Private Practice, no insurance

[jojo100]

Has anyone had any experience working in private practice and not dealing with insurance companies?

It would be nice if anyone has started up their own practice and could shed some light on this issue - were you able to make a competitive income based on this model? if so, how much? how long did it take you to start up? is this a viable option fresh out of residency? etc. (there was a similar thread on this, but in the surgery forum)

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[nitemagi]

The only people who do this straight out of residency take out business loans to do it. No matter where it will take some time to fill your practice. Especially cash-only.

More commonly people take a day job, at least part-time, while they're building their practice, then shed the day job once their PP is full enough or self-sustaining. An alternative avenue is to get on insurance panels, then once full slowly shed the panels and stick with a cash practice.

I'm just starting my PP, cash-only, take credit cards. But I have a FT day job that more than pays the bills, so no pressure to fill my practice too quickly.

And can I just make a general statement to medical students posting on the forum asking about cash private practice but are otherwise interested in surgery, derm, etc. Your motives at surface inspection seem only motivated by financial interests with as little effort as possible. That's a piss-poor reason to enter our field. Do me a favor and pick something else.

 

[digitlnoize]

And can I just make a general statement to medical students posting on the forum asking about cash private practice but are otherwise interested in surgery, derm, etc. Your motives at surface inspection seem only motivated by financial interests with as little effort as possible. That's a piss-poor reason to enter our field. Do me a favor and pick something else.

Love. That being said, I am not surprised that so many people (myself included) are interested in avoiding insurance, given the headaches, cost, and uncertain future. Like it or not, psych is one of the few fields remaining that has managed to stay somewhat distanced from the insurance industry, although not entirely by choice in our case.

However, I agree that medical students deciding on a specialty should really only consider what they love doing, and what they think they'll be able to do best. Everything else will come. I know a lot of people wanting ortho who will be unpleasantly surprised when medicare cuts reimbursement for hip replacements.

 

[jojo100]

Thanks for the input.

I've applied to psych this year, and I have a genuine interest. I am interested in what the future holds for us, so I ask these questions to those who could impart a little bit of knowledge. I am not doing this as an easy way to make money.

The only people who do this straight out of residency take out business loans to do it. No matter where it will take some time to fill your practice. Especially cash-only.

More commonly people take a day job, at least part-time, while they're building their practice, then shed the day job once their PP is full enough or self-sustaining. An alternative avenue is to get on insurance panels, then once full slowly shed the panels and stick with a cash practice.

I'm just starting my PP, cash-only, take credit cards. But I have a FT day job that more than pays the bills, so no pressure to fill my practice too quickly.

And can I just make a general statement to medical students posting on the forum asking about cash private practice but are otherwise interested in surgery, derm, etc. Your motives at surface inspection seem only motivated by financial interests with as little effort as possible. That's a piss-poor reason to enter our field. Do me a favor and pick something else.

 

[nitemagi]

Thanks for the input.

I've applied to psych this year, and I have a genuine interest. I am interested in what the future holds for us, so I ask these questions to those who could impart a little bit of knowledge. I am not doing this as an easy way to make money.

Jojo, not knowing you personally and being shielded by the partial anonymity of the internet, there's a dissonance between your self-professed interest in psych, which I hope is authentic, and your prior posts which list you as an applicant to both ophtho and anesthesiology, with prior posts with an interest in derm as well.

 

[notdeadyet]

Jojo, not knowing you personally and being shielded by the partial anonymity of the internet, there's a dissonance between your self-professed interest in psych, which I hope is authentic, and your prior posts which list you as an applicant to both ophtho and anesthesiology, with prior posts with an interest in derm as well.

Nicely put. Not knowing anything about the OP, optho, derm, gas and psych is an.... interesting mix given a cash-only preference.

 

[jojo100]

My interests are broad. I am not denying that. But having many interests doesn't preclude me from having a real sincere interest in those given fields. I am curious about the future of a field I may end up matching into, so I want to be knowledgeable about what the future holds. That's just prudent on my part. There are plenty of other fields I can match into that I know will net me more income than psych. And I know I am not the only one on here who feels that way. You guys really need to relax.

