Private practice attending ready to answer questions

[jettavr6]

You could screen a patient though in doing so, you could technically become their doctor. Just talking to someone about anything medical could tie them to you in a doctor-patient relationship.

Agree with Whopper on many things.... but strongly disagree on this point. You may find in conversation with another medical colleague that the case is so complex, that you don't have the expertise to treat the patient. Are you then tied to treating the patient?

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[whopper]

You could disagree but this is actually printed in textbooks. What exactly starts the doctor patient relationship is any type of communication between you and the patient that could be considered medical practice. Asking the person questions about their condition, in other words screening, about medical stuff, this could bind you into such a relationship. A problem here is there is no clear definition as to what is "medical" or not enough to justify the relationship.

If you're in a bar, some guy just asks you, "hey doc, my thumb hurts, any advice?" and you answer him in anything other than "I can't give you an answer because I'm not your doctor", you could be considered his doctor.

A common question along these lines is the above that has occurred in exams.

And there have been plenty of malpractice cases that won against a doctor that didn't even know he had a doctor/patient relationship. It's a reason why Good Samaritan laws had to be passed. If some guy was choking, you saved him, wish him well, then 1 year later, didn't tell him he had Chlamydia and didn't do the testing for it....wow, bad doctor! He's your patient! You didn't screen him for Chlamydia despite his high risk lifestyle!?!?!?

The goal of several lawyers here is to simply lock you into a situation where you'd rather settle out of court cause if you fight it, you'll be spending more money on that in terms of lost work.

My advice, if you screen, you don't do it. Have someone else like the receptionist do it. Train the receptionist for people you want to screen out.

As for charge them a high fee, I better double check on this. I think you can do this, but I'd rather check before I tell you it's okay.

This is in reference to insurance companies, not self-pay services.

and BTW, I do believe 300-400K is attainable in private practice. I know this for a fact because I was at a place where I could have made as much if I simply increased my PP hours but was doing about 32 hours elsewhere. A problem here is it could take you some time, realistically about 1-2 years before you attain a full caseload. Also, PP doesn't pay retirement or health insurance unless you're in a large PP group that's established one for it's employees. And for me, doing PP all the time would drive me nuts. I needed to mix it up a bit.

 

[michaelrack]

300-400 k in psychiatry private practice as the OP states in the first post without selling your soul or working crazy hours??? Lol if anyone thinks this can be done working 9a-5p M-F..

That must be a gross income number. No way can anyone generate this amount as net income that isn't working 8a-8pm daily in their private practice outpatient office and maybe even then having to round on inpts during the weekday for an hour or two. Plus weekened call coverage and maybe even needing saturday office hours to get anywhere close to 400k net income..


am i right?

300k+ is doable working 60 hours per week (with some of this time being weekend call coverage)

 

[medicaresucks]

Was speaking with two different attendings of mine today and they said they will easily be making 400K plus this year because of the new code changes.

They work monday thru thursday 8-5 and say they sees something like 25-30 patients a day (no medicaid and private and medicare insured only) but with the new code changes he says he is billing everyone at least a level 3 E/M and then add on psychotherapy for everyone and says its paying like 110 ish for medicare rates.. He does this for 46 weeks a year and says he no longer will be working friday-sunday in any capacity because how busy his office is.

I dont know if this is complete hogwash.. 25-30 patients a day in an 8-9 hour workday.. is that possible in psychiatry?

 

[LimbicResponse]

Was speaking with two different attendings of mine today and they said they will easily be making 400K plus this year because of the new code changes.

They work monday thru thursday 8-5 and say they sees something like 25-30 patients a day (no medicaid and private and medicare insured only) but with the new code changes he says he is billing everyone at least a level 3 E/M and then add on psychotherapy for everyone and says its paying like 110 ish for medicare rates.. He does this for 46 weeks a year and says he no longer will be working friday-sunday in any capacity because how busy his office is.

I dont know if this is complete hogwash.. 25-30 patients a day in an 8-9 hour workday.. is that possible in psychiatry?

Sounds like a surgical/radiology intern has joined our forum, welcome !

 

[dl2dp2]

Was speaking with two different attendings of mine today and they said they will easily be making 400K plus this year because of the new code changes.

They work monday thru thursday 8-5 and say they sees something like 25-30 patients a day (no medicaid and private and medicare insured only) but with the new code changes he says he is billing everyone at least a level 3 E/M and then add on psychotherapy for everyone and says its paying like 110 ish for medicare rates.. He does this for 46 weeks a year and says he no longer will be working friday-sunday in any capacity because how busy his office is.

I dont know if this is complete hogwash.. 25-30 patients a day in an 8-9 hour workday.. is that possible in psychiatry?

it's possible, if you see 3 medicare patients for "20-30" min per hour, nonstop for 8 hours that's 24 patients. Add in 30 min for lunch.

This doesn't seem very "lifestyle" though, but maybe that's your thing. we are talking about nonstop paperwork to get reimbursed, hiring a secretary, having a huge army of referrals for therapists to refer your huge patient base to. Although I think maybe that's close-ish to the derm lifestyle? i dunno.

