--there are currently good opportunities for psychologists to make a solid income via a primarily assessment-based practice, both clinically and medico-legally, depending on your area of specialty/practice. It sometimes requires some thinking outside the box, and to maximize earnings, requires some business sense and knowledge of billing principles. The relative objectivity of our methods related to other mental health professionals, combined with a viable amount of research knowledge, provides us a distinct expertise and advantage, at least for the time being.

 

[ThatPsyGuy]

Not in California. Study the fee schedule.

Not disagreeing with you there. But that's why some practitioners can make 1mm net. Even 1.5mm is possible.

Not sure what we're arguing about anymore. Seems if you're smart and hard-working you can have a very successful assessment-based practice. Even more successful than the illustrious PsyDr seems to realize.

Does WC means Workers Compensation? Not going to lie, I started to get a bit lost once you all started using abbreviations.

 

[WisNeuro]

Does WC means Workers Compensation? Not going to lie, I started to get a bit lost once you all started using abbreviations.

Yes, worker's comp. The less well-paying little sibling of civil litigation cases.

 

[PsyDr]

Not in California. Study the fee schedule.

Not disagreeing with you there. But that's why some practitioners can make 1mm net. Even 1.5mm is possible.

Not sure what we're arguing about anymore. Seems if you're smart and hard-working you can have a very successful assessment-based practice. Even more successful than the illustrious PsyDr seems to realize.

I am very well aware of more successful psychologists than myself. I have several mentors among them. I’m playing my own game, not for totally for money.

But I’m also inclined to use basic multiplication when people make claims of using WC to make millions. 2000 work hours per year. But you move the goal post.

* To be very clear: my goal in discussing income is to:
1) get people to ask for a reasonable income relative to effort
2) which raises the overall income potential, including mine

 

[NeuroTrope]

No where did I indicate that WC makes "millions." I personally know about 3-4 small practitioners who do not run "factory" type practices who net at least a million doing a mix of work comp and other types of med legal. A couple of them don't do WC at all (because civil absolutely pays more on average) but there are niches within the WC niche that can be lucrative, which I can personally attest to. That's the potential we're working with. It's good for people to know.

 

[PsyDWannabe]

I know two people who are. But yes they have employees and run a large-scale business.

I certainly know a couple of people who decided to go all in, sacrifice, and scale up their practice. They have solid business sense and are able to bring in millions per year. I also know others who played it more safe and were afraid to scale up to that level, so they stuck with what they knew. They make around the lower end of your range, but they’re not complaining.

 

[PsyDWannabe]

I will add that ultimately, the back and forth is a bummer. My spouse is a physician with full ownership of his private practice, so I have good insight into what that revenue is like. To borrow a phrase from a certain 90s supermodel, he wouldn’t get out of bed for even triple the highest revenue being argued about in here, and he’s the only doc on staff for now. We’re not physicians, and I’m not saying we need to have that earning potential, but damn, the fact that it’s so unlikely for a psychologist to make a kick ass living is depressing. Especially since we literally keep the world sane haha!

Moral of the story: marry rich because it doesn’t look like things will get any better with the steady inflation and stagnant reimbursement rates.

 

[WisNeuro]

I think the real moral of the story is don't go into a primarily clinical practice. I am handily beating my physician spouse on hourly reimbursement.

 

[PsyDWannabe]

I think the real moral of the story is don't go into a primarily clinical practice. I am handily beating my physician spouse on hourly reimbursement.

Yes! We are financially punished for doing clinical work. That’s where not ‘being in it for the money’ gets us. Pivoting into PP and ultimately forensic work is a goal. Never too late to learn new tricks.

 

[NeuroTrope]

I will add that ultimately, the back and forth is a bummer. My spouse is a physician with full ownership of his private practice, so I have good insight into what that revenue is like. To borrow a phrase from a certain 90s supermodel, he wouldn’t get out of bed for even triple the highest revenue being argued about in here, and he’s the only doc on staff for now. We’re not physicians, and I’m not saying we need to have that earning potential, but damn, the fact that it’s so unlikely for a psychologist to make a kick ass living is depressing. Especially since we literally keep the world sane haha!

Moral of the story: marry rich because it doesn’t look like things will get any better with the steady inflation and stagnant reimbursement rates.

Now I'm the one confused...a solo physician PP is netting 6 million a year? (3x the 2 million banter going on here). Guess there always is a bigger fish!

Anyway yeah PP forensic is the last ship standing. And that DOES include work comp forensic. I'll die on that hill.

 

[WisNeuro]

I'm skeptical of any solo PP doc, outside of plastics in a desirable area pulling down 6 mil.