 

[digitlnoize]

My interests are broad. I am not denying that. But having many interests doesn't preclude me from having a real sincere interest in those given fields. I am curious about the future of a field I may end up matching into, so I want to be knowledgeable about what the future holds. That's just prudent on my part. There are plenty of other fields I can match into that I know will net me more income than psych. And I know I am not the only one on here who feels that way. You guys really need to relax.

While I understand having broad interests...did you seriously apply to 3 specialties (ophtho, anesthesia, psych)? That is SO broad that maybe you should consider FM or EM? In FM or EM, you could do eyes, procedures, and psych, and satisfy your BROAD interests. So, why not FM or EM? EM is very well compensated (also work the fewest hours total of pretty much everybody) and FM should do well in the future.

I understand needing a backup to ophtho, given how competitive it is, but which one is your backup? But, a backup to your backup?

I'm not buying it.

 

[billypilgrim37]

You might take notice that if on a pretty forgiving anonymous message board you create such strong negative reactions, you should be prepared to take the heat for this in the non-cyber world as well. People aren't going to take you seriously unless you give them a really good reason. So you should be working on a really good explanation, and even then you're probably looking at an uphill battle. No self-respecting psych program, if they knew what you were doing, would give you the time of the day.

 

[Sneezing]

You guys really need to relax.

I agree with the new guy. There isn't anything wrong with some one having such goals or aspirations. The more we demonize the fact business is a part of medicine or the finanical aspirations of those in medicine the greater the chance we will destroy the field and ultimately the quality and care we all strive to give for patients. It irks me to think people are so narrowed minded (or perhaps just liberal) to think that financial/business aspirations are prohibitive of being a patient centered physician. They are not mutually exclusive.

We need to start coming to terms with the fact that as obamacare and who knows what else comes down the pipeline that more medical students are going to start recognizing how awesome psychiatry is. Now how we chose to accept this changing demographic is up to us. We can stick with the old fashioned medical hierarchy of trying to squash it and beat it down in the name of academic ivory tower sainthood or recognize it, accept it, and guide it towards the end goal of better patient care.

Look around folks. The system is broken and has been since CMS was established in the 1960's. The best thing we can do is seperate ourselves from insurance companies and if it means outpatient based physicians lead the way then so be it.

Besides, most folks who have spent a rotation or two doing psych quickly realize they either can or can't do it for the rest of their life. Its a visercal reaction that doesn't reside in the grayzone.

 

[whopper]

Assuming you mean not accepting private insurance (not malpractice insurance), you can do it, but expect a slower process of filling up your practice, and at the same time having to cater to patients who are especially more needy and having to bend-over more because you have less selection.

In a private practice, expect a lot of patients to want to call you up because their favorite football team lost and now they want to talk to their "favorite" doctor. If they are paying you top dollar, expect the odds of that person to be ticked off with you and walk away if you don't cater to their every need quickly (edit: to go up).

Also self-check to make sure you are not doing something unethical because you are in a different situation than the norm.

 

[Sneezing]

It can be done but you also must realize that it will likely narrow down a practice to certain illness. Anxiety spectrum and mood disorders. OCD, PTSD, some bipolar, anxiety, panic disorder, depression, dysthmia, adjustment disorder, grief, MR, some dementia, substance use, etc...

Are you prepared and interested in working with this population? Do you want to be saddled with phone calls, numerous faxes, and ample benzo/panic complaints? Are you willing to give up the pathology one sees in inpatient units? Or even the sound of a galloping zebra on the C/L service? Don't forget that psychiatry as a whole is mentally exhausting.

A cash only private practice is a very narrow focus. Is it what you want your career to be? Think about it. Also make sure that you are still patient focused. We don't need ... unsavory characters.

 

[F0nzie]

If you want to make money I say moonlight as an orthopedic surgeon for a higher hourly rate at a hospital and start a lifecoaching for executives "cash only" business on the side.

