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deleted1100659
Just trying to compare what a reasonable load is, as far as average number of patients a day and time alloted for f/us for adults/kids and new patient evals.
Thanks!
Thanks!
Average number of patients you guys are seeing in outpatient setting?
I see new patients for 80 minutes and follow ups for 40 minutes. There is no documentation time built into the day. 12 patients per day, 8am-5pm with 1 hour lunch. 4 day week. Compensation is low end at 240/ year. Work life balance is excellent.
Edit: adults only
Edit: adults only
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deleted1100659
yeah that sounds amazing especially since 4 day work week
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Doesn't sound low for compensation at all since you work 32 hours, adding an extra day would bring that 300k with longer-than-average appointment times (particularly in the adult space). Particularly if there is no call/weekend responsibilities.
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nexus, is that in a cash only practice or insurance accepting?
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*Still in practice building phase of a solo private practice
Have 27 possible clinical hours on schedule.
Currently filling about ~9 hours per week. (*When counting I only count a consult as 60 minutes in this stat because that is more the norm in our specialty)
Max for my 6 hour clinical day is 12 follow ups, which currently is uncommon.
90 min consults
30 min follow ups
Adult only
Anticipate pocketing ~110-115K after overhead for this year. Still need to deduct retirement and taxes and health insurance etc from that.
Have 27 possible clinical hours on schedule.
Currently filling about ~9 hours per week. (*When counting I only count a consult as 60 minutes in this stat because that is more the norm in our specialty)
Max for my 6 hour clinical day is 12 follow ups, which currently is uncommon.
90 min consults
30 min follow ups
Adult only
Anticipate pocketing ~110-115K after overhead for this year. Still need to deduct retirement and taxes and health insurance etc from that.
Perhaps this is off-topic, but I’ve always wondered: for those who express a desire for or an appreciation of these longer appointment times, are you doing therapy during these visits?
I’m in forensics fellowship and don’t currently have any clinic time other than seeing some patients in prison and jail. When I was a resident, though, we worked in an outpatient community clinic. There were social workers who saw the patients separately for therapy. I’m trying to remember but I think the slots were 60 min intakes and either 20 or 30 min follow-ups. At the risk of sounding like a bad psychiatrist, I think I finished more than half of visits under 15 minutes (some of after only 10), then just used the rest of the time to document. I was almost never pressed for time, and even then I could usually develop an appropriate plan that would mitigate risk and allow them to safely return for a close follow up appointment.
And with intakes, I always felt that I could get the important information to safely treat a person well under an hour, and usually spent the remainder collecting helpful, but not essential, information. If I couldn’t collect all the information, since I had the essential parts, I could safely end the visit and collect some additional information during their first follow-up.
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this is in a hospital system taking insurance with a lot of medicare and medicaid, and I'm sure we do not make the hospital money, but it's a non-profit community hospital that has a mission to serve the local population. Our clinic has been somewhat forgotten about, or rather, the hospital focuses like 98% of their time on inpatient, so we can just do our thing and provide good care.
And I do have to be on call about once a week for the hospital, but that's phone call. And I sometimes cover the hospital inpatient unit, which I actually enjoy, but that just swaps what would be a clinic day for a hospital day. Or sometimes my clinic gets blocked out and I cover the whole week in the hospital, which is okay with me. I don't think they'd get this flexibility from most other doctors or specialties.
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For me, there is therapy on about half the patients, and those are longer visits, sometimes we end up running through the full 40 minutes. Some patients take less time...so anywhere from 10 minutes to 40 minutes, which isn't always predictable which patient's will be able to have shorter appointments. I don't have any straight ADHD follow-ups. Most patients are some type of treatment resistant depression, personality disorder, or bipolar/schizophrenia patient with social problems. Having 40 minutes I have plenty of time to address whatever comes up, and if the patient only needs 10 minutes, I have time to stay caught up on notes, orders, clinical tasks, etc. And not stay 2 hours after close or take work home on weekends. I could work harder, do shorter visits, and have more stress and insist on an RVU pay structure to ensure compensation for the work, but for me it's just not that important. I make enough money.
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Gotta have some place to arrange follow-up on discharge for liability's sake, why not try to generate some revenue with it as well?