 

[Freud’sMommy]

I think the real moral of the story is don't go into a primarily clinical practice. I am handily beating my physician spouse on hourly reimbursement.

Yup. This might be a hot take, but the value proposition of neuropsychological assessment has always seemed larger in the legal realm compared to most clinical settings. For most neuropsychological disorders, will our cognitive assessments significantly improve final treatment compared to if we hadn't evaluated the patient? On the other hand, our assessment results can make or break a legal case. I think this discrepancy partly explains the earning differential of a forensic vs. clinical case.

 

[PsyDWannabe]

Now I'm the one confused...a solo physician PP is netting 6 million a year? (3x the 2 million banter going on here). Guess there always is a bigger fish!

Anyway yeah PP forensic is the last ship standing. And that DOES include work comp forensic. I'll die on that hill.

Yep, per his speciality which is ‘esteemed’ but also not niche. And there was no small business loan of $1 million from daddy either, this was all self-funded from the ground up. But what gave him the confidence to pull it off was knowing that the revenue was a certainty, so it wasn’t really a gamble. Unfortunately, can’t say the same for us liberal arts folks. It is not hard to achieve that as a PP physician, depending on specialty of course. Doesn’t make us psychologists feel good, but that’s the reality in other fields provided one has the skills, drive, and focus.

 

[PsyDWannabe]

I'm skeptical of any solo PP doc, outside of plastics in a desirable area pulling down 6 mil.

I won’t get specific, but it’s not plastics, it’s mostly but not entirely self-pay, and it’s definitely more than 6M and that’s with just one physician (and a solid team of staff and APs/ mid-levels).

There is so much money to be made out there if we self select ourselves into the right positions, but that’s not even possible in some fields.

 

[WisNeuro]

I won’t get specific, but it’s not plastics, it’s mostly but not entirely self-pay, and it’s definitely more than 6M and that’s with just one physician (and a solid team of staff and APs/ mid-levels).

There is so much money to be made out there if we self select ourselves into the right positions, but that’s not even possible in some fields.

Ah, so nowhere near a solo PP.

 

[WisNeuro]

Yup. This might be a hot take, but the value proposition of neuropsychological assessment has always seemed larger in the legal realm compared to most clinical settings. For most neuropsychological disorders, will our cognitive assessments significantly improve final treatment compared to if we hadn't evaluated the patient? On the other hand, our assessment results can make or break a legal case. I think this discrepancy partly explains the earning differential of a forensic vs. clinical case.

Particularly when people are only hooked in with with primary care, our evaluations definitely improve treatment in many cases. Even when neurology is involved, we often pick up on things that they miss, which changes the treatment and referral stream from that point. We have literature on how neuropsych evals in certain settings is a cost cutting procedure in the long-term. I'd say it's much more important than the legal use of neuropsych, it just doesn't may nearly as well. Also, you can have an open and shut case with nearly incontrovertible evidence, and the case is still up to the whims of the trier of fact. It's just irrelevant, we're not there to win or lose cases.

 

[PsyDWannabe]

Ah, so nowhere near a solo PP.

I don’t know about y’all but I use Solo PP = 1 doc. I also emphasized that multiple times, it was literally spelled out in the first post I made about it. Nothing to hide here lol the facts are what they are, no matter how it makes us feel on the inside.

 

[WisNeuro]

I don’t know about y’all but I use Solo PP = 1 doc. I also emphasized that multiple times, it was literally spelled out in the first post I made about it. Nothing to hide here lol the facts are what they are, no matter how it makes us feel on the inside.

I think most of us are thinking of business terminology, in which sole proprietorship in a business setting means just that, solo. The comments about making 6 million in that setting stand. I have no doubt that a practice of a certain size in certain size, getting x percentage of all of its billing providers, can make multi millions. A solo billing provider, not so much.

 

[PsyDWannabe]

I think most of us are thinking of business terminology, in which sole proprietorship in a business setting means just that, solo. The comments about making 6 million in that setting stand. I have no doubt that a practice of a certain size in certain size, getting x percentage of all of its billing providers, can make multi millions. A solo billing provider, not so much.

I completely agree. Some industries absorb the costs of a whole bunch of support staff better than others. And I swear, I love being a psychologist so I don’t mean to sound so bitter about it, but I am pissed off from time to time about how our earning potential is capped at what I consider to be a very low ceiling. Especially relative to the utility of the service we provide to society.

 

[WisNeuro]

I completely agree. Some industries absorb the costs of a whole bunch of support staff better than others. And I swear, I love being a psychologist so I don’t mean to sound so bitter about it, but I am pissed off from time to time about how our earning potential is capped at what I consider to be a very low ceiling. Especially relative to the utility of the service we provide to society.