IMHO the real lifestyle in psychiatry is at the far right end of the curve for hourly business in very select markets, getting close to a standard fee of $600 per hour. This kind of thing is hard to achieve though, and you have to be very exclusive, savvy and have an impeccable pedigree. But for those people, psychiatry is probably the best field in medicine in terms of financial leverage. How does this work? In private insurance, patients get reimbursed $150 out of network per 30 min psychopharm visit. You however balance bill them $300, and they pay another $150 out of pocket. If you see the patient once a month, that adds up to be about $2000 per year out of pocket, which, while substantial, isn't very high for the upper middle class, especially if their mental health is critical for their optimal work performance or family life. This is to a large extent cosmetic psychiatry. You really only have to work 5 hours a day doing this sort of thing. But yes, they fill slowly (as whooper said), and you need to live in the right place.

 

[alina_s]

If you do cash-only, how do you build up a referral base? Go out and meet primary care doctors? Phone calls? Mailing?

 

[dl2dp2]

If you do cash-only, how do you build up a referral base? Go out and meet primary care doctors? Phone calls? Mailing?

If you even have to ask that question, you may not be at the right place. I would add that the best way to figure this out is to find a local mentor who you know already has a solid cash practice. This is very geographically dependent and very complex.

 

[F0nzie]

In private insurance, patients get reimbursed $150 out of network per 30 min psychopharm visit.

Are you sure insurance pays that much? $150 for 30 min seems kinda high. I thought there was an "allowable amount" that they designate and they pay a percentage of that.

 

[whopper]

If you do cash-only, how do you build up a referral base? Go out and meet primary care doctors? Phone calls? Mailing?

IMHO no. No one will see you cash-only unless they're convinced you're good or they have no choice because you're the only one in town.

The way to do it IMHO, is to be a good psychiatrist, have a decent CV and start out accepting insurance. Fill your open slots first. Then over time, as your rep builds up, you can accept more and more out-of-pocket patients while slowly getting rid of the lower paying insurances, eventually going out-of-pocket all the way. This process could take a few years.

 

[dl2dp2]

Are you sure insurance pays that much? $150 for 30 min seems kinda high. I thought there was an "allowable amount" that they designate and they pay a percentage of that.

I'm just using this as an example. My own personal hospital insurance, for instance, pays out of network for ~$300 for a 90806 with med management (this is old terminology--and the pricing is dated)--though a substantial deductible. I ended up not having to use it because I refused to see a private psychoanalyst here "for educational purposes" and stayed in-network with a PhD, who I think is an excellent analyst, but yes, depending on where you are, private insurance can reimburse, even out-of-network, really well.

I think for all practical purposes, networking is a major key if your are private practice bound. Although I'm not sure exactly how things work elsewhere, if I was say in a mid sized city from a mid tier academic program, the first thing I would do is to network with the local APA chapter, and ask around to see if there are private pay patients being referred. I would set up my office in a wealthy suburb, and start advertising via local groups, such as giving talks about mental health at schools, etc. I would probably do groups, esp. substance groups if I was addiction, etc. I would market really hard, with a website, going to fund raisers... Meanwhile, I would probably join either a full time HMO arrangement or "group practice without walls" with in-network insurance and gradually ramp up the private practice time.

It's not that easy. You can't get derm lifestyle fresh out of residency. I especially wouldn't get too comfortable with the whole Medicare only $300k plan---it's not that easy, and the overhead is likely very high. For cash patients, there are various other issues... I would not deal with some of those wealthy personality disordered patients for $1000 an hour. Be sure you know the game before going into it.

It IS easy though to get a 200k F/T managed care job. So I think a lot of middle of the road residents just end up doing that, which is really FINE in my book. 40-50 hours a week, full benefits, 200k+, full vacation time. Why the hell not?

BTW, just for the heck of it, I'll share an anecdote. I was at APA this year and some random guy told me he has a huge roster of 500 patients in a fancy suburb and I should ditch research and "just do private practice" because it's "very lucrative", and "how many days a week do you want to work"? LOL, my program director would have a cardiac.

 

[PistolPete]

It seems the OP has forgotten about this thread...

 

[HealthHare]

It seems the OP has forgotten about this thread...

He's too busy counting his money

 

[whopper]

I would not deal with some of those wealthy personality disordered patients for $1000 an hour. Be sure you know the game before going into it.

Wealthy patients with big cluster B issues can be the biggest pain in the butt of all time. They are trigger happy for a lawsuit and have the money to tote around for frivolous ones. I'd rather make less money than deal with the above types for more money.

 

[Postictal Raiden]

Is being a non-native English speaker going to be an obstacle if choose to pursue psychiatry?

 

[F0nzie]

I am fresh out of residency (about 2 weeks) with a cash practice in a new city. Zero contacts. Zero reputation. I began networking 6 months before residency ended. I charge $250 an hour and I see 1.5 hr intakes and 30-60 minute follow ups. I've seen 5 patients thus far. All my patients have been very nice and courteous and I have not seen the cluster B wealthy entitlement issue yet. Most of these folks A) have the means to pay out of pocket or can tolerate the wait to receive out-of-network reimbursement or B) have a high deductible insurance plan so it doesn't matter who they see anyways.

My experience thus far is that a cash practice built from the ground up without piggybacking on insurance companies is possible, but be prepared to invest A LOT of time (at the start and likely on continuous basis).Your income stream is directly related to your ability to promote yourself and willingness to meet with potential referral sources (this takes up a HUGE amount of uncompensated time and some money).

