What is the outpatient psychiatric hourly rate for outpatient work?

[jbomba]

If you take insurance tele might be more acceptable, I really don't know. I can only say what we've seen and it seems like a lot of the folks doing tele with multiple licenses live in CA (which is where I think you wanted to live/practice if I remember correctly). Insurance companies are starting to reimburse less for tele-only appointments as well though that seems to be state dependent. If CA allows them to pay less for tele-only make sure to factor that into your equation as well.

Yeah thats also a good point. I'm going to continue my license in the state I am in for residency as well as CA. So ideally will have two states which should help make up for slower traffic potentially.

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[TexasPhysician]

I hear your point. However, waiting lists are months long. Are people really going to opt for a mid level or just sit on a waiting list to be seen in person rather than seeing an actual MD/DO via tele right now who also happens to take their insurance? I mean, the big telepsych companies are cashing in on the stay at home crowd.

The big telepsych companies are also ruining it for legit private practice psychiatrists. I see quite the influx of patients that tried tele psych and/or counseling and felt it was a horrible experience. They felt not listened too, lesser quality clinicians, and low rapport. They don’t mind switching back to tele with me sporadically, but we have built rapport already.

 

[splik]

I hear your point. However, waiting lists are months long. Are people really going to opt for a mid level or just sit on a waiting list to be seen in person rather than seeing an actual MD/DO via tele right now who also happens to take their insurance? I mean, the big telepsych companies are cashing in on the stay at home crowd.

This is false. The big telepsych companies made their money prescribing industrial quantities of stimulants to people who were probably selling them. No one was making money trying to do telepsych for depression or other common mental disorders w/o prescribing controlled drugs. In fact, before the pandemic and the suspension of Ryan haight those companies were hemorrhaging money. Those companies have now gone under or are under criminal investigation. Most of the conventional telepsych companies (i.e. the non-tech ones) contract with institutions (e.g. hospitals, jails etc) to provide care to patients who are not outpatient and not in their homes.

Lots of people have gone to telepsych only during the pandemic. Many of those who are cash only are struggling to fill even with multiple state licenses. I know people with 10+ state licenses who aren't full. For insurance based practices it is much easier, but you are not going to stand out if you are telepsych only, and if you are telepsych only the insurance companies will pay you much less and won't be willing to negotiate good rates with you. In some places, insurances are refusing to cover telepsych.

As for your mid level point, if you are offering limited quality care via telepsych in an insurance based model, your clientele does not care if you are an NP or an MD and many don't know the difference. The number of pts who say "my psychiatrist" when they are talking about an NP is staggering. The masters level therapists prefer referring to NPs over psychiatrists and many pts prefer NPs because they will get the dx and candy they want from someone who is perceived to be more empathic.

 

[jbomba]

This is false. The big telepsych companies made their money prescribing industrial quantities of stimulants to people who were probably selling them. No one was making money trying to do telepsych for depression or other common mental disorders w/o prescribing controlled drugs. In fact, before the pandemic and the suspension of Ryan haight those companies were hemorrhaging money. Those companies have now gone under or are under criminal investigation. Most of the conventional telepsych companies (i.e. the non-tech ones) contract with institutions (e.g. hospitals, jails etc) to provide care to patients who are not outpatient and not in their homes.

Lots of people have gone to telepsych only during the pandemic. Many of those who are cash only are struggling to fill even with multiple state licenses. I know people with 10+ state licenses who aren't full. For insurance based practices it is much easier, but you are not going to stand out if you are telepsych only, and if you are telepsych only the insurance companies will pay you much less and won't be willing to negotiate good rates with you. In some places, insurances are refusing to cover telepsych.

As for your mid level point, if you are offering limited quality care via telepsych in an insurance based model, your clientele does not care if you are an NP or an MD and many don't know the difference. The number of pts who say "my psychiatrist" when they are talking about an NP is staggering. The masters level therapists prefer referring to NPs over psychiatrists and many pts prefer NPs because they will get the dx and candy they want from someone who is perceived to be more empathic.

What do you recommend to make a hybrid insurance/cash based practice work on today's environment? Ideally I'd like an 80/20 split of tele to in person.

I'll have extensive training in a niche area of psychiatry when I finish residency next year which I'm hoping makes me more marketable to this particular population. But for the general adult stuff I'm curious to hear how you think one could go about staying relevant today.