 

[nitemagi]

I agree with the new guy. There isn't anything wrong with some one having such goals or aspirations. The more we demonize the fact business is a part of medicine or the finanical aspirations of those in medicine the greater the chance we will destroy the field and ultimately the quality and care we all strive to give for patients. It irks me to think people are so narrowed minded (or perhaps just liberal) to think that financial/business aspirations are prohibitive of being a patient centered physician. They are not mutually exclusive.

The intention is not to demonize business, but to weed out those that choose a profession for the purpose of money only, without a discernible other interest in mental illness. Sure, psych is a secret lifestyle specialty, and in some ways that should lead to attracting the best and the brightest, but if we advertise the money only then we may be attracting only the predatory or greedy. This only furthers the maximization of the 10-15 minute med check( the way to maximize income), and IMHO doesn't serve our patients.

 

[whopper]

I mentioned this in another thread months ago. I have a multimillionaire patient who wanted to talk to me on a moment's notice despite me telling him it was not appropriate.

I thought of making him a "private" patient. He wants to talk to me over trivial issues, for extended periods of time, I'm going to charge him. Ethically, I felt this was justified if I informed him that he was taking time away from other duties so I had to charge him, talking to him over the phone was not billed by insurance, and that I didn't think it was even needed but that if he wanted to take that option, I could only do it for a price. Otherwise, please do not call me up every fifteen minutes on issues such as his stock is going down so he now feels anxious.

 

[Sneezing]

No. The 10-15 minute med check is a product of insurance. That is maximization if you take insurance. Google cash psychiatrists out there or talk with them. They aren't doing 10-15minutes. They do 20 minute at the minimum and 30 is the norm. We don't like it, patients don't like it which are both driving incentives in a cash status to maintain quality and prevent insurance related destruction.

When a patient is paying out of their own pocket they will always set the quality bar higher than any insurance company.

 

[nitemagi]

No. The 10-15 minute med check is a product of insurance. That is maximization if you take insurance. Google cash psychiatrists out there or talk with them. They aren't doing 10-15minutes. They do 20 minute at the minimum and 30 is the norm. We don't like it, patients don't like it which are both driving incentives in a cash status to maintain quality and prevent insurance related destruction.

When a patient is paying out of their own pocket they will always set the quality bar higher than any insurance company.

That presumption is that patients have a frame of reference to recognize high quality from low quality, which they don't always. Sometimes higher price is presumed higher quality. Anecdotally a psychiatrist opens a cash practice for $400/hr, and fills in not too long a time because in the city he is in, people presume he must be really good, despite the fact that he has marginal credentials and shoddy work.

Quality and cash practice don't necessarily follow a free market ideal. Now one could argue that if this guy is awful, word will spread and his PP will dry up, which may happen, and high quality providers will fill up. But that's again following a presumption. The 15 minute med check is often talked about as being "forced" on us, but really grew as a product of psychiatrists receiving equal payment for a short med visit as a full hour visit, so naturally we'd work less for the same money. That isn't exactly being "forced" on us, but trying to get as much money for as little effort. And thus quality suffers.

Longer visits and higher quality in cash practices aren't guaranteed if the endpoint for the practitioner is primarily financial.

 

[F0nzie]

I think you can provide a 15 minute med check and still offer good care. The time allotments for follow ups (15 min, 25 min, 45 min) should be taken on a case by case basis. Some patients are stable on medications and may only need a refill or minor med adjustments. It also makes financial sense for the patient. Let's say theoretically it costs the patient $75 for 15 minutes vs. $125 for 30 minutes. Certainly you should use your clinical judgment to determine which patients would be suitable for a 15 minute med check. On the opposite end of the spectrum if you restrict yourself to 15 minute med checks, be prepared for unsatisfied patients.

The challenge of having 15 minute med checks in a cash only private practice is potentially seeing 4 patients an hour. Anybody in the field of psychiatry can see the potential pitfalls with cramming this many patients in an hour.(eg. the late patient, the talkative patient, the needy patient, the unstable patient). The increased responsibility and time constraints may require safeguards such as hiring a secretary or additional staff which will cut into your bottom line and raise your overhead fees at which point you may as well accept insurance and raise your rates.