Here's the good news: The satisfaction so far is UNBEATABLE. I spend 1.5 to 2 hours with patients on an initial intake. I take their phone calls and emails. Instead of battling with insurance companies I spend my time corresponding with their primary care physicians and therapists and keeping them updated with my treatment plan. Patients LOVE IT when the focus is on the doctor-patient relationship and things that matter to them. Go figure.

 

[PistolPete]

Very cool Fonzie! Keep us updated on how your practice flourishes! Do you see kids/adolescents also or just adults? How are you marketing your practice?

 

[F0nzie]

Very cool Fonzie! Keep us updated on how your practice flourishes! Do you see kids/adolescents also or just adults? How are you marketing your practice?

TV, social media, blogs, website, directories, mail, email, phone, flyers, business cards, buying fancy sweets, going to lunch, dinner, dressing well... I see adults.

 

[vistaril]

it's possible, if you see 3 medicare patients for "20-30" min per hour, nonstop for 8 hours that's 24 patients. Add in 30 min for lunch.

This doesn't seem very "lifestyle" though, but maybe that's your thing. we are talking about nonstop paperwork to get reimbursed, hiring a secretary, having a huge army of referrals for therapists to refer your huge patient base to. Although I think maybe that's close-ish to the derm lifestyle? i dunno.

IMHO the real lifestyle in psychiatry is at the far right end of the curve for hourly business in very select markets, getting close to a standard fee of $600 per hour. This kind of thing is hard to achieve though, and you have to be very exclusive, savvy and have an impeccable pedigree. But for those people, psychiatry is probably the best field in medicine in terms of financial leverage. How does this work? In private insurance, patients get reimbursed $150 out of network per 30 min psychopharm visit. You however balance bill them $300, and they pay another $150 out of pocket. If you see the patient once a month, that adds up to be about $2000 per year out of pocket, which, while substantial, isn't very high for the upper middle class, especially if their mental health is critical for their optimal work performance or family life. This is to a large extent cosmetic psychiatry. You really only have to work 5 hours a day doing this sort of thing. But yes, they fill slowly (as whooper said), and you need to live in the right place.

A google search shows that the superduper 'elite' analysts with 'names'(that make up less than 1% of all psychiatrists in practice) in places like manhattan, LA, etc bill 350/hr or so.......why stop at 600/hr? Why not 1800/hr? 3500/hr? 12,000/hr?

 

[vistaril]

it's possible, if you see 3 medicare patients for "20-30" min per hour, nonstop for 8 hours that's 24 patients. Add in 30 min for lunch.
QUOTE]

An outpt psychiatrist seeing 24 medicare patients per day isn't going to do very well, and certainly make nothing close to the figure cited earlier. If it were that easy more people would do it.

The numbers don't add up for psychiatry to take medicare. Internal medicine outpt offices can do 'ok' taking medicare because they see 50patients daily(and bill under the same codes), and have other revenue sources on top of that for those patient visits. And internal med offices aren't making 600k or anything doing this. If they are seeing twice as many patients(or more), have extra sources of revenue, and are billing the same office visit codes, it doesn't seem like a good way to go....

My guess is a practice who is scheduling 24 medicare patients and day(and maybe actually seeing 20) would generate maybe a thousand to 1200 dollars GROSS. That's before office expenses(you're going to need employees if you take medicare), rent, other overhead, etc.....it's a recipe for financial disaster, and goes to how tight the margins are in outpt psych.

 

[digitlnoize]

it's possible, if you see 3 medicare patients for "20-30" min per hour, nonstop for 8 hours that's 24 patients. Add in 30 min for lunch.
QUOTE]


My guess is a practice who is scheduling 24 medicare patients and day(and maybe actually seeing 20) would generate maybe a thousand to 1200 dollars GROSS. That's before office expenses(you're going to need employees if you take medicare), rent, other overhead, etc.....it's a recipe for financial disaster, and goes to how tight the margins are in outpt psych.

That's a pretty low ball estimate. $1200 / 20 pt's is only $60 per pt. Thats about a level 2 visit. Most psych visits should get a level 3 or 4 if your coding right, which should pay (in most places closer to the 80-100 range. 20 pt's would gross closer to $1600-2000 per day. Psych overhead is still much lower than medicine overhead and if you're smart you can run a busy insurance based psych office at max 30-40% overhead, which would net you $960 - 1400 per day. Most people I know who take insurance run in the 25-30% overhead range. Although it'd obviously be higher in rent-expensive places...

Netting 1k per day (conservatively) is still pretty good. That's 4-5k/wk depending on how much you want to work. 4k/wk * 48 weeks/yr = 192k per year. Not 300k, but still, not bad.

That being said, I think coding properly and aiming for more 4's, taking some well paying private insurances that pay better than Medicare rates, and running a smart office could net you over 300k for a 40 hour week. Definitely if you use physician extenders. Add a couple PA's and you're set.