 

[forchinet121]

This is false. The big telepsych companies made their money prescribing industrial quantities of stimulants to people who were probably selling them. No one was making money trying to do telepsych for depression or other common mental disorders w/o prescribing controlled drugs. In fact, before the pandemic and the suspension of Ryan haight those companies were hemorrhaging money. Those companies have now gone under or are under criminal investigation. Most of the conventional telepsych companies (i.e. the non-tech ones) contract with institutions (e.g. hospitals, jails etc) to provide care to patients who are not outpatient and not in their homes.

Lots of people have gone to telepsych only during the pandemic. Many of those who are cash only are struggling to fill even with multiple state licenses. I know people with 10+ state licenses who aren't full. For insurance based practices it is much easier, but you are not going to stand out if you are telepsych only, and if you are telepsych only the insurance companies will pay you much less and won't be willing to negotiate good rates with you. In some places, insurances are refusing to cover telepsych.

As for your mid level point, if you are offering limited quality care via telepsych in an insurance based model, your clientele does not care if you are an NP or an MD and many don't know the difference. The number of pts who say "my psychiatrist" when they are talking about an NP is staggering. The masters level therapists prefer referring to NPs over psychiatrists and many pts prefer NPs because they will get the dx and candy they want from someone who is perceived to be more empathic.

What about teladoc and talkiatry? They are growing and don’t prescribe stimulants or controlled substances, they just treat depression and anxiety from what I understand

 

[Jules A]

What do you recommend to make a hybrid insurance/cash based practice work on today's environment? Ideally I'd like an 80/20 split of tele to in person.

I'll have extensive training in a niche area of psychiatry when I finish residency next year which I'm hoping makes me more marketable to this particular population. But for the general adult stuff I'm curious to hear how you think one could go about staying relevant today.

In my experience hybrid is ideal to give them their choice and 80/20 is about the unintentional split I'm seeing in my cash practice. Most of my geri and child/adolescents are coming in person at least for the first visit. Having an actual office also allows availability for in person when the Haight act is reinstated and AIMS which feel is nearly impossible to do appropriately via telehealth.

 

[jbomba]

What about teladoc and talkiatry? They are growing and don’t prescribe stimulants or controlled substances, they just treat depression and anxiety from what I understand

A colleague started with them a couple of months ago. She's being paid low 300s for 36 hrs a week. Completely full schedule within a week or two of starting.

 

[forchinet121]

A colleague started with them a couple of months ago. She's being paid low 300s for 36 hrs a week. Completely full schedule within a week or two of starting.

That seems pretty solid

 

[trophyhusband]

In my experience hybrid is ideal to give them their choice and 80/20 is about the unintentional split I'm seeing in my cash practice. Most of my geri and child/adolescents are coming in person at least for the first visit. Having an actual office also allows availability for in person when the Haight act is reinstated and AIMS which feel is nearly impossible to do appropriately via telehealth.

Other thing to note is that if providers intend to keep their DEA license they better have a physical office. Apparently the DEA has been going around looking for physical offices to make sure folks are in compliance with the requirement. They can't enforce Haight right now but they seem to be gearing up by enforcing the requirement that providers have a physical office to see patients in once it starts back up. Guessing a lot of folks are using those UPS store addresses or their home addresses (which is insane) where there isn't an office to see patients.

 

[calvnandhobbs68]

Other thing to note is that if providers intend to keep their DEA license they better have a physical office. Apparently the DEA has been going around looking for physical offices to make sure folks are in compliance with the requirement. They can't enforce Haight right now but they seem to be gearing up by enforcing the requirement that providers have a physical office to see patients in once it starts back up. Guessing a lot of folks are using those UPS store addresses or their home addresses (which is insane) where there isn't an office to see patients.

Yeah this has been popping up on the facebook groups. DEA agents randomly showing up (especially in new york apparently) if you have or are applying for a DEA license to make sure you have an actual office. Doesn't have anything to do with suboxone either, which is often what they've usually shown up about in the past.

 

[splik]

What about teladoc and talkiatry? They are growing and don’t prescribe stimulants or controlled substances, they just treat depression and anxiety from what I understand

Teladoc and talkiatry are both private equity backed. These PE backed companies have artificially inflated growth by money pumped into them. Teladoc had a 40% drop of stock value because of not meeting their targets back in April (it is also mostly not mental health and they focus on prescribing antibiotics to anyone who wants them which is the same principle is stims). They also contract with insurance companies to provide on demand care on the cheap. Talkiatry has some offices in NYC for in person care and is expanding its offices for in person care.