That is on psychologists. They refuse to advocate and/or pay someone else to advocate for them. And, when it comes to their disagreements with APA, many psychologists would rather be "right" than effective. As a profession, we're cheap, lazy, and stupid when it comes to these things.

 

[NeuroTrope]

It's all relative. There's finance guys who scoff at 10 million a year. There's billionaires. A neuropsychologist making 2mm a year is doing just fine in my book.

 

[PsyDWannabe]

It's all relative. There's finance guys who scoff at 10 million a year. There's billionaires. A neuropsychologist making 2mm a year is doing just fine in my book.

I agree but that is so far from the norm. An extreme outlier. I’m not saying we should all be millionaires, but we should definitely be compensated more.

 

[PsyDWannabe]

That is on psychologists. They refuse to advocate and/or pay someone else to advocate for them. And, when it comes to their disagreements with APA, many psychologists would rather be "right" than effective. As a profession, we're cheap, lazy, and stupid when it comes to these things.

At the risk of getting too off topic, I think this is the biggest take away from this thread. How do we do this? Actionable steps? For those of us at different stages of our careers?

In the beginning, right after training, we’re just so happy to be getting paid. But eventually reality starts to sink in that we really need to do better in terms of advocating for better compensation, more than we currently are. Insurance companies treat us like crap because they know they can get away with it, and they’ve been getting away with it for decades.

 

[WisNeuro]

At the risk of getting too off topic, I think this is the biggest take away from this thread. How do we do this? Actionable steps? For those of us at different stages of our careers?

In the beginning, right after training, we’re just so happy to be getting paid. But eventually reality starts to sink in that we really need to do better in terms of advocating for better compensation, more than we currently are. Insurance companies treat us like crap because they know they can get away with it, and they’ve been getting away with it for decades.

Getting involved at your state level org is a start. Good place to learn how to advocate and communicate with your state legislative reps. All state psych assns should have legislative committees. Join APA, donate to the advocacy and PAC efforts. Regularly communicate with your state and national reps. Phone calls are great. Personalized emails are ok. If you're really lazy, the least you can do is the pre-prepared form letters.

 

[NeuroTrope]

I agree but that is so far from the norm. An extreme outlier. I’m not saying we should all be millionaires, but we should definitely be compensated more.

FWIW your partner is an extreme outlier too. Survey puts most physicians under 1mm annual...https://www.whitecoatinvestor.com/2022-wci-survey/

Granted most are employees.

 

[PsyDWannabe]

FWIW your partner is an extreme outlier too. Survey puts most physicians under 1mm annual...https://www.whitecoatinvestor.com/2022-wci-survey/

Granted most are employees.

True, but my bigger point is that I wish all the salary stats for us were higher and we really should advocate more vehemently for that. We will never make as much as physicians or some other doctors, but dammit, we can do better than we currently are. And I’m not pointing fingers, I’m frustrated with myself too, because I don’t engage in nearly as much advocacy as I should.

 

[Sanman]

True, but my bigger point is that I wish all the salary stats for us were higher and we really should advocate more vehemently for that. We will never make as much as physicians or some other doctors, but dammit, we can do better than we currently are. And I’m not pointing fingers, I’m frustrated with myself too, because I don’t engage in nearly as much advocacy as I should.

It is not even about laziness. I know plenty of successful psychologists that actively advocate against the field so that they may make a quick buck. This field likes to prey on the younger and less fortunate.

 

[Freud’sMommy]

Particularly when people are only hooked in with with primary care, our evaluations definitely improve treatment in many cases. Even when neurology is involved, we often pick up on things that they miss, which changes the treatment and referral stream from that point. We have literature on how neuropsych evals in certain settings is a cost cutting procedure in the long-term. I'd say it's much more important than the legal use of neuropsych, it just doesn't may nearly as well. Also, you can have an open and shut case with nearly incontrovertible evidence, and the case is still up to the whims of the trier of fact. It's just irrelevant, we're not there to win or lose cases.

That makes sense. Here's a relevant paper that helped with understanding our clinical value.

I get what you're saying about "whims of the trier of fact", and agree we aren't there to win or lose. But in practice we are doing the assessment because the lawyer thinks it could improve her argument (even if it does the opposite), right? That would mean data we provide are generally relevant.

 

[PsyDWannabe]

It is not even about laziness. I know plenty of successful psychologists that actively advocate against the field so that they may make a quick buck. This field likes to prey on the younger and less fortunate.