 

[vistaril]

That's a pretty low ball estimate. $1200 / 20 pt's is only $60 per pt. Thats about a level 2 visit. Most psych visits should get a level 3 or 4 if your coding right, which should pay (in most places closer to the 80-100 range. 20 pt's would gross closer to $1600-2000 per day. Psych overhead is still much lower than medicine overhead and if you're smart you can run a busy insurance based psych office at max 30-40% overhead, which would net you $960 - 1400 per day. Most people I know who take insurance run in the 25-30% overhead range. Although it'd obviously be higher in rent-expensive places...
.

If you're billing 20+ level 3-4 medicare visits under the same provider number every day, I suspect that's going to:

1) be open to a lot of rejections, difficulties in getting all those through, whatever....
2) possible audits
3) more labor intensive if you plan on not having problems with 1 or 2. I don't think you're going to be able to push that volume of medicare level 3-4 visits with one $12/hr employee for example. Think about the groups that DO take medicare now(for psych purposes).....mostly cmhcs, academic outpt clinics, agencies, etc. Now look at how many people they have to do the paperwork and claims for all that. They aren't running all that lean iow.

for the *very* limited number of individual groups or pp non-agency providers who do take medicare, I'd be interesting in what their total reimbursement is for patient encounter(not including intakes). Even in the world of cmhc bundling it's like 80-85 bucks, and that's with bundling(and with that comes a completely different level of overhead projections).

 

[285963]

If you're billing 20+ level 3-4 medicare visits under the same provider number every day, I suspect that's going to:

1) be open to a lot of rejections, difficulties in getting all those through, whatever....
2) possible audits
3) more labor intensive if you plan on not having problems with 1 or 2. I don't think you're going to be able to push that volume of medicare level 3-4 visits with one $12/hr employee for example. Think about the groups that DO take medicare now(for psych purposes).....mostly cmhcs, academic outpt clinics, agencies, etc. Now look at how many people they have to do the paperwork and claims for all that. They aren't running all that lean iow.

for the *very* limited number of individual groups or pp non-agency providers who do take medicare, I'd be interesting in what their total reimbursement is for patient encounter(not including intakes). Even in the world of cmhc bundling it's like 80-85 bucks, and that's with bundling(and with that comes a completely different level of overhead projections).

Full disclosure: I am new to this forum, though I have been following it for some time. And I am in my fourth year of medical school.

Seems like an awfully pessimistic view of medicare reimbursements. I just spent 5 months in a Family Medicine office and they have a billing employee who knows Medicare reimbursements inside and out. My understanding is that billing an E/M code at level 2 is a waste of time. In fact I've actually been told Medicare will sometimes come after a provider who is "under"-coding because they will claim they are seeing the patient too infrequently. However "over"-coding is a real risk too I admit.

If you look at the criteria for billing at level 3 they're pretty straightforward. You should easily get all the required points necessary for the history. MDM simply requires two stable chronic illnesses that are controlled or improved. Your patient has depression and a sleep issue... you're set.

If any of the patient's problems are worsened that's immediately two points in the MDM section and you qualify for a level 3 visit. A level three visit is supposed to be 15 minutes. A level four visit is supposed to be 25 minutes if you simply look at criteria based on face-to-face time spent with the patient.

There's a lot of literature out there that physicians generally undercode for most things they do. Most physicians (regardless of specialty) do enough patient care work to bill at a level 3 or level 4 visit, they just don't document it well enough.

I've been told that what Medicare is really looking for is an ebb-and-flow in the billing. In other words, if you follow a patient over time you shouldn't always code a level 3 or a level 4. Sometimes a level 3 is warranted; sometimes a level 4 is warranted. You've gotta mix it up based on the circumstances.

Audits are a pain in the ass. I've heard some horrible stories. Won't argue with you there.

 

[honsano]

An outpt psychiatrist seeing 24 medicare patients per day isn't going to do very well, and certainly make nothing close to the figure cited earlier. If it were that easy more people would do it.

The numbers don't add up for psychiatry to take medicare. Internal medicine outpt offices can do 'ok' taking medicare because they see 50patients daily(and bill under the same codes), and have other revenue sources on top of that for those patient visits. And internal med offices aren't making 600k or anything doing this. If they are seeing twice as many patients(or more), have extra sources of revenue, and are billing the same office visit codes, it doesn't seem like a good way to go....

My guess is a practice who is scheduling 24 medicare patients and day(and maybe actually seeing 20) would generate maybe a thousand to 1200 dollars GROSS. That's before office expenses(you're going to need employees if you take medicare), rent, other overhead, etc.....it's a recipe for financial disaster, and goes to how tight the margins are in outpt psych.

Rather than trying to make all your money in one setting you could diversify: nursing homes, depositions and rTMS. The latter is still in its infancy so it would be difficult to get anything but cash payment. The first two I have heard from people in my area to be lucrative. Nursing homes do open you up to litigation..... though you have to take the risks for the rewards I suppose.

Anyone here have experience with these?

 

[michaelrack]

If you're billing 20+ level 3-4 medicare visits under the same provider number every day, I suspect that's going to:

1) be open to a lot of rejections, difficulties in getting all those through, whatever....
2) possible audits
3) more labor intensive if you plan on not having problems with 1 or 2. I don't think you're going to be able to push that volume of medicare level 3-4 visits with one $12/hr employee for example. Think about the groups that DO take medicare now(for psych purposes).....mostly cmhcs, academic outpt clinics, agencies, etc. Now look at how many people they have to do the paperwork and claims for all that. They aren't running all that lean iow.

for the *very* limited number of individual groups or pp non-agency providers who do take medicare, I'd be interesting in what their total reimbursement is for patient encounter(not including intakes). Even in the world of cmhc bundling it's like 80-85 bucks, and that's with bundling(and with that comes a completely different level of overhead projections).

