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I am planning to do my internship and post-doc in geropsychology at a VA. I am also hoping to eventually be board certified in geropsychology. Is the VA the best setting for gero-related careers long term? Are there any other settings that are better in terms of work/life balance, salary, etc?
 
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I am planning to do my internship and post-doc in geropsychology at a VA. I am also hoping to eventually be board certified in geropsychology. Is the VA the best setting for gero-related careers long term? Are there any other settings that are better in terms of work/life balance, salary, etc?

It's a good specialization where you might be able to offer services wherever you find older adults from long term care facilities, private practice, and certainly the VA. Outside a salaried position In the private sector most senior have limited income and there is a lot of erosion of medicare/medicaid reimbursement rates for psychologists. Something to think about.

Consider checking out Psychologists in Long Term Care PLTC - Psychologists in Long-Term Care
 
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WisNeuro

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This is one area where I would suggest staying within the VA. Not a forgiving landscape outside. I've seen a good amount of geropsychologist positions cut and never backfilled in non-VA hospital systems.
 
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Sanman

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I would generally agree with the point others have mentioned, but it depends on your career goals. There seem to be some good positions in academia if you are going in that direction. Having been a geropsychologist in practice both in the real world and the VA, I think that the VA is a much easier place to work. Certainly easier to navigate earlier in your career. As mentioned, medicare/medicaid rates are declining while audits and scrutiny are increasing. In addition to that, much of the great work that we can do (behavior management, caregiver support, staff education) does not lend itself well to billable work in the real world. Depending on the region you live in, there may be some PP opportunity or the landscape might be filled with large companies that do not pay so well or treat employees well that are hiring for most facility (LTC/ALF) work. I can write a long diatribe on that landscape, but will not do so. In addition, if you want to go for ABPP, VA or academia is where you need to be due to the requirements, though I have mixed thoughts on that as well.

I would second joining PLTC. If you join soon, they are taking applications for people interested in being mentored for next year until Dec 31. It is a great network of professionals and a very active listserv!
 
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AcronymAllergy

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Because of some of the supports and resources available in VA gero-focused settings (e.g., CLC), I could see those being some of the more fulfilling places to work from a professional standpoint. That is, you may actually have the opportunity to do some of what you're capable of doing. And lord knows we need good geropsychologists here; I alone could probably completely fill your schedule with dementia referrals who need behaviorally-focused interventions for irritability, wandering, caregiver support, etc.
 
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foreverbull

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I will second those who question the positions offered by corporations—I know folks who work in skilled care facilities who get no retirement benefits, terrible insurance (not fully paid for, either), and are reimbursed at ridiculously low rates while going in to Covid positive areas. In my region, they are overworked and underpaid in the private sector, whether salaried or paid per service.

The VA doesn’t sound like a bad option in comparison, depending on the site.
 

PsyDr

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A.
1) Get an office address
2) Set up an LLC and EIN number using your office address, NOT YOUR HOME ADDRESSS
3) Get an NPI using your office address
4) Get an NPI for your LLC using your office address and EIN
5) identify a billing company or software.
6) Open a business bank account using the LLC and EIN
7) enroll as a CMS provider for medicare.


B.