 

[forchinet121]

Teladoc and talkiatry are both private equity backed. These PE backed companies have artificially inflated growth by money pumped into them. Teladoc had a 40% drop of stock value because of not meeting their targets back in April (it is also mostly not mental health and they focus on prescribing antibiotics to anyone who wants them which is the same principle is stims). They also contract with insurance companies to provide on demand care on the cheap. Talkiatry has some offices in NYC for in person care and is expanding its offices for in person care.

Yeah but they provide good pay for the average psychiatrist as seen above, 325k for 36 hours of work, it seems like things are working for them without prescribing controlled substances

 

[Candidate2017]

This is an impossible goal. You can not do everything alone. Blaming yourself is going to lead to burnout

The goal is to reflect upon recurring clinic problems, come up with potential solutions, implement them, experiment, and solve them. This is not unlike therapy (or business). The supervisors I had in training definitely knew what they were doing. Today as an attending, I run on time, staff understands what I need and how I operate, notes are almost always signed by closing time.

So yes, definitely, if clinic consistently runs late or a problem consistently pops up (i.e., patients can't find the clinic, all new evals are asking for benzos), then I need to exercise initiative and implement better processes.

Too many clinics have failed me on call backs, so missing a live call with me and I’ll go elsewhere. I’m still waiting on some clinics to call me back from months ago. I end taking my family or myself to somewhere with better service. My response is common. My family uses a DPC/concierge PCP.

It is your practice to run how you want, but if you want growth, these are the issues that will certainly lead to problems.

More issues will lead to more patients initiating chargebacks with credit card companies. Those you’ll need to respond too or just lose the money. Then you’ll need to decide whether to issue and mail termination paperwork or try to repair the relationship. More phone calls or trips to post office for certified mail.

I feel I have good "customer service". At the same time, I have explicit guidelines as to when/where/what/how to contact me, and when to expect call backs. Though I generally will answer calls by end of day, I'm not going to answer calls "live".

I'm not saying this is the right or wrong way, but I'm not into growth for sake of growth. I actually don't mind terminating patients. Again, I have a streamlined termination process that takes little effort. To me, terminating patients is akin to an artist chipping away at a massive block of stone to create something desirable... which is a patient panel that works for me and with me.

 

[liquidshadow22]

Yeah but they provide good pay for the average psychiatrist as seen above, 325k for 36 hours of work, it seems like things are working for them without prescribing controlled substances

i dont think this is correct, pretty sure they rx controlleds

 

[calvnandhobbs68]

Too many clinics have failed me on call backs, so missing a live call with me and I’ll go elsewhere. I’m still waiting on some clinics to call me back from months ago. I end taking my family or myself to somewhere with better service. My response is common. My family uses a DPC/concierge PCP. My initial call was answered live, and in rare instances that it is missed, I get a call back within 15 minutes. My urologist and derm answers immediately or max 5 min hold. I don’t think my PCP is any better than other PCP’s. Im paying for the service, low wait times, and access.

It is your practice to run how you want, but if you want growth, these are the issues that will certainly lead to problems.

More issues will lead to more patients initiating chargebacks with credit card companies. Those you’ll need to respond too or just lose the money. Then you’ll need to decide whether to issue and mail termination paperwork or try to repair the relationship. More phone calls or trips to post office for certified mail.

Uh that type of callback response is….not typical. So acting like it’s somehow common to be able to get ahold of your urologist or dermatologist directly in 5 minutes is bizarre. Maybe, maybe for direct primary care where you’re basically paying them for direct access. But what, you expect all your doctors to drop whatever they’re doing in the middle of a patient appointment to talk to you live? Or are you talking about office staff?

 

[romanticscience]

The goal is to reflect upon recurring clinic problems, come up with potential solutions, implement them, experiment, and solve them. This is not unlike therapy (or business). The supervisors I had in training definitely knew what they were doing. Today as an attending, I run on time, staff understands what I need and how I operate, notes are almost always signed by closing time.

So yes, definitely, if clinic consistently runs late or a problem consistently pops up (i.e., patients can't find the clinic, all new evals are asking for benzos), then I need to exercise initiative and implement better processes.



I feel I have good "customer service". At the same time, I have explicit guidelines as to when/where/what/how to contact me, and when to expect call backs. Though I generally will answer calls by end of day, I'm not going to answer calls "live".

I'm not saying this is the right or wrong way, but I'm not into growth for sake of growth. I actually don't mind terminating patients. Again, I have a streamlined termination process that takes little effort. To me, terminating patients is akin to an artist chipping away at a massive block of stone to create something desirable... which is a patient panel that works for me and with me.