In my opinion, the best care is personalized care by dedicating yourself to the specific needs of your patients rather than standardization of care dictated by insurance companies. The problem with insurance driven care is it attempts to force physicians to comply with a model that is primarily financially driven(eg. psychiatrists only seeing patients for 15 minute follow ups). Another prime example is the fact that psychotherapy offered by psychiatrists is reimbursed at half the rate compared with med management. This is because psychologists and social workers can offer psychotherapy at reduced rates, however, you can see how care may be fragmented. If you're an entrepreneur and can accept the business aspect of medicine and get over your perceived duty to work for someone else, there will always be patients that will be looking for traditional personalized care with the option of self-submission of insurance claims. The ideal form of care may not be realistic due to today's reimbursement realities, however, small deviations in our current practices toward the ideal may help bring about change.

 

[edumacator]

"I love lawyers. They always pay cash and they never get better." -Niles Crane.

 

[Rhayven44]

This topic comes up a ton, and for good reason (I think). Lets be honest...we bombard medical students with the concept that insurance companies are the "boogey man" and suddenly are surprised when people actively attempt to avoid them?

As I move more and more towards the idea of private practice, I do have a question. Is there anywhere that has a list of insurance companies that are heinous vs. those that are not? The biggest horror I hear are the companies that withhold reimbursements for months at a time...but then, I don't ever see posts about which companies do that. Any enlightenment would be appreciated or pointing me in the direction where that info is routinely found.

 

[sunlioness]

In my year of private practice, Medicare never paid me. I eventually gave up asking them to. You always hear about Medicare fraud and I often wondered what the criminals knew about getting Medicare to pay them that I didn't. Highmark, UPMC and CCBH (the local medicaid people) paid promptly and fairly. I believe all of those are local to here though. Aetna paid me rarely and hardly anything and was a huge pain. United paid me promptly and poorly.

This is my personal experience only.

 

[nitemagi]

This topic comes up a ton, and for good reason (I think). Lets be honest...we bombard medical students with the concept that insurance companies are the "boogey man" and suddenly are surprised when people actively attempt to avoid them?

As I move more and more towards the idea of private practice, I do have a question. Is there anywhere that has a list of insurance companies that are heinous vs. those that are not? The biggest horror I hear are the companies that withhold reimbursements for months at a time...but then, I don't ever see posts about which companies do that. Any enlightenment would be appreciated or pointing me in the direction where that info is routinely found.

Not that I can answer this, but I suspect there's some regional differences. Blue cross and blue shield are essentially franchises, medicaid is state dependent. I'd be curious if national insurances function differently btwn regions.

 

[michaelrack]

When a patient is paying out of their own pocket they will always set the quality bar higher than any insurance company.

unless they just want benzo's

 

[michaelrack]

You always hear about Medicare fraud and I often wondered what the criminals knew about getting Medicare to pay them that I didn't. .

the criminals know how to fill out the Medicare enrollment forms correctly (this is quite complex).

 

[TheWowEffect]

In my year of private practice, Medicare never paid me. I eventually gave up asking them to. You always hear about Medicare fraud and I often wondered what the criminals knew about getting Medicare to pay them that I didn't. Highmark, UPMC and CCBH (the local medicaid people) paid promptly and fairly. I believe all of those are local to here though. Aetna paid me rarely and hardly anything and was a huge pain. United paid me promptly and poorly.

This is my personal experience only.

I am surprised to learn this..I am in private practice too..Medicare is actually one of the most prompt payers but don't pay as well...BC/BS, Anthem, Aetna, United all pay but at various rates...Some quicker than others...We don't take Medicaid but I know they pay promptly but very poorly...So, wonder why you had this experience...may be it has to with how you structure the practice, credentialling etc...

For OP- Even if you take insurance, it is not hard to make up to 400K in private practice..

 

[TheWowEffect]

the criminals know how to fill out the Medicare enrollment forms correctly (this is quite complex).

It can be very simple if you hire an experienced biller or credentialling specialist..they do it for a very reasonable amount of money...