Come again? how does that even work? Can you please give a concrete example of that? I need to know how to easily spot it, so I can squash it before it germinates. I know I have the irrational core belief that all mental health professionals are good-natured at heart, and mean no harm, and no matter how many times that belief has been violated, I cling to it like I’m on life-support. But this…is just insane. Talk about eating your own.

 

[Sanman]

Come again? how does that even work? Can you please give a concrete example of that? I need to know how to easily spot it, so I can squash it before it germinates. I know I have the irrational core belief that all mental health professionals are good-natured at heart, and mean no harm, and no matter how many times that belief has been violated, I cling to it like I’m on life-support. But this…is just insane. Talk about eating your own.

I know a lot of practice owners and managers that advocate for allowing midlevels to practice in currently protected areas (such as skilled nursing facilities) so that they can hire them for cheap. I mean, they will say it is to better serve an undeserved population. Want it better served? Pay clinicians more.

 

[AcronymAllergy]

That makes sense. Here's a relevant paper that helped with understanding our clinical value.

I get what you're saying about "whims of the trier of fact", and agree we aren't there to win or lose. But in practice we are doing the assessment because the lawyer thinks it could improve her argument (even if it does the opposite), right? That would mean data we provide are generally relevant.

Yes, there are ongoing efforts to evaluate and, ideally, support the clinical utility of neuropsychological evaluation. Also, given neuropsychologist's training intersection of neuropathology, cognition, and psychology, we can often provide insights to the patient and referral source regarding factors either causing or contributing to reported symptoms. We also get to spend a lot longer with patients, on average, than just about every other provider they see, and can be a source of psychoeducation and support for them (and their families and other providers). There's also a lot to be said from the patient perspective for just being able to put a name/diagnosis to something. We may not be able to do anything currently about, say, Alzheimer's disease, but it's helpful for patients (and their families) to know what's going on so they can plan ahead and know what to expect in terms of problems and needed supports down the line (and this is where cost savings can come in). We can also provide some insights in behavioral techniques for managing various symptoms, although I really wish we also had more geropsychologists to be able to help with this on a longer-term perspective.

From a medicolegal standpoint, yes, attorneys likely see value in the services we provide, otherwise they wouldn't pay for them. But like WisNeuro said, the strength of the evaluation doesn't always (or even often) relate to the ultimate judgment. It can be helpful to know this when writing reports and providing testimony. That being said, although we don't monitor or request information relating to outcomes, it stands to reason our work is probably helpful enough of the time for them to continue seeking out the services. From a civil perspective, we can also help in putting numbers to things that are otherwise hard to objectively and reliably measure (e.g., cognitive functioning).

 

[Sanman]

Yes, there are ongoing efforts to evaluate and, ideally, support the clinical utility of neuropsychological evaluation. Also, given neuropsychologist's training intersection of neuropathology, cognition, and psychology, we can often provide insights to the patient and referral source regarding factors either causing or contributing to reported symptoms. We also get to spend a lot longer with patients, on average, than just about every other provider they see, and can be a source of psychoeducation and support for them (and their families and other providers). There's also a lot to be said from the patient perspective for just being able to put a name/diagnosis to something. We may not be able to do anything currently about, say, Alzheimer's disease, but it's helpful for patients (and their families) to know what's going on so they can plan ahead and know what to expect in terms of problems and needed supports down the line (and this is where cost savings can come in). We can also provide some insights in behavioral techniques for managing various symptoms, although I really wish we also had more geropsychologists to be able to help with this on a longer-term perspective.

From a medicolegal standpoint, yes, attorneys likely see value in the services we provide, otherwise they wouldn't pay for them. But like WisNeuro said, the strength of the evaluation doesn't always (or even often) relate to the ultimate judgment. It can be helpful to know this when writing reports and providing testimony. That being said, although we don't monitor or request information relating to outcomes, it stands to reason our work is probably helpful enough of the time for them to continue seeking out the services. From a civil perspective, we can also help in putting numbers to things that are otherwise hard to objectively and reliably measure (e.g., cognitive functioning).

The largest issue with the highlighted portion is that there is no good mechanism for reimbursing this kind of work.

 

[Therapist4Chnge]

I won’t get specific, but it’s not plastics, it’s mostly but not entirely self-pay, and it’s definitely more than 6M and that’s with just one physician (and a solid team of staff and APs/ mid-levels).

There is so much money to be made out there if we self select ourselves into the right positions, but that’s not even possible in some fields.

My guess is injections (i.e. PRP, stem cells, etc)…the markup on the products *and* procedure(s) are massive. Stack ‘em & Wack ‘em at a surgery center a few days a week is easily 7 figures. NPs can handle everything else, then just a scheduler and/or admin. Documentation is minimal. Owning the surgery center & leasing out the extra days are the cherry on top.