It's rare, but it's possible. I remember planning these things while in my chaotic residency outpatient clinic too! My practice runs this way. I'm solo w/o staff and have numbers close to your goal. It takes a combination of comfort with direct patient care/psychodynamic issues, psychotherapy skill, smart use of technology, careful selection of patients, flexibility with scheduling, restriction to good payors, etc.

I want to keep your hopes up! PM me if you're curious about my setup.

 

[TexasPhysician]

Uh that type of callback response is….not typical. So acting like it’s somehow common to be able to get ahold of your urologist or dermatologist directly in 5 minutes is bizarre. Maybe, maybe for direct primary care where you’re basically paying them for direct access. But what, you expect all your doctors to drop whatever they’re doing in the middle of a patient appointment to talk to you live? Or are you talking about office staff?

I think you misunderstood my post or maybe I wasn’t clear. I’m saying that I can reach someone at the office quickly. It may be a receptionist to schedule an appointment.

I’ve been responding here to someone about how a telepsych practice can easily have 0 staff. That doesn’t fly with me or most people I know.

I’ve tried calling and emailing psychologists, counselors, etc that don’t have staff. They don’t respond back in a timely manner for scheduling or other minor issues. If I have a psychiatrist, urologist, or whatever, I have a baseline expectation that I can reach someone to do a basic task in a reasonable timeframe. This could be scheduling, getting a fax number, asking a billing question, or whatever. Waiting hours to weeks doesn’t fly for busy professionals.

 

[Ironspy]

I intentionally select for private patients who prefer email to phone. My intake process has been streamlined for this. My phone goes to voicemail directing patients to my website to complete a new patient form that has my basic policies and billing info. Once they do the intake form they can confirm billing themselves. Only after that is done, I schedule a quick screening call and schedule an intake.

Existing patients can reschedule their own appts >48 hours prior if needed. I tell patients that i respond to messages within 48h and anything more urgent goes to the ED. I do see a younger patient population and probably miss out on some patients who like the phone but all my patients know these expectations up front. Someone who excepts to speak to me or staff within an hour of calling would not be a good fit for my practice

 

[clausewitz2]

I intentionally select for private patients who prefer email to phone. My intake process has been streamlined for this. My phone goes to voicemail directing patients to my website to complete a new patient form that has my basic policies and billing info. Once they do the intake form they can confirm billing themselves. Only after that is done, I schedule a quick screening call and schedule an intake.

Existing patients can reschedule their own appts >48 hours prior if needed. I tell patients that i respond to messages within 48h and anything more urgent goes to the ED. I do see a younger patient population and probably miss out on some patients who like the phone but all my patients know these expectations up front. Someone who excepts to speak to me or staff within an hour of calling would not be a good fit for my practice

Doximity dialer's direct-to-VM feature is really a godsend. It is essentially the only way I return phone calls and always make sure to suggest sending a message through the patient portal. Most people can be conditioned to do this pretty quickly once they figure out there is a chance I might respond within minutes on the portal (if I happen to have downtime and am already reading my messages) and by end of the next business day at worst. I have some well-established patients from my early days who already have hold of my direct work email who I can't seem to herd over to the patient portal but nobody else gets direct emails from me anymore.

I have only made a handful of live calls to patients in the last year, one of which was a "I would like you to go directly to [local psych hospital emergency room] right now, and if when I call them in two hours I hear that you didn't show up I will be petitioning an involuntary"

 

[liquidshadow22]

Is there any way to do med mgmt and see 3 pts per hour and actually bill in a way that makes it worthwhile?

99214+90833, you can't really do 3 an hour for this, correct? Likely to trigger audit.

Is it just more common sense to do 2 of these visits an hour as opposed to for example 1)99214+90833 2) 99213 3)99213

I don't see from a billing standpoint why it make sense to see more than 2 patients per hour

 

[jbomba]

Is there any way to do med mgmt and see 3 pts per hour and actually bill in a way that makes it worthwhile?

99214+90833, you can't really do 3 an hour for this, correct? Likely to trigger audit.

Is it just more common sense to do 2 of these visits an hour as opposed to for example 1)99214+90833 2) 99213 3)99213

I don't see from a billing standpoint why it make sense to see more than 2 patients per hour

Isn't medicare paying ~120 for a 99214? So four 15-minute checks would be more than 2 99214 +90833. I'm not talking about quality of care, just the ability to do this without breaking rules.

 

[Bartelby]

Is there any way to do med mgmt and see 3 pts per hour and actually bill in a way that makes it worthwhile?

99214+90833, you can't really do 3 an hour for this, correct? Likely to trigger audit.