I do 1-2 days a week of clinic (sleep)- so no add-on psychotherapy codes. In a typical clinic day I will see 16 return patients (majority 99213, occasional 99214) and 7 new patients ( 99202/99242, occasional 99203 or 99243). A large minority of the patients are Medicare (over 1/3) .

Although Medicare is a pain to enroll in (and I just got something in the mail about a mandatory "validation" of my medicare status), submitting a medicare claim isn't that difficult and audits haven't been a problem. It is sometimes a pain dealing will all the secondary insurances medicare pts have.

Whatever insurances a doc is taking, figure at least 10% of revenue to collect on it (this covers billing services, credit card fees, someone to process payments/take copays, etc)

 

[medicaresucks]

If you're billing 20+ level 3-4 medicare visits under the same provider number every day, I suspect that's going to:

1) be open to a lot of rejections, difficulties in getting all those through, whatever....
2) possible audits
3) more labor intensive if you plan on not having problems with 1 or 2. I don't think you're going to be able to push that volume of medicare level 3-4 visits with one $12/hr employee for example. Think about the groups that DO take medicare now(for psych purposes).....mostly cmhcs, academic outpt clinics, agencies, etc. Now look at how many people they have to do the paperwork and claims for all that. They aren't running all that lean iow.

for the *very* limited number of individual groups or pp non-agency providers who do take medicare, I'd be interesting in what their total reimbursement is for patient encounter(not including intakes). Even in the world of cmhc bundling it's like 80-85 bucks, and that's with bundling(and with that comes a completely different level of overhead projections).

Well i dont know what region of the country you'll be practicing in but where i am at everyone is coded at a level 3 (99213) with the coding changes and that alone is paid 70 dollars and increasing yearly. The new add on psychotherapy codes for medicare in conjunction with a med visit (99213) are 40 dollars in addition to the level 3 visit. Most people dont know this or think its too hard to set up private shop because they have no business experience. The place i'll be doing it the psychiatrists are booked and not accepting new pts and these guys say they see 25-30 pts daily with medicare and private insurance mix and no medicaid. Plus they could see more but are older 55+ and don't want to at this age. These docs were netting 300-350k under the old coding system and this new one if you know how to code will pay more. Its all about volume and if you do call or admit patients then you'll make more.

 

[jettavr6]

You could disagree but this is actually printed in textbooks. What exactly starts the doctor patient relationship is any type of communication between you and the patient that could be considered medical practice. Asking the person questions about their condition, in other words screening, about medical stuff, this could bind you into such a relationship. A problem here is there is no clear definition as to what is "medical" or not enough to justify the relationship.

If you're in a bar, some guy just asks you, "hey doc, my thumb hurts, any advice?" and you answer him in anything other than "I can't give you an answer because I'm not your doctor", you could be considered his doctor.

A common question along these lines is the above that has occurred in exams..

I'm not trying to be a Vistaril here... but this link has some great examples of what establishes a doctor-patient relationship: http://virtualmentor.ama-assn.org/2012/05/hlaw1-1205.html

But I will concede that anyone can sue you for anything.

If I ask some questions and feel that I cannot treat the patient, I inform the patient and recommend a few names of others who might be able to treat them.

 

[vistaril]

Full disclosure: I am new to this forum, though I have been following it for some time. And I am in my fourth year of medical school.

Seems like an awfully pessimistic view of medicare reimbursements. I just spent 5 months in a Family Medicine office and they have a billing employee who knows Medicare reimbursements inside and out. My understanding is that billing an E/M code at level 2 is a waste of time. In fact I've actually been told Medicare will sometimes come after a provider who is "under"-coding because they will claim they are seeing the patient too infrequently. However "over"-coding is a real risk too I admit.

If you look at the criteria for billing at level 3 they're pretty straightforward. You should easily get all the required points necessary for the history. MDM simply requires two stable chronic illnesses that are controlled or improved. Your patient has depression and a sleep issue... you're set.

If any of the patient's problems are worsened that's immediately two points in the MDM section and you qualify for a level 3 visit. A level three visit is supposed to be 15 minutes. A level four visit is supposed to be 25 minutes if you simply look at criteria based on face-to-face time spent with the patient.

There's a lot of literature out there that physicians generally undercode for most things they do. Most physicians (regardless of specialty) do enough patient care work to bill at a level 3 or level 4 visit, they just don't document it well enough.

I've been told that what Medicare is really looking for is an ebb-and-flow in the billing. In other words, if you follow a patient over time you shouldn't always code a level 3 or a level 4. Sometimes a level 3 is warranted; sometimes a level 4 is warranted. You've gotta mix it up based on the circumstances.