 

[Sneezing]

It doesn't cease to amaze me if you cruise nursing forums or psychology to NP type forums that there isn't any self flagellation going on. But here there are allusions to being a benzo dispensary, being amoral, or just general malaise. While we are culturally road blocking ourselves to patient care improvement, economic progression, and even greater effeciency midlevels are opening such practices. They are making more money which in turn is used for their PACs and propagates the notion they can function as equivalents.

Now should we saturate the private practice market it would essentially only leave employed positions left which are apt to dictate a more realistic scope of practice for them. Big picture we are giving a silent nod to midlevels as equivalents by not pursuing private practice more aggressively and permitting the 'need' for them to open shop.

 

[roubs]

Psychology has it's fair share of self flagellation. You don't have Capella and Argosy handing out MDs yet. I know you have the Caribbean but there are residency slots to absorb those grads, unlike in our system that has something like 4200 people competing for 2300 APA-accredited spots. Anyway, I will not go on.

I also wanted to say thanks for the private practice ideas, I will charge $200+/hr for my CBT and people will think its the best evarr.

 

[Sneezing]

Best wishes with the CBT practice - your work is needed. Now, prescribing midlevels is a different topic.

 

[medium rare]

No. The 10-15 minute med check is a product of insurance. That is maximization if you take insurance. Google cash psychiatrists out there or talk with them. They aren't doing 10-15minutes. They do 20 minute at the minimum and 30 is the norm. We don't like it, patients don't like it which are both driving incentives in a cash status to maintain quality and prevent insurance related destruction.

When a patient is paying out of their own pocket they will always set the quality bar higher than any insurance company.

I'm cash only and offer 30- and 50-minute appointments after a 90-minute intake. The vast majority of patients I see come to me specifically because I offer both therapy and medication. The only time I do medication only is when the patient either already has a therapist or has been in therapy prior and now only needs routine med management.

Cash only is completely doable, but as Whopper mentioned, it will take you longer to build, but not necessarily a long time.

 

[whopper]

it will take you longer to build, but not necessarily a long time.

One could fill up the practice with insured patients, then when filled up, refuse to take any new patients unless cash-only. Then gradually over time fill up with cash-only patients while the insured patients stabilize.

 

[F0nzie]

One could fill up the practice with insured patients, then when filled up, refuse to take any new patients unless cash-only. Then gradually over time fill up with cash-only patients while the insured patients stabilize.

Any forseeable disadvantages with starting fresh out of residency with a cash-only practice 2-3 days per week and supporting the overhead costs with part-time employment and moonlighting, and then gradually transitioning to fulltime private practice? Instead of going through the hassles of getting on insurance panels, quickly filling up, then telling patients "sorry not gonna take insurance anymore". Or maybe alternate paths to cash private practice that may be more or less effective?

 

[sunlioness]

One could fill up the practice with insured patients, then when filled up, refuse to take any new patients unless cash-only. Then gradually over time fill up with cash-only patients while the insured patients stabilize.

Don't some insurance contracts actually prohibit people from doing this?

 

[nitemagi]

Any forseeable disadvantages with starting fresh out of residency with a cash-only practice 2-3 days per week and supporting the overhead costs with part-time employment and moonlighting, and then gradually transitioning to fulltime private practice? Instead of going through the hassles of getting on insurance panels, quickly filling up, then telling patients "sorry not gonna take insurance anymore". Or maybe alternate paths to cash private practice that may be more or less effective?

That's what I'm doing, except the overhead is covered by a FT job with flexible hours, some evening work. Depends on how much you NEED to make right out of residency, what you're willing to sacrifice, and whether you want to deal with insurance companies (I don't). Going PT from the beginning would mean you'll have a lower salary in the beginning.

 

[medium rare]

Don't some insurance contracts actually prohibit people from doing this?

Yes, some do. One needs to read the fine print of their contract and make sure they know what they're signing.

If you think you want to eventually transition to self-pay, then I recommend picking 2-3 high volume panels in your area to get you going while still having enough of a potential patient base to build the cash practice.

In my practice, only about 1 in 4 new patient calls actually end up scheduling because of the need for a paneled provider.