Is it just more common sense to do 2 of these visits an hour as opposed to for example 1)99214+90833 2) 99213 3)99213

I don't see from a billing standpoint why it make sense to see more than 2 patients per hour

I think if you consistently bill 99214 + 90833 x2 per hour that is hard to beat. The only catch I have run into is that once patients stabilize sometimes they only need/want a brief check in, which at least for me means doing a quick visit and dropping the 90833 (gives some downtime but decreases productivity).

 

[ObsequiousAplomb]

Is there any way to do med mgmt and see 3 pts per hour and actually bill in a way that makes it worthwhile?

99214+90833, you can't really do 3 an hour for this, correct? Likely to trigger audit.

Is it just more common sense to do 2 of these visits an hour as opposed to for example 1)99214+90833 2) 99213 3)99213

I don't see from a billing standpoint why it make sense to see more than 2 patients per hour

3 x 99214 ~= 2 x 99214+90833. At least where I am 99214 is 150 and 90833 is 75. So 225 x 2 = $450 an hour, and 150 x 3 = $450 an hour.

I would rather see two patients per hour than 3 per hour most of the time. Then put the usually very stable and not at all interested in psychotherapy, just there for a refill patients in an hour dedicated for 3 x 99214, knowing that the ones with stable ADHD with zero comorbidities will at times be 99213s.

I don't like the idea of 4 x 99214, it makes it hard to stay on time all day when even one of the ~30 people runs longer than 12 minutes.

 

[TexasPhysician]

3 x 99214 ~= 2 x 99214+90833. At least where I am 99214 is 150 and 90833 is 75. So 225 x 2 = $450 an hour, and 150 x 3 = $450 an hour.

I would rather see two patients per hour than 3 per hour most of the time. Then put the usually very stable and not at all interested in psychotherapy, just there for a refill patients in an hour dedicated for 3 x 99214, knowing that the ones with stable ADHD with zero comorbidities will at times be 99213s.

I don't like the idea of 4 x 99214, it makes it hard to stay on time all day when even one of the ~30 people runs longer than 12 minutes.

If I was trying to maximize revenue in an insurance practice, I would schedule 3 per hour every hour. Sometimes 1 won’t show. 1 of the 3 are likely easier and won’t need therapy. 1 will benefit from therapy. The 3rd could go either way.

 

[liquidshadow22]

If I was trying to maximize revenue in an insurance practice, I would schedule 3 per hour every hour. Sometimes 1 won’t show. 1 of the 3 are likely easier and won’t need therapy. 1 will benefit from therapy. The 3rd could go either way.

Can you give an example of how you could bill if they all show?

1)99214+90833
2)99214
3)99214

1)99214+90833
2)99214+90833
3)99214

Could the second set work or would it definitely raise red flags?

 

[ObsequiousAplomb]

Can you give an example of how you could bill if they all show?

1)99214+90833
2)99214
3)99214

1)99214+90833
2)99214+90833
3)99214

Could the second set work or would it definitely raise red flags?

If you're coding for what you actually did and documented, then even if it raises flags it is irrelevant. The way you're asking, it sounds like you're asking about fraudulently billing the 90833. You probably shouldn't do that.

 

[jbomba]

What's a reasonable amount of time to spend on 99214+90833?

 

[ObsequiousAplomb]

What's a reasonable amount of time to spend on 99214+90833?

You tell me. It's at least 16 minutes but less than 38 minutes of therapy plus the E&M portion. How long does it take you to do that? That's your answer.

If you still have to ask questions like this, presumably because you don't practice in that way, maybe you should read the dozens of threads on this forum where people say that it's usually 30 minutes but you could occasionally (and not habitually) do this in 20 minutes. There are plenty of people who spend 40 minutes on these encounters. It all depends on the provider and the needs of the patient.

 

[liquidshadow22]

If you're coding for what you actually did and documented, then even if it raises flags it is irrelevant. The way you're asking, it sounds like you're asking about fraudulently billing the 90833. You probably shouldn't do that.

Understandable but supportive psychotherapy is not exactly the most objective modality. I can make an argument that I do this in every encounter.

In my opinion, this is just a stupid billing game we play with the insurance companies. If you are scheduling each patient for 20 min, then you are going to end the encounter and move on to the next pt regardless of what discussion took place with the patient

I'm sure the NPs are. Billing plenty of 90833 even tho the majority have no legitimate psychotherapy training. It's all a sham.

 

[TexasPhysician]

Can you give an example of how you could bill if they all show?

1)99214+90833
2)99214
3)99214

1)99214+90833
2)99214+90833
3)99214

Could the second set work or would it definitely raise red flags?