Audits are a pain in the ass. I've heard some horrible stories. Won't argue with you there.

allright so you mention a family med clinic....that is billing routine visits at 3+. Under the same cods as psych. And they have other revenue sources during those same visits. And they are seeing 2.5x as many people(they are).......Do the math........

either family medicine physicians under that model are all making 750k and psychs are making what you say they are, or family med physicians in that model are making 250ish and psychs aren't doing that model.....your choice.

 

[vistaril]

I do 1-2 days a week of clinic (sleep)- so no add-on psychotherapy codes. In a typical clinic day I will see 16 return patients (majority 99213, occasional 99214) and 7 new patients ( 99202/99242, occasional 99203 or 99243). A large minority of the patients are Medicare (over 1/3) .

Although Medicare is a pain to enroll in (and I just got something in the mail about a mandatory "validation" of my medicare status), submitting a medicare claim isn't that difficult and audits haven't been a problem. It is sometimes a pain dealing will all the secondary insurances medicare pts have.

Whatever insurances a doc is taking, figure at least 10% of revenue to collect on it (this covers billing services, credit card fees, someone to process payments/take copays, etc)

I know NOTHING about how sleep medicine is billed.....so I can't add a lot here.

 

[vistaril]

Well i dont know what region of the country you'll be practicing in but where i am at everyone is coded at a level 3 (99213) with the coding changes and that alone is paid 70 dollars and increasing yearly. The new add on psychotherapy codes for medicare in conjunction with a med visit (99213) are 40 dollars in addition to the level 3 visit. Most people dont know this or think its too hard to set up private shop because they have no business experience. The place i'll be doing it the psychiatrists are booked and not accepting new pts and these guys say they see 25-30 pts daily with medicare and private insurance mix and no medicaid. Plus they could see more but are older 55+ and don't want to at this age. These docs were netting 300-350k under the old coding system and this new one if you know how to code will pay more. Its all about volume and if you do call or admit patients then you'll make more.

someone coding a level 3 and coding psychotherapy add on(both of those) during the visit and doing that 30 times a day is committing medicare fraud. Maybe they get caught, maybe they don't. That's all there is to it. Unless that person is opening up at 5am and leaving the office at 8pm daily.

And I know people do sketchy as hell things in a lot of settings. From psychiatry to selling used cars to selling insurance. But if you're going to stoop to that level, why not go all out?

But again, I go back to the main issue- if medicare is so darn sweet, why does almost NOBODY(except agencies who are bottom feeders and cmhcs who can bundle) take it? It sure as hell isn't because bcbs is paying that massive money for actual 1 hr therapy codes(obviously they aren't).......when humana and bcbs are paying much more for their crappy med mgt codes than medicare is(and the reality is they do because most people take humana and bcbs and nobody takes medicare)....well.......

 

[vistaril]

Rather than trying to make all your money in one setting you could diversify: nursing homes, depositions and rTMS. The latter is still in its infancy so it would be difficult to get anything but cash payment. The first two I have heard from people in my area to be lucrative. Nursing homes do open you up to litigation..... though you have to take the risks for the rewards I suppose.

Anyone here have experience with these?

lmfao....TMS? TMS?

 

[digitlnoize]

lmfao....TMS? TMS?

I don't get the joke. If you're saying its not a money maker, that's not true.

 

[285963]

allright so you mention a family med clinic....that is billing routine visits at 3+. Under the same cods as psych. And they have other revenue sources during those same visits. And they are seeing 2.5x as many people(they are).......Do the math........

either family medicine physicians under that model are all making 750k and psychs are making what you say they are, or family med physicians in that model are making 250ish and psychs aren't doing that model.....your choice.

Well you and I both know most Family Docs are not making 750. Though I've heard of quite a few who can make 300-350 with good business practices and a good work ethic.

Per other revenue sources it depends on which sources you're referencing. Immunizations, rapid strep tests, EKGs, ect. don't pay too well from my understanding. They're barely worth the nursing time required to administer them. And if you do enough of them you have to hire another nurse which takes out from your overhead and slows efficiency. That said if you can do some cosmetic derm or maybe enough cryotherapy that can net you a couple extra hundred each day. But even that can take more time than is expected. I'm skeptical of those docs who are still doing things like vasectomies in the office. And this is coming from someone who thinks very highly of family physicians in general.

I don't want to argue revenue because I simply don't know. And I can't speak with any authority on that matter. But the higher numbers quoted on this forum don't seem outlandish to me. One of the child psych docs in my area flat out told me he makes about 500k each year. Works about 55-60 clinical hours per week. And he's not cash pay--he takes insurance.

 

[notdeadyet]

someone coding a level 3 and coding psychotherapy add on(both of those) during the visit and doing that 30 times a day is committing medicare fraud. Maybe they get caught, maybe they don't. That's all there is to it. Unless that person is opening up at 5am and leaving the office at 8pm daily.

Did you end up in private practice, V?

 

[dl2dp2]

Big picture points that V can't really argue with and that I think are reasonably true: if you go academic or CMHC, your pay is substantially lower, in the mid-high 100s range to start, maybe higher when established. If that's your psychological starting point, the overall gist that I've gathered from lots of people is that if you commit a life of optimizing profit in a private practice setting, you can do VERY well in psychiatry, with or without taking insurance---this is primarily psychopharm. The need for proper utilization of psychotropic medications in this country is enormous.