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Working as contractor for group private practice, I'm the only psychiatrist and keep 80% of collections. Doing this three days per week, about 80% insurance and 20% cash as I only take one insurance. 85% adults, 15% teenagers, nobody under 15. For a while I was seeing 14-16 per day due to being totally full and trying to make sure people could follow up appropriately but this is not sustainable and I am cutting back to aiming for no more than 12 per day and gradually spacing stable folks out a bit more.
I was doing 60 minutes for new evals and thirty minutes for f/us but starting in the new year not seeing anybody new under 18 without 90 minutes for initial eval and considering extending this to adults. I am full to randos or someone from Psychology Today but make a point of trying to accommodate any therapy patients of the practice (a population that is often very med-shy) and referrals from colleagues in from the Old Mothership for a very particular sub-population.
I also have a handful of long-term therapy patients who I see for an hour weekly. Uniformly personality disordered, generally MBT. Work I can do and pretty well in small volumes. If it was my main job I would change my name and flee to Mexico.
As said cutting back to 12 per day and if these three days per week were my sole income I would gross around 250-260k.
I do have some straight ADHD follow-ups and I only see them every couple of months but even with them I do a fair amount of behavioral interventions and solution-focused stuff. With most of my people a lot of brief CBT and ACT work. A great holy h*ll of CBT-I. In general I also often have a somewhat phenomenological approach to interviewing (the Husserl/Jasper/Parnas sense, not the "DSM criteria" sense) and eliciting people's own detailed descriptions of their own experience takes time.
One of the reasons I stopped working in gen pop community mental health was the insistence on 20 minute follow-ups. It was okay-ish for some folks, like people with a psychotic disorder who had been on the same injection for 5 years and would like to get their injection please and not really talk about anything else. most people's lives were vastly too complicated for me to have a really good sense of what was going on AND have sensible conversations about treatment.
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5 days per week, 6 clinical hours per day, 2 hours dedicated chart/messages/phone/paperwork time, 1 hour lunch which I take as a true break most days, 30 minute f/u and 60 min new. Overall good support staff although sad about losing excellent MA soon. $300k/yr.
Is this cash?
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This. Spent like 25 minutes of my appointment with a pt today trying to figure out what he actually experiences that had been labeled "mania" and, to no surprise, basically nothing at all consistent with mania or hypomania. But because it was mostly my trying to ask about a few specific concepts in a bunch of different ways it is most aptly summarized in my note as "no symptoms consistent with narrowly defined mania or hypomania."
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Can I shadow you lol?
I wish that were my life, but it’s not. Some patients take 10 mins but at other times 30 minutes is not enough. There are a few reasons, some well summarized by a few other posters here, including:
1) if someone is not a good historian I have to ask a lot of follow up questions and ask questions in different ways to figure out what actually is going on
2) people who won’t stop talking and need to constantly be interrupted and redirected to get what info you actually need, all while maintaining rapport
3) many of my patients have the bio, the psycho, and the social going to ****, and multiple diagnoses, all of which are unstable. Comes with the territory of building one’s practice with a lot of referrals from desperate colleagues, I guess.
Stuff unique to me:
4) I care a lot about medical sequelae and a lot of my patients are medically complex. So I ask a lot of medical ROS to figure out side effects and interactions. I communicate with PCP’s a lot, too.
5) I’m a big believer in patients knowing what they are getting into so I do spent up to half of each appt talking through the options and explaining what meds do, how they do it, and what side effects to watch for. I gauge my discussion to the patient’s level of function, of course. Patients appreciate this, and many have told me so.
I try to beat the system by simply seeing some of my more complex or long winded patients more often. Like, if you want/need more time with me, pay for it. 🙂
For OP, I see 60 minute intakes and a mix of 20-30 minute follow ups. I am not yet full but on a full day I see 2 news and 10 follow ups, or as many as 14 follow ups. I work 4 days a week, which really helps sanity. A few of my colleagues see as many as 20-30 per day but that is uncommon, usually they are the experienced and hyperthymic sorts.
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Yeah, I think part of it is just a style thing. Pretty sure my brain is built to just be an emergency psychiatrist, at least in the treatment domain. As long as someone is not going to get super sick or die between now and their next appointment, I figure that there is time to figure the rest out. Forensic evals are different, but they have a different question and it’s pretty much a given that those are going to take a lot of time.
I’m looking at jobs now for after fellowship, and I’m questioning whether I have the temperament to do the usual types of psych work on a daily basis. I’m seriously considering a full time emergency department job and then trying to build a forensic practice on the side.