I don’t have an issue with either if you do the work and document appropriately. The real answer is that you’ll probably have a mix. Patient X can have periods of doing great, is busy at work, and doesn’t want to spend more than 2 minutes via telepsych to get refills for 2 chronic conditions. That’s a 99214. Now I have time for two 29 minute sessions - 16+ for therapy and <13 for meds. The next hour may be completely different. I could get stuck with 3 straight stable ADHD follow-ups for three 99213’s. That leaves time for a bathroom and lunch break.

 

[allantois]

Largely agree, wife makes it clear she has no staff so there will never be a way to call and all messages have to go through the patient portal. No real complaints so far but it only works when you're the only Psychiatrist in town I'd think. Since she's really the only one referrers are aware and let their clients know before they refer.

For directions I send very detailed directions when the appointment is set so folks don't usually have issues but again that only works if you don't do appointments over the phone and everything goes through the portal.

But if you have competitors I don't know that folks will go through the hassle if they can just go to a competitor instead.

Honestly I can’t imagine having to deal with patient messages directly through a portal
without staff. I have a few who got a hold of my email and it’s been a nightmare to say the least.

 

[trophyhusband]

Honestly I can’t imagine having to deal with patient messages directly through a portal
without staff. I have a few who got a hold of my email and it’s been a nightmare to say the least.

I mean no staff in that there is no one in office with her and no one answering phones outside of new patient calls (I answer those). I handle portal messages for scheduling and superbills but otherwise she handles the rest. She has a 2 business day message return policy.

 

[Jules A]

Honestly I can’t imagine having to deal with patient messages directly through a portal
without staff. I have a few who got a hold of my email and it’s been a nightmare to say the least.

I have a very small cash practice without employees and mostly communicate through texts, some emails and the occasional phone call. Few contact me excessively except anxious patients early on but it subsides as they improve. With the exception of texts later than 8pm I'm generally able to respond in <a couple of hours. The feedback has been that my availability and communication are excellent largely because they aren't fighting the firewall of a receptionist. The most common behavior mod is discretely teaching them to contact pharmacy to check on refills first because 99% of the time it has already been ordered. There are times I miss my old watch dog office manager who thoroughly triaged calls when I was doing community clinic but overall it isn't too cumbersome.

 

[clausewitz2]

I have a very small cash practice without employees and mostly communicate through texts, some emails and the occasional phone call. Few contact me excessively except anxious patients early on but it subsides as they improve.

The super-anxious reassurance-seeking patients tend to require a more structured approach, but so far I've only had to explicitly tell one person that I am only going to respond to one message from them per day. Just delaying response to the others to the limits of my response policy and not responding at all to messages that don't contain a direct question or request of any kind seems to mostly do the trick. It very much reminds me of when I did a DBT rotation during residency and I was incredibly nervous about giving out my phone number, but none of my patients ever called; the transitional object was often enough.

With the exception of texts later than 8pm I'm generally able to respond in <a couple of hours. The feedback has been that my availability and communication are excellent largely because they aren't fighting the firewall of a receptionist. The most common behavior mod is discretely teaching them to contact pharmacy to check on refills first because 99% of the time it has already been ordered. There are times I miss my old watch dog office manager who thoroughly triaged calls when I was doing community clinic but overall it isn't too cumbersome.

Very much this. when I get inquiries about getting refills for things I know I ordered with refills, my response is "Looks like I sent this in with refills, is the pharmacy telling you they can't fill it?" This quickly curtails this behavior.

 

[heartsink]

I have a very small cash practice without employees and mostly communicate through texts, some emails and the occasional phone call. Few contact me excessively except anxious patients early on but it subsides as they improve. With the exception of texts later than 8pm I'm generally able to respond in <a couple of hours. The feedback has been that my availability and communication are excellent largely because they aren't fighting the firewall of a receptionist. The most common behavior mod is discretely teaching them to contact pharmacy to check on refills first because 99% of the time it has already been ordered. There are times I miss my old watch dog office manager who thoroughly triaged calls when I was doing community clinic but overall it isn't too cumbersome.

If your practice became larger than "very small", do you think you would change much in how you structure communication with patients?

This thread has been fascinating to me as it seems like there is a wide spectrum of availability being described. I'm very surprised at some of the responses that paint a picture of easy / quick access to their physicians and I'm curious how sustainable that is for psychiatrists when they are "full".

 

[Ironspy]

Honestly I can’t imagine having to deal with patient messages directly through a portal
without staff. I have a few who got a hold of my email and it’s been a nightmare to say the least.