1) Use the state or federal licensing website to look up every nursing home within 50 miles of you. If you live somewhere oversaturated, you'll want to look at more rural ones.
2) Got an SO? Friend? Number of a temp agency? Have one of those call up #1, and ask, "Hey, who is the attending physician there?" wihtout identifying who they are or why they are calling. Write that down.
3) Look up the attending physician's contact information using the NPI tool or your state's licensing website.
4) Send a business letter and business card to those physicians. Tell them you're a psychologists who likes geropsychology work in medically compromised patients. DO NOT MENTION PSYCHIATRIC ILLNESS.
5) Do #4, but to the nursing homes's directores. Offer to meet with the nursing director. Mention that you know that CMS requires that CARF residents receive annual depression screening as part of quality assurance whatever.
6) Wait 2-3 weeks. Call those physicians up. Ask him if he'd be interested in some help with behavioral stuff. Mention that you know that CMS requires that CARF residents receive annual depression screening as part of quality assurance whatever.
7) One of those people or places will say yes. Ask him if they would be willing to write an order for psych consult. They will.
8) Go see that person. Use H&B codes at the facility fee location. Chart it. Look at @Sanman 's stuff from recent posts about how to make money in H&B codes. It looks legit.
9) On site, sweet talk staff. Bring food. Mention that you're interested in helping increase treatment compliance for medically compromised patients. Repeatedly.
10) Consult that one patient as clinically appropriate, once a week maybe? Repeat #9 each time you are there. Flirt if you have to, but do not start any relationships.
11) Ask staff if there's anyone else they want you to check on, each time you're there. Grow that population, with the goal being every patient there for which H&B services are clinically indicated.
12) Create a form for your charting. Look up what the CPT official descriptor requires for that service. Put that on the form. Look at your state regs, put whatever they require in your form. You want to document appropriately, but you're trying to have that chart note done before the end of that 15 min consult. Remember, you're NOT treating mental illness.
13) Create a form of a daily log of services, times, dates, medical dx, cpt code. Goes like: LOCATION (header), DATE, NAME, CPT CODE, START TIME, END TIME, ICD10 CODE FOR MEDICAL DIAGNOSIS.
14) Take #13 to your office every single day. throw it in a pile. Periodically take that pile to whoever bills for you. Or hire someone to put it into your billing software, if that's your thing. NEVER DO YOUR OWN BILLING. Why? I'll assume you're not trying to commit fraud. Insurance is gonna audit you at some point. There are going to be some billing mistakes, at some point. Someone else is doing your billing and making mistakes? Itlooks like a mistake. You doing everything and making a mistake= looks like fraud.


Ideally, you're gonna identify a nursing home with long halls, that is staffed by an attending physician that finds H&B services to be helpful (or straight up does not care what anyone does), that is populated with 50-200 patients who are in said nursing home because they have a qualifying medical dx for which H&B services are clinically indicated.

Why long halls? You're billing in 15 min intervals. Walk in, do your service, walk to the next one.

Make sure to treat my buddy Sanman well. He lives in one of those because he’s old AF. But he has Worthers originals in the pockets of his cardigan (I assume).
 
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Sanman

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Make sure to treat my buddy Sanman well. He lives in one of those because he’s old AF. But he has Worthers originals in the pockets of his cardigan (I assume).
It is spelled Werthers and the sugar-free flavors make you very popular at the old folks' home. I rock red cardigans and blue Sperry top-sider sneakers after my hero, Fred Rogers. At happy hour and on casual Fridays, I rock Cosby sweaters because I am secretly a baaaad man!
 
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foreverbull

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A.
1) Get an office address
2) Set up an LLC and EIN number using your office address, NOT YOUR HOME ADDRESSS
3) Get an NPI using your office address
4) Get an NPI for your LLC using your office address and EIN
5) identify a billing company or software.
6) Open a business bank account using the LLC and EIN
7) enroll as a CMS provider for medicare.


B.

1) Use the state or federal licensing website to look up every nursing home within 50 miles of you. If you live somewhere oversaturated, you'll want to look at more rural ones.
2) Got an SO? Friend? Number of a temp agency? Have one of those call up #1, and ask, "Hey, who is the attending physician there?" wihtout identifying who they are or why they are calling. Write that down.
3) Look up the attending physician's contact information using the NPI tool or your state's licensing website.
4) Send a business letter and business card to those physicians. Tell them you're a psychologists who likes geropsychology work in medically compromised patients. DO NOT MENTION PSYCHIATRIC ILLNESS.
5) Do #4, but to the nursing homes's directores. Offer to meet with the nursing director. Mention that you know that CMS requires that CARF residents receive annual depression screening as part of quality assurance whatever.
6) Wait 2-3 weeks. Call those physicians up. Ask him if he'd be interested in some help with behavioral stuff. Mention that you know that CMS requires that CARF residents receive annual depression screening as part of quality assurance whatever.
7) One of those people or places will say yes. Ask him if they would be willing to write an order for psych consult. They will.
8) Go see that person. Use H&B codes at the facility fee location. Chart it. Look at @Sanman 's stuff from recent posts about how to make money in H&B codes. It looks legit.
9) On site, sweet talk staff. Bring food. Mention that you're interested in helping increase treatment compliance for medically compromised patients. Repeatedly.
10) Consult that one patient as clinically appropriate, once a week maybe? Repeat #9 each time you are there. Flirt if you have to, but do not start any relationships.
11) Ask staff if there's anyone else they want you to check on, each time you're there. Grow that population, with the goal being every patient there for which H&B services are clinically indicated.
12) Create a form for your charting. Look up what the CPT official descriptor requires for that service. Put that on the form. Look at your state regs, put whatever they require in your form. You want to document appropriately, but you're trying to have that chart note done before the end of that 15 min consult. Remember, you're NOT treating mental illness.
13) Create a form of a daily log of services, times, dates, medical dx, cpt code. Goes like: LOCATION (header), DATE, NAME, CPT CODE, START TIME, END TIME, ICD10 CODE FOR MEDICAL DIAGNOSIS.
14) Take #13 to your office every single day. throw it in a pile. Periodically take that pile to whoever bills for you. Or hire someone to put it into your billing software, if that's your thing. NEVER DO YOUR OWN BILLING. Why? I'll assume you're not trying to commit fraud. Insurance is gonna audit you at some point. There are going to be some billing mistakes, at some point. Someone else is doing your billing and making mistakes? Itlooks like a mistake. You doing everything and making a mistake= looks like fraud.