 

[TheWowEffect]

As long as the patient signs a waiver, it is fine. The waiver has to say that you will not bill their insurance, and they will pay cash. Many pilots, judges, politicians who have insurance do this.

 

[silas2642]

I was wondering how many green attendings still moonlight to supplement their income? I'm likely going to go down the path of income based repayment, and once I'm making an attending salary, an enormous chunk of that is going back to loans...

I think I want to stay in academics in Boston, but I'm not sure how feasible this would be with a family (hopefully) and serious debt.

 

[romanticscience]

For a patient to receive "out-of-network" benefits from their insurer, does the cash-practice doc need to go through the credentialling process?

 

[nexus73]

For a patient to receive "out-of-network" benefits from their insurer, does the cash-practice doc need to go through the credentialling process?

No

 

[swisschard]

For a patient to receive "out-of-network" benefits from their insurer, does the cash-practice doc need to go through the credentialling process?

I am in private practice and recently got a letter from an insurer asking me to enroll--unclear to me how they could refuse to reimburse a patient on the basis of my not enrolling, but I'm sure they'll try anything to minimize payouts.

 

[splik]

For a patient to receive "out-of-network" benefits from their insurer, does the cash-practice doc need to go through the credentialling process?

erm out-of-network means you are out-of-network, i.e. not credentialed and paneled....

 

[nexus73]

It seems like it should be illegal to reimburse more for "in network" doctors and less for "out of network" doctors. What is the rationale behind this? I understand not paying the out of network doctor's full charge, but I think insurance should pay the in-network rate, even if the doctor is out of network.

 

[romanticscience]

Does practicing out of your home preclude one from getting on insurance panels? I'm planning on opening a psychoanalytic psychotherapy practice.


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[splik]

Does practicing out of your home preclude one from getting on insurance panels? I'm planning on opening a psychoanalytic psychotherapy practice.


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it doesn't but you would be crazy to see patients out of your own home if you are just establishing a practice. new practices tend to get more questionable shall we say patients and you really want to have been seeing someone for years before you even consider inviting them into your home for treatment. one of my psychoanalytic supervisors would see some patients in her home (but not most) but only after she had been seeing them for years. I think the general consensus it is rather unwise to invite narcissistic and borderline pastients (which is essentially what psychoanalytic practice consists of these days) into your home. and remember the more recent a graduate you are the more disturbed the patients coming to you will be

 

[digitlnoize]

Does practicing out of your home preclude one from getting on insurance panels? I'm planning on opening a psychoanalytic psychotherapy practice.


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Agree with splik. This is a terrible idea. There are lots of ways to defer the cost of renting a space. Talk to some other therapists of various kinds (talk therapy, massage therapy, PT/OT, yoga, etc...or even doctor's offices) and see if you can rent a room from them 1-2 days a week as you're getting started.

 

[romanticscience]

Thanks guys. I got this big house that I could potentially use (first floor). I guess the golden days are gone! It's hard shaking this overly thrifty resident attitude.


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[WisNeuro]

Thanks guys. I got this big house that I could potentially use (first floor). I guess the golden days are gone! It's hard shaking this overly thrifty resident attitude.

To add to this, writing off part of your home (office) as a business expense, is one of the best ways to get audits from the IRS.

 

[Ceke2002]

I've seen a couple of general counsellors who worked from their own homes - one did at least have a separate area with the rest of the house closed off, but the other just lead you through her house and went 'Okay where do you want to sit, in the lounge or in the kitchen? (like we were going to sit at the kitchen table and have tea and biccies like I was a friend dropping by, not a patient). Both situations were uncomfortable, one more than the other. If you're talking full blown psychotherapy/psychoanalytical work though...a therapist with an office in their house? No way, uh-uh, get stuffed, ain't happenin'. I don't even like it when therapists decorate their offices to make them look too cosy. My Psychiatrist's office has 2 chairs, a desk with a computer and a few items of stationery on it, an old metal filing cabinet in the corner, and neutral paintwork and carpeting. That'll do me, anything much beyond that and I'll probably start wondering why your room looks like you think we're going to be friends.