I have an employed job with RNs and MAs and my solo private practice. Some of messages that are forwarded to me by support staff at my employed job are frankly bonkers and support staff boundaries vary from porous to nonexistent. Most issues in my employed job have been a mismatch of patient expectations and reality because of a lack of communication, consistent boundaries etc.

I set and maintain the boundaries in my private practice, select appropriate patients and make my expectations clear in the paperwork patients receive and sign prior to their first appt. Portal messages that take more than 3 minutes to reply to are discussed in appointments, controlled substances are refilled in appointments only (with rare exceptions), existing patients can reschedule themselves, controlled substances dont get early refills, I'm not available evenings or weekends etc etc. I have higher risk patients who have been hospitalized recently but cannot see brittle borderlines or others who are constantly in crisis.

 

[liquidshadow22]

I don’t have an issue with either if you do the work and document appropriately. The real answer is that you’ll probably have a mix. Patient X can have periods of doing great, is busy at work, and doesn’t want to spend more than 2 minutes via telepsych to get refills for 2 chronic conditions. That’s a 99214. Now I have time for two 29 minute sessions - 16+ for therapy and <13 for meds. The next hour may be completely different. I could get stuck with 3 straight stable ADHD follow-ups for three 99213’s. That leaves time for a bathroom and lunch break.

I don’t have an issue with either if you do the work and document appropriately. The real answer is that you’ll probably have a mix. Patient X can have periods of doing great, is busy at work, and doesn’t want to spend more than 2 minutes via telepsych to get refills for 2 chronic conditions. That’s a 99214. Now I have time for two 29 minute sessions - 16+ for therapy and <13 for meds. The next hour may be completely different. I could get stuck with 3 straight stable ADHD follow-ups for three 99213’s. That leaves time for a bathroom and lunch break.

Technically doing 99214+90833 if it is actually done in 20 minutes is not incorrect.

You are equired to use EM code by complexity and when using a psychotherapy add on and the minimum for 90833 is 16 minutes.

Who is to say whether or not I can or cannot do e & m in 4 minutes on a regular basis?

 

[rjs2131]

Understandable but supportive psychotherapy is not exactly the most objective modality. I can make an argument that I do this in every encounter.

In my opinion, this is just a stupid billing game we play with the insurance companies. If you are scheduling each patient for 20 min, then you are going to end the encounter and move on to the next pt regardless of what discussion took place with the patient

I'm sure the NPs are. Billing plenty of 90833 even tho the majority have no legitimate psychotherapy training. It's all a sham.

Exactly. It’s a game and we’re expected to play by the rules. Interpret the rules in the best way you can and as long as you’re providing good care and documenting well…working smarter > working harder.

 

[allantois]

Technically doing 99214+90833 if it is actually done in 20 minutes is not incorrect.

You are equired to use EM code by complexity and when using a psychotherapy add on and the minimum for 90833 is 16 minutes.

Who is to say whether or not I can or cannot do e & m in 4 minutes on a regular basis?

It’s not a regular basis tho; it would be 4 mins all the time

 

[Jules A]

If your practice became larger than "very small", do you think you would change much in how you structure communication with patients?

This thread has been fascinating to me as it seems like there is a wide spectrum of availability being described. I'm very surprised at some of the responses that paint a picture of easy / quick access to their physicians and I'm curious how sustainable that is for psychiatrists when they are "full".

I don't have plans to quit my hospital jobs but if I decided to do it full time I would hire receptionist/secretary to greet people and do things like answer new client inquiry calls, email lab slips/superbills, appointment reminders, process credit card payments and scheduling. I'm billing about 5h a week now and think I could manage solo for 16-20 billable hours per week.

 

[jbomba]

Do people generally agree using a billing service is worth the 7ish percent cost?

 

[Ironspy]

I don't have plans to quit my hospital jobs but if I decided to do it full time I would hire receptionist/secretary to greet people and do things like answer new client inquiry calls, email lab slips/superbills, appointment reminders, process credit card payments and scheduling. I'm billing about 5h a week now and think I could manage solo for 16-20 billable hours per week.

All of these except answering calls can be automated

 

[TexasPhysician]

Do people generally agree using a billing service is worth the 7ish percent cost?

What type of practice? My OON practice can bill a day’s worth of patients for 2.2% including paying a staff for 2 hours worth of billing time. We have it fairly streamlined. I could automate this for an extra 1% or so. That’s not worth it. That 1% savings at what I am billing essentially pays that staff to work in other areas the rest of the day. Maybe there is a cheaper way to automate it, but I haven’t found it.