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See child and young adult (<30yo), work in a larger primarily therapist group insurance based PP with a couple other psychiatrists.
Child (<18yo): 60min initial info gathering intake + 30min f/u to discuss treatment within 5-7 days. I know some people in PP who also do 2x 60min intake (90792s) in the same week which tend to be covered under insurance if you do a parent (guardian) and child intake separately. Really the only way to get the 90+ minutes you need for a good child intake covered by insurance in a reasonably reimbursed way is by splitting the intake. Otherwise, you're definitely losing a bunch of money on a per hour basis doing 90 minute initial intakes all in one day.
Adult: 60min intakes
Everyone: 30min followups
Every now and then I get someone who i could truly get in and out in 10-15 minutes but that's basically never for child. I don't think it's feasible to do child followups in <30 minutes, if you think about it thats like 15min with the kid alone, 5 minutes with kid and parents to hear about whatever they have to say now and 5-10 minutes to talk about what you're gonna actually do now....haven't even finished your note yet. I'm also fortunate that like 90+% of my patients have separate therapists, most of them within the practice, so they aren't necessarily relying on me offload all their life's worries in a 30 min followup. I have a couple patients I actually do weekly real manualized CBT with that I block for 50min.
14 patients a day max (7 contact hours, 1 hour for lunch but not paid cause I'm purely collections). 5 days a week. So max 70 patients a week. Max 3 intakes a day now (was doing 5 when I started up and running but not sustainable anymore). I'll probably cut back to 2 max intakes a day in the next month or two.
Child (<18yo): 60min initial info gathering intake + 30min f/u to discuss treatment within 5-7 days. I know some people in PP who also do 2x 60min intake (90792s) in the same week which tend to be covered under insurance if you do a parent (guardian) and child intake separately. Really the only way to get the 90+ minutes you need for a good child intake covered by insurance in a reasonably reimbursed way is by splitting the intake. Otherwise, you're definitely losing a bunch of money on a per hour basis doing 90 minute initial intakes all in one day.
Adult: 60min intakes
Everyone: 30min followups
Every now and then I get someone who i could truly get in and out in 10-15 minutes but that's basically never for child. I don't think it's feasible to do child followups in <30 minutes, if you think about it thats like 15min with the kid alone, 5 minutes with kid and parents to hear about whatever they have to say now and 5-10 minutes to talk about what you're gonna actually do now....haven't even finished your note yet. I'm also fortunate that like 90+% of my patients have separate therapists, most of them within the practice, so they aren't necessarily relying on me offload all their life's worries in a 30 min followup. I have a couple patients I actually do weekly real manualized CBT with that I block for 50min.
14 patients a day max (7 contact hours, 1 hour for lunch but not paid cause I'm purely collections). 5 days a week. So max 70 patients a week. Max 3 intakes a day now (was doing 5 when I started up and running but not sustainable anymore). I'll probably cut back to 2 max intakes a day in the next month or two.
Trying to reconcile this thread with another from a few days ago. In that thread, general consensus was most patients could be billed as 99214. When you consider adding 90833 to roughly half of these encounters, you were looking at something like $3-400/hr with insurance.
The hourly rate seemingly described in this thread is much lower. What's going on?
The hourly rate seemingly described in this thread is much lower. What's going on?
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PGY-3 resident here just learning outpatient this year. What about 90836 and a 99214 for a 60 minute therapy + med management visit? Usually we do like 40-45 minutes of therapy and then 10-15 minutes of med management. Is this common in the "real world?" Is a practice like this after residency sustainable? Or is it better like you mentioned (30 minutes for 99214 + 90833?)
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Yeah, I think emergency psych would be a good fit, but you could also become one of those op docs who does 15 minute visits and make a lot of money, because you can bill based on complexity, not time.
It is consistent with this thread, for example nexus job of seeing 12 per day at 150/patient (or 300/hr) results in 1800 per day and he works 4 days a week and 48 weeks a year which gets you to 345k in revenue then you get 70 percent of that because 30 percent is for overhead and that gets you to his income of 240k per year so he’s making 300/hr or 150/ patient which is good
To answer the OPs question, I'd assume a typical outpatient employed job would by 5 days a week with 60-90 minute intakes, 30 minute followups, 30 minutes of documentation time every 4 hours (1 hour per day), so 7 hours of direct patient care per day, 35 hours per week. My job defines full time as 32 direct patient hours per week, I've heard some places as low as 30, others as high as 36. I'd imagine the salary would be 250-300/year, but open to other opinions.