Ideally, you're gonna identify a nursing home with long halls, that is staffed by an attending physician that finds H&B services to be helpful (or straight up does not care what anyone does), that is populated with 50-200 patients who are in said nursing home because they have a qualifying medical dx for which H&B services are clinically indicated.

Why long halls? You're billing in 15 min intervals. Walk in, do your service, walk to the next one.

Make sure to treat my buddy Sanman well. He lives in one of those because he’s old AF. But he has Worthers originals in the pockets of his cardigan (I assume).
Is there something different this person would be offering that large corporations that contract with skilled care facilities to send in psychologists can’t do? Because in my area, many corporations already infiltrated the market themselves and have contracts with skilled care facilities and rehab facilities to send in a psychologist, and these corporations promise lofty things like group therapy, staff inservice trainings, crisis intervention/“on-call psychologists”, etc. on top of standard services like brief evals and 90834s, etc.

What would this private practice psychologist offer above and beyond those services?
 

PsyDr

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Is there something different this person would be offering that large corporations that contract with skilled care facilities to send in psychologists can’t do? Because in my area, many corporations already infiltrated the market themselves and have contracts with skilled care facilities and rehab facilities to send in a psychologist, and these corporations promise lofty things like group therapy, staff inservice trainings, crisis intervention/“on-call psychologists”, etc. on top of standard services like brief evals and 90834s, etc.

What would this private practice psychologist offer above and beyond those services?

The business model for those companies creates substantial market inefficiencies. Because of their overhead, there is a break even point at which they cannot afford to provide services. I'll bet there is a specific dollar amount per nursing home in their prospectus. In a major metro area, this might mean that the market rate for psychologists is way too high, and they'd lose money if they took that contract (e.g., a Manhattan psychologist could make $300/hr all day long in PP, and the company can't afford to pay more than $80/hr, so there are no takers). In rural areas, this might mean that there are no psychologists stupid enough to drive 90 minutes out to Cousinlover, ID to make $40. Or maybe there is some hellhole nursing home that no one will work in.

So, if you're in a semi-metro area like .... IDK....Portland..., then yeah.... the big boy corporations have those nursing home contracts locked up . But I'd bet that there is some small town within a 90 minute drive that has a nursing home not covered by those companies.
 

Sanman

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Is there something different this person would be offering that large corporations that contract with skilled care facilities to send in psychologists can’t do? Because in my area, many corporations already infiltrated the market themselves and have contracts with skilled care facilities and rehab facilities to send in a psychologist, and these corporations promise lofty things like group therapy, staff inservice trainings, crisis intervention/“on-call psychologists”, etc. on top of standard services like brief evals and 90834s, etc.

What would this private practice psychologist offer above and beyond those services?

Things to think about when doing this:

1. In general, you will hold a contract with the Exec Director of the facility and need to be approved by the medical director. Many of the medical directors are physicians who do this on the side or are part of an independent company. Becoming friends with groups local to you that provide local medical support for facilities is good. Most places also have outpatient practices. Having a relationship with the corporate parent is good as well. In general, locally owned smaller chains and independent homes may be more interested in working with you.