Assuming insurance, it is a big hassle to monitor either way. Teaching staff to do this once big enough is often cost effective if you have extra space. A third party company is usually 5-10%. The trouble is that these companies can get lazy, ignore accounts, or fail to resubmit claims properly. You could think you are getting a deal at 5% yet do better with the 8% company.

Regardless you should be auditing the $$. Sketchy things happen with money.

 

[painballer27]

I have a question. Do outpatient psychiatrists always sit in an office and have the patients walk in to see them?

 

[Bartelby]

I have a question. Do outpatient psychiatrists always sit in an office and have the patients walk in to see them?

Not always. These days telehealth to the patient's home is common. There are also some less common scenarios. Some psychiatrists still do home calls (usually in a cash-only model at a higher rate). Some psychiatrists also do things like going to nursing homes and rounding. In general, though I suspect 99% of outpatient psychiatry is either the patient coming to the office or a telehealth visit.

 

[painballer27]

Not always. These days telehealth to the patient's home is common. There are also some less common scenarios. Some psychiatrists still do home calls (usually in a cash-only model at a higher rate). Some psychiatrists also do things like going to nursing homes and rounding. In general, though I suspect 99% of outpatient psychiatry is either the patient coming to the office or a telehealth visit.

I see, I meant of the ones that do in person visits, does the psychiatrist physically remain seated in an office room and the patients come in and out as opposed to having exam rooms seeing patients?

Having a ton of exam rooms could be expensive, so I imagine a psychiatrist could set up a large room with some partitions in it and have the patients sit in a cubicle, like maybe 6 patients at a time. Would need to hire someone to keep things flowing. Then the doc could bounce from "room to room" and see the patients. This could be an efficient set up thus allowing many more patients to receive treatment. I think you could see 50 patients a day like this. Have patients fill out a questionnaire before appointment with some SIGECAPS, etc to have a presumptive diagnosis before entering the room. Thoughts?

 

[trophyhusband]

I see, I meant of the ones that do in person visits, does the psychiatrist physically remain seated in an office room and the patients come in and out as opposed to having exam rooms seeing patients?

Having a ton of exam rooms could be expensive, so I imagine a psychiatrist could set up a large room with some partitions in it and have the patients sit in a cubicle, like maybe 6 patients at a time. Would need to hire someone to keep things flowing. Then the doc could bounce from "room to room" and see the patients. This could be an efficient set up thus allowing many more patients to receive treatment. I think you could see 50 patients a day like this. Have patients fill out a questionnaire before appointment with some SIGECAPS, etc to have a presumptive diagnosis before entering the room. Thoughts?

I see you're taking your "how can I make $1M as a Psychiatrist" questions in a new direction nowadays. Kudos.

There is/was a doc with something like this arrangement in another part of our state. He sees patients for roughly 5 min each and everyone gets their controlled substance cocktail of choice and then it's on to the next patient. Not sure if he goes room to room or if they just quickly shuffle in and out. I'd think this is probably the only way to build a panel of thousand(s) if you're only seeing them for a few min. Most Psych patients who don't want this actually want to talk to talk to their doctor for more than a minute or two.

 

[painballer27]

I see you're taking your "how can I make $1M as a Psychiatrist" questions in a new direction nowadays. Kudos.

What? I don't follow. Where I am, there are patients waiting a long time to see psychiatrists, like 6 months or more. I just think that this would be a possible way to fill a need

 

[trophyhusband]

What? I don't follow. Where I am, there are patients waiting a long time to see psychiatrists, like 6 months or more. I just think that this would be a possible way to fill a need

Same where my wife's practice is and patients would wait for months rather than go to a practice like you described because they actually want to talk to their doctor. Our local CMHC and hospital system's Psych Dept (such as it is) see patients for 20 min follow-ups and the complaints are epic along with everyone trying to escape to community providers. The set up you're proposing would probably have the most entertaining Google reviews possible unless it was a Dr. Feelgood situation like I described in my edited comment.

 

[painballer27]

Same where my wife's practice is and patients would wait for months rather than go to a practice like you described because they actually want to talk to their doctor. Our local CMHC and hospital system's Psych Dept (such as it is) see patients for 20 min follow-ups and the complaints are epic along with everyone trying to escape to community providers. The set up you're proposing would probably have the most entertaining Google reviews possible unless it was a Dr. Feelgood situation like I described in my edited comment.

I see. Okay. I thought patients would be eager to see any psychiatrist rather than having to wait so long. I'm sure they'd understand that you're very busy providing care to lots of people in the community, and as much as you'd like to do longer visits, its just not possible.