And I'm part of a hospital clinic, and have no idea what actually gets billed but I assume they have negotiated the best possible rates for the area and are tacking on a decent facility fee you wouldn't see in a private practice.
Is overhead really 30%? That seems high.
It’s not high..he’s also getting paid benefits along with 300/hr
The majority of costs in a practice are fixed, regardless of revenue.
If a practice is bringing in 600k vs 300k, is overhead really 180k vs 90k? What's that extra 90k going to?
This is a solid setup as well, know your worth people he works 30 clinical hours per week and makes 300k with benefits…then we have people asking if they should see 20 per day for 285k…lol
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Only a few of us mentioned pay. Two of us are employed and sushi's practice has been filling slowly / overhead % currently much higher than it would be if he was full and in a cheaper space. Using my schedule, 30*46*300 = 414000. Depending on assumed value of overhead, support staff, and benefits, $300k base salary is not far off.
Sorry I want to clarify this, he’s not making 300/hr he’s billing 300/hr and then netting 70 percent of that so he’s making about 200/hr but he’s also being paid benefits and has support staff so that’s worth something as well so on a 1099 basis this is like he’s making approx 230/hr valuing the worth of benefits as 30/hr
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Child and adolescent practicing outpatient in community mental health setting. I get 90 minutes for intakes and 30 minutes for follow-ups. I work 10 hour days 4 days a week, one of those days is entirely locked up providing clinical supervision to three psych residents and a child fellow. Psychiatrists who see adults get 60 and 20 respectively. Each day includes a half-hour lunch break and two hours of administrative time. Salary is 295k w/benefits. Happy to answer any questions.
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deleted1100659
Interesting; i have an offer right now seeing adolescents for med management that are currently in an IOP and its 4 days a week 10 hour days. Do you like that setup overall?
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This is a pretty great setup cause they are absolutely losing money on you at 295K with 2.5 hours of each day off the table (although if you can bill for the patients seen by the psych residents/fellow that one day that might make up for it).
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It's a setup that allows me to have a pretty awesome side-gig (just posted about it on an older thread if you want to reference), so it works well for me. They do bill for the work the trainees do, so I don't think they'll be losing money on me once I'm full, though I suspect they are now.
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This setup for outpatient and IOP are really quite different. Outpatient is a lot more developmental delays, ADHD, ASD, long-term relationship, school issues (IEP/504s) etc. IOP is always going to be more acute depression, OCD, school refusal, substance use disorders, eating disorders. There is a surprisingly limited overlap between OP and IOP days in CAP, I think IOP has more in common with inpatient (Except 100x less hassle) than outpatient despite the name having outpatient in it.
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What part of the country are you in?
Can you tell us about your side gig?
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Working class city in the northwest.
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Take a look at my recent posts. I described it in another thread right after making the above post.
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Self-pay, child/adolescent and adult private practice here. 12-16 patients/day on average, 5 days/week. 90 minute new evals, 30- and 60-minute follow ups; mix of ongoing therapy and med management.
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Solo private practice, mostly insurance, some cash.
Thirty 30-min med focused and thirty 45-min therapy +/- med appointments per week. Comes to about 12-16 patients per day.
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I thought the common consensus was insurance is not worth it or takes too much admin time for a solo PP? How are you able to be solo and handle insurance?
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There are definitely people who are solo PP who take 1-2 insurance panels. Sushirolls is solo PP too. Typically tends to be 1-2 panels + cash as it's too much logistically to deal with submitting billing to 5 different insurance panels on your own but you can hire a billing service to submit charges for you for a fee.
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If I recall, Sushi has an assistant to work on insurance billing. Even with one commercial payor, there are many different permutations of copays and deductibles. It seems it will take 10-20 hrs/week to verify benefits/copays/deductibles, collect copays, follow up on insurance reimbursements and outstanding patient balances?
I had an EMR demo and the amount of clicks to send off an insurance bill seemed awfully time consuming (this isn't even counting the time it takes to enter insurance info manually prior to the initial eval).
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If you feel comfortable sharing, how much do you net?
Can't you just get a biller to do this for 7 ish percent?