At some point though you have to ask yourself what the point is in making all this cash. You'll never make enough money to live the life of a hedgefunder. You'll always make more than enough than almost everyone else. Outside of select metros, it's very rare to even find a house that costs more than 600k. You work work work till you retire and die. And pass on that wad of cash to your kids. That's your life. Think about that.

 

[notdeadyet]

The need for proper utilization of psychotropic medications in this country is enormous.

As much as folks slam private practice docs who do heavy psychopharm in addition to psychotherapy (and this is not me), it's worth pointing out that you are doing more than titrating med during a med management visit.

If you do a search you'll find that studies have shown that people have better outcomes when they have med management visits with a psychiatrist than when they have a rx for an SSRI with a bunch of refills from a PCP.

This is not a slam on PCPs. Most of their follow-up appointments are as long as our med management visits and they have a LOT more ground to cover. But supportive and other therapy done during a brief medication management visit is therapeutic. This is one explanation for why folks who are given an SSRI rx do not seem to do as well as you would think from studies. Folks participating in studies tend to be given a supportive environment with lots of attention paid to them.

Again, I'm not likely private practice bound, but there are folks on this board who are very quick to paint the picture of med management visits lasting 5-7 minutes with a tic in a titrtation plan. If that's all you're doing in your medication management visits, then the problem lies with you.

 

[NYCMS2]

Big picture points that V can't really argue with and that I think are reasonably true: if you go academic or CMHC, your pay is substantially lower, in the mid-high 100s range to start, maybe higher when established. If that's your psychological starting point, the overall gist that I've gathered from lots of people is that if you commit a life of optimizing profit in a private practice setting, you can do VERY well in psychiatry, with or without taking insurance---this is primarily psychopharm. The need for proper utilization of psychotropic medications in this country is enormous.

At some point though you have to ask yourself what the point is in making all this cash. You'll never make enough money to live the life of a hedgefunder. You'll always make more than enough than almost everyone else. Outside of select metros, it's very rare to even find a house that costs more than 600k. You work work work till you retire and die. And pass on that wad of cash to your kids. That's your life. Think about that.

Are you being serious? It isn't about making "all this cash" but being well compensated for your blood, sweat, and tears (training) and for your time and expertise.

I want to make as much money as possible in the shortest possible work week and work year. I want a life outside of medicine, but I want to be well compensated for the time in it. And one day I want the option of walking away from medicine and doing something else with my time.

 

[strangeglove]

But supportive and other therapy done during a brief medication management visit is therapeutic. This is one explanation for why folks who are given an SSRI rx do not seem to do as well as you would think from studies. Folks participating in studies tend to be given a supportive environment with lots of attention paid to them.
.

Actually, I think this explains why medications are more effective in clinical practice than in research studies. In most clinical trials, both the placebo and the active medication are accompanied by supportive psychosocial elements, or sometimes psychotherapy outright. These psychosocial elements may explain the high placebo response rates that we tend to see in these studies. Some interpret this as the medications not working very well. In clinical practice, there is no placebo arm, so you are often seeing the (relatively small) effect of medication, combined with the (relatively large) effect of supportive psychosocial elements, which most good psychiatrists are providing to all of their patients, including those receiving "med management only". The flip-side is if you are an brilliant psychopharmacologist, but you don't know how to talk to your patients or care for their emotional needs, they will usually not obtain as much relief from their symptoms. BTW, I think there are many highly empathic and caring PCP's who probably do a better job of this than most psychiatrists out there. I suspect that their patients tend to do better on the first-line treatments that they prescribe.

 

[michaelrack]

I know NOTHING about how sleep medicine is billed.....so I can't add a lot here.

Sleep clinic is billed pretty much the same as a family med clinic. Sleep studies are separate from clinic and are a whole different story.

 

[strangeglove]

Also, keep in mind that family medicine clinics need to hire MA's and other staff for non-billing purposes, such as drawing blood and checking vitals etc., that increase overhead. Psychiatrists in a relatively small practice need, at most, a biller, and this can be contracted out to someone rarer than having to hire an employee and pay for benefits, etc.

 

[SeniorWrangler]

I know NOTHING about how sleep medicine is billed.....so I can't add a lot here.

Sleep medicine is a good gig... I suspect the market is highly saturated in most metropolitan areas, though. Tons of neurologists and IM docs are in this business already.

 

[michaelrack]

Sleep medicine is a good gig... I suspect the market is highly saturated in most metropolitan areas, though. Tons of neurologists and IM docs are in this business already.

It was a good gig, but reimbursements for sleep studies are declining... BCBS just cut their reimbursement for sleep study interpretation by 25% in Mississippi. Metro areas are saturated.

 

[medicaresucks]

16 minutes is enough to bill the 30 minute code.. its a range.. so in a 20 minute visit you can do both easy once the patient has been established of course. And i think its ok for a psychiatrist to be doing the add on codes for everyone.. thats what we do or are suppose to do.

medicare used to be the lowest paying once upon a time and that stigma has stayed with it. Also it can be a bit more complicated getting started but once thats done they are not that difficult compared to private insurance. Most people dont do it because most people dont know. Think what you want i was just sharing some information. There is a lot more that i won't share with you that you wont know and thus will likely never make the kinda money that is possible. I know this because i have had multiple family members in private practice but otherwise i also would be ignorant to most of these things. oh and the shhit your wife is going through doing colonoscopies to make some $$ will be making roughly half by the time she's done. GI procedures are going to get slaughtered soon. I know because my dad is in GI; but he was lucky to have been in the golden years that being the last 30.

someone coding a level 3 and coding psychotherapy add on(both of those) during the visit and doing that 30 times a day is committing medicare fraud. Maybe they get caught, maybe they don't. That's all there is to it. Unless that person is opening up at 5am and leaving the office at 8pm daily.