 

[Sanman]

My guess is injections (i.e. PRP, stem cells, etc)…the markup on the products *and* procedure(s) are massive. Stack ‘em & Wack ‘em at a surgery center a few days a week is easily 7 figures. NPs can handle everything else, then just a scheduler and/or admin.

That was my thought as well. It really is sad what people prioritize in society.... boob jobs and filler are where the money is at, forget all those folks with diabetes and cancer. It really is quite the country we have built.

 

[WisNeuro]

That was my thought as well. It really is sad what people prioritize in society.... boob jobs and filler are where the money is at, forget all those folks with diabetes and cancer. It really is quite the country we have built.

Just ration the insulin, it'll be ok...

 

[AcronymAllergy]

Just ration the insulin, it'll be ok...

Wait, insulin isn't a designer drug?

 

[ThatPsyGuy]

Then another big consideration is the type of facility that people who want to focus on assessment should do for internship/practicum.
What are some good signs or features of an internship/practicum environment that would provide a rich and meaningful training environment in assessment?

 

[AcronymAllergy]

Then another big consideration is the type of facility that people who want to focus on assessment should do for internship/practicum.
What are some good signs or features of an internship/practicum environment that would provide a rich and meaningful training environment in assessment?

It's tough to say, honestly. Some VAs and AMCs offer lots of opportunities for assessments while others are marginal at best. In general, I'd say focusing on larger hospital systems like VAs and AMCs is the best bet, but you'll want to read the brochures and, while interviewing, ask current interns.

 

[WisNeuro]

Then another big consideration is the type of facility that people who want to focus on assessment should do for internship/practicum.
What are some good signs or features of an internship/practicum environment that would provide a rich and meaningful training environment in assessment?

Agree with @AcronymAllergy , VAs and AMCs going to usually have the best opportunities. Hopefully you are getting experience beyond a general neuro assessment clinic. Do they have specialty clinics (TBI, MS, Movement disorders, epilepsy), or brain cuttings, or wadas, etc? You can get general clinic experience in a lot of places, but it's nice to get some depth experience beyond dementia evals.

 

[borne_before]

Yep- I'm not a neuropsychologist (though there are no legal requirements or restrictions on calling yourself that as long as you are a licensed psychologist). I do primarily ASD evals bill neuropsych CPT codes for them. I occasionally do some basic "neuropsych" tests, but would never consider myself a neuropyschologist.

Man, this is the second time i've heard of someone billing the neuropsych cpt codes...

 

[WisNeuro]

Man, this is the second time i've heard of someone billing the neuropsych cpt codes...

RVUs are better than the general psych assessment codes.

 

[quickpsych]

I've known a number of clinicians who have made $$$ catering to private school parents. Obviously you need to have good boundaries and make sure the parents understand that it's an assessment and not a rubber stamp, but a halfway decent psych should be able to be full once the word-of-mouth gets going with the parents. There likely will already be someone in that space, so it won't be available on a silver platter, but usually a little bit of research and effort can pay off nicely.

I know a psychologist who focuses on this population. Had the opportunity to occasionally pick up an assessment case or two from the practice. While there isn't a ton of referrals, these private schools cost $20-40K a year (high school). I was amazed one time a parent showed up with an envelope of cash to "just pay in full from the start" for , I think a $5,500 evaluation. And that wasn't even the most expensive option.

But you have to have tough skin while also having a keen ability to read the room and present your findings in a way that are accurate but also "agreeable." The nuances in wording and presenting results is something you notice real quickly with this population if you chose the "wrong" way to phrase it. Same with if there's a waiting list or any kind of delay. Many of these parents are CEOs, business owners, other top level "corporate types." Some tend to treat the psychologist like another person on their payroll. Sadly there's also a "fix this problem" mentality too; sometimes you discover a big factor in the poor kid or teen's presenting problem is the "throw money at the problem parenting."

 

[Pragma]

RVUs are better than the general psych assessment codes.

Not really with that 90791…

 

[WisNeuro]

Not really with that 90791…

Yeah, but you can bill 90791 in place of 96116, depending on your documentation and which side you are credentialed on, and then use the 96136/7 and 96132/3 codes.

 

[ClinicalABA]

Yeah, but you can bill 90791 in place of 96116, depending on your documentation and which side you are credentialed on, and then use the 96136/7 and 96132/3 codes.

That's exactly what I do. 90791 still best rate.

 

[Sanman]

That's exactly what I do. 90791 still best rate.

Seems to be standard practice. I do the same.