2 . Most large corporations provide more coverage, but have high turnover. Lack of consistent services are an issue for many facilities. Get a contract for places closer to home and you are both happy.

3. Given that most of these corporations make money on high volume, low quality services (9-18 sessions a day for $80k anyone?) there is an opportunity when a facility is not near other facilities as it can be difficult to retain staff who don't want to drive out there and not make their RVU quota.

4. Many people who do this work suck at the job and have no training (no offense to anyone). Offer proper management of services, solutions for difficult and minimally billable problems such as dementia patients with behavioral concerns, be familiar with MDS requirements and help facilities manage the psych portion, know how to complete a proper decisional capacity assessment, etc

5. The largest difficulty will be with not providing medication management services. If you know a psychiatrist or psych NP that is interested in sharing work that is gold. If not, identify a medical director that has some comfort with management of psychotropics as this can lead to money for you (see#7).

6. Identifying a facility with a large rehabilitation arm is useful as you can see many 90791 patients due to large turnover with no more than 2-3 sessions of follow-up before discharge.

7. If you are enterprising and have a willing PCP on site, audit the facility charts, identify all of the BS psychotropics added at the hospital (sertraline 25mg, xanax .25 mg, etc) have the PCP discontinue them (nothing complex that requires much of a taper) and then get a consult to see all of them. Throw a BDI/GDS at them and a few min of supportive counseling to ensure ongoing remission of mood sx. Easy 90791 + a few 90832s until they are tapered. Bonus, you just helped facility reduce psychotropic med use in MDS reporting.

8. Recognize that medicare algorithms lean toward auditing high frequency of care on a small population (lots of 90837s) and not minimal care on a large population (many 90832s or H & B codes). Also be aware that the government just passed an exemption removing low utilizers of medicare from being audited and that this threshold is about what one full-time psychologist can see in a year.
 
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Sanman

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The business model for those companies creates substantial market inefficiencies. Because of their overhead, there is a break even point at which they cannot afford to provide services. I'll bet there is a specific dollar amount per nursing home in their prospectus. In a major metro area, this might mean that the market rate for psychologists is way too high, and they'd lose money if they took that contract (e.g., a Manhattan psychologist could make $300/hr all day long in PP, and the company can't afford to pay more than $80/hr, so there are no takers). In rural areas, this might mean that there are no psychologists stupid enough to drive 90 minutes out to Cousinlover, ID to make $40. Or maybe there is some hellhole nursing home that no one will work in.

So, if you're in a semi-metro area like .... IDK....Portland..., then yeah.... the big boy corporations have those nursing home contracts locked up . But I'd bet that there is some small town within a 90 minute drive that has a nursing home not covered by those companies.

I worked in the NY metro area. Most of those places are offering more like $40-50/hr even there. The math does not work otherwise and there are plenty willing to accept the work.
 

WisNeuro

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I worked in the NY metro area. Most of those places are offering more like $40-50/hr even there. The math does not work otherwise and there are plenty willing to accept the work.

$40-50/hr? In a high COL area? I wouldn't accept that rate in a super low COL area. Why are people doing this?
 

foreverbull

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I worked in the NY metro area. Most of those places are offering more like $40-50/hr even there. The math does not work otherwise and there are plenty willing to accept the work.

This is my point: there are one or two major corporations that have contracts with the vast majority of facilities in my major metro area, and because jobs are scarce, ECPs and those piecing together multiple jobs will do the work and be underpaid due to supply/demand in large cities. Thus, I’m not seeing a lot of inroads for folks to step in as independent, private practitioners to come in and offer the same or fewer services? By the way, these corps also hire NPs to go in to sites as well and they make employees sign non-competes. They’re really dominating the market where I live.

And as far as quality, there are some good psychologists and not so great ones doing this work, but if the site complains, that psychologist would be removed another would just take their place. The corporation will do whatever they need to keep their contracts.

Maybe outside of large cities like mine with less competition, this business model would work? I’m just not seeing why a site would end a contract with a Corp that promises many services to go with an unknown offering fewer services in a for-profit model that tries to squeeze everything they can out of psychologists.