And I know people do sketchy as hell things in a lot of settings. From psychiatry to selling used cars to selling insurance. But if you're going to stoop to that level, why not go all out?

But again, I go back to the main issue- if medicare is so darn sweet, why does almost NOBODY(except agencies who are bottom feeders and cmhcs who can bundle) take it? It sure as hell isn't because bcbs is paying that massive money for actual 1 hr therapy codes(obviously they aren't).......when humana and bcbs are paying much more for their crappy med mgt codes than medicare is(and the reality is they do because most people take humana and bcbs and nobody takes medicare)....well.......

 

[vistaril]

Big picture points that V can't really argue with and that I think are reasonably true: if you go academic or CMHC, your pay is substantially lower, in the mid-high 100s range to start, maybe higher when established. .

I don't neccessarily agree with all this....cmhcs(and agencies that pay by the hour) do pay more than many people I know doing private practice. Especially after you consider benefits. Many people still pick private practice over cmhc or agency work because you will be seeing crazy numbers of patients at many such places(for that 100+ per hour guaranteed with bennies).

Lots of people would rather make their own schedule, have their own autonomy, practice the way they want to practice, spend time with patients, etc than have little autonomy and have a ton of med check patients and intakes(where the SWs are doing the heavy lifting and most of the face to face contact and then serving them up to you)

I can't speak for every single cmhc in the country, but their goal is generally to get the psychs name on as many charts as possible per hour. That often doesn't go along with doing work that is fun, fulfulling, enjoyable.

 

[dl2dp2]

I can't speak for every single cmhc in the country, but their goal is generally to get the psychs name on as many charts as possible per hour. That often doesn't go along with doing work that is fun, fulfulling, enjoyable.

This can be true. However, if you can get into a government run CMHC system, the life is pretty sweet--it's a government job, and your salary isn't incentivized based on the number of patients seen. Some academic-ish CMHC are similar (i.e. Kaiser, etc.).

Also keep in mind that while being an employee at a CMHC isn't necessarily awesome, being an OWNER can net you a LOT in the end. Some people end up running a clinic like that. It's sort of soul sucking--a bit like taking advantage of the worst off in our society, but you can make a lot of money.

This is all very theoretic though. Those who have the most credibility are the practicing attendings like whooper, strangeglove, fonze, etc. Everyone seems genuinely pretty happy. Big picture: psychiatry is a good job! don't worry, medical students.

 

[strangeglove]

I appreciate being seen as credible on this subject, though my experience may not generalize to everyone. I am located in the NYC area, graduated from a "top" residency, and have a faculty appointment at same. This may play a role in my particular private practice success story (I certainly hope it does). I acknowledge that things are probably different in the Midwest, or even in NYC for folks who don't have some kind of "niche" or academic cred.

 

[UnicornDemon]

What percentage of your patients come in seeking anti-depressants?

 

[vistaril]

This can be true. However, if you can get into a government run CMHC system, the life is pretty sweet--it's a government job, and your salary isn't incentivized based on the number of patients seen. Some academic-ish CMHC are similar (i.e. Kaiser, etc.).

Also keep in mind that while being an employee at a CMHC isn't necessarily awesome, being an OWNER can net you a LOT in the end. Some people end up running a clinic like that. It's sort of soul sucking--a bit like taking advantage of the worst off in our society, but you can make a lot of money.

This is all very theoretic though. Those who have the most credibility are the practicing attendings like whooper, strangeglove, fonze, etc. Everyone seems genuinely pretty happy. Big picture: psychiatry is a good job! don't worry, medical students.

I guess the term cmhc means different things to different people....I used to the term agency to describe a clinic that is privately owned and catering to the same crowd as a cmhc. I used the term cmhc to describe clinics that are not privately owned.

 

[Indodo]

Was speaking with two different attendings of mine today and they said they will easily be making 400K plus this year because of the new code changes.

They work monday thru thursday 8-5 and say they sees something like 25-30 patients a day (no medicaid and private and medicare insured only) but with the new code changes he says he is billing everyone at least a level 3 E/M and then add on psychotherapy for everyone and says its paying like 110 ish for medicare rates.. He does this for 46 weeks a year and says he no longer will be working friday-sunday in any capacity because how busy his office is.

I dont know if this is complete hogwash.. 25-30 patients a day in an 8-9 hour workday.. is that possible in psychiatry?

What modifier would you add to a 20 minute visit? The psychotherapy modifiers are to 30 minute or longer visits AFAIK. Won't a 20 minute visit be just a straight 99213 unless its a more complicated visit to warrant 99214?

 

[motz]

By impeccable pedigree for private practice in wealthy communities, do you mean a good medical school with lay prestige, i.e. no DO?