Edit: just thinking of unpaid admin time as an independent practitioner, I’m thinking of all the time needed to check eligibility for services, get the census every week at every site and check charts for Medicare patients, etc. (some will be paper, some electronic) at every site, and go through insurances and see what they’re covered for, then submit billing. You’d need another employee part-time or full time to handle this or else half of your work time will be unpaid.

And this private practitioner can’t expect overworked staff to report these things or lift a finger to get this info in the charts to the psychologist—they will balk at the request and treat the person like an outsider at their facility, as most already do to psychologists who come in to their sites once a week unless they need something. Getting info/support from staff at sites is very difficult.
 
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PsyDr

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This is my point: there are one or two major corporations that have contracts with the vast majority of facilities in my major metro area, and because jobs are scarce, ECPs and those piecing together multiple jobs will do the work and be underpaid due to supply/demand in large cities. Thus, I’m not seeing a lot of inroads for folks to step in as independent, private practitioners to come in and offer the same or fewer services? By the way, these corps also hire NPs to go in to sites as well and they make employees sign non-competes. They’re really dominating the market where I live.

And as far as quality, there are some good psychologists and not so great ones doing this work, but if the site complains, that psychologist would be removed another would just take their place. The corporation will do whatever they need to keep their contracts.

Maybe outside of large cities like mine with less competition, this business model would work? I’m just not seeing why a site would end a contract with a Corp that promises many services to go with an unknown offering fewer services in a for-profit model that tries to squeeze everything they can out of psychologists.

Edit: just thinking of unpaid admin time as an independent practitioner, I’m thinking of all the time needed to check eligibility for services, get the census every week at every site and check charts for Medicare patients, etc. (some will be paper, some electronic) at every site, and go through insurances and see what they’re covered for, then submit billing. You’d need another employee part-time or full time to handle this or else half of your work time will be unpaid.

And this private practitioner can’t expect overworked staff to report these things or lift a finger to get this info in the charts to the psychologist—they will balk at the request and treat the person like an outsider at their facility, as most already do to psychologists who come in to their sites once a week unless they need something. Getting info/support from staff at sites is very difficult.

My limited experience in this area differs substantially from yours. Might be regional, or personal, or something else.
 

Sanman

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Maybe outside of large cities like mine with less competition, this business model would work? I’m just not seeing why a site would end a contract with a Corp that promises many services to go with an unknown offering fewer services in a for-profit model that tries to squeeze everything they can out of psychologists.

Having done this for a number of years and having poached dozens of contracts, it can be done. Most common reason is that the company is having trouble providing consistent services or the quality of the services suck. Go into a facility and fix their biggest problem patient, they will give you a contract. That said, this is also a small world. When I left my previous job, I had a number of facility directors come to me and offer to break their contract with my company if I ever got back in the game and sign with me because I provided the best services they ever received. Even on the corporate side, the CFO of a former company I worked for was neighbors with the guy who owned the nursing home I was working in. A rival company tried to poach the contract a facility director level and it ended up being a no go.

As for getting staff to help paperwork, census, facesheets, etc, it is a crapshoot and depends who is on your side. I was often in meetings with facility directors and DONs when we signed new facilities and became friendly with the executive team at all of my facilities. You better believe staff new this and got me what I asked for or their boss was asking for it next. That said, you got no respect as a regular psychologist in a large contracting company and would be mostly ignored (my experience a youngin' in the industry).
 

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$40-50/hr? In a high COL area? I wouldn't accept that rate in a super low COL area. Why are people doing this?

As @foreverbull mentioned, lots of ECPs with poor prospects looking for a steady salary once licensed. Some while they try to build a private practice others for longer. They often hire child psychs as the behavioral training can carryover. If you wanted to know where many of the Argosy and similar grads end up for a career, check out the staff trainings for the large nursing home companies. That said, if you are in geriatrics and know what you are doing, there is money to be made at the top. It was not uncommon to be paid well to be a clinical area manager for multiple states. It is a lot of travel and requires being able to be licensed in most states, but there is money there when you are managing dozens of clinicians that are all underpaid and billing huge money (Paid $70-90k and billing $200k+ annually). VP of clinical services for a group of 200+ practitioners? $$$$
 
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