CAP administrative work

[budda10000]

So I have heard many CAP complaining about the excessive burden of administrative work in this field. My question to you practicing in this field. Why don't you bill for this work? Lawyers and most other professional charge for all labor rendered, shouldn't you as well?

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[wolfvgang22]

In short, medicaid and insurance rules.

 

[nexus73]

An orthopedist can see you for a bad shoulder in 10 minutes and review radiology reports/imaging in 5-10 minutes, and that's a 99203 (1.42 RVUs), full new patient evaluation.

A child psychiatrist see the kid/parents alone and together over 90+ minutes and that's a full patient eval 99205+99354 (5.5 RVUs), plus more time coordinating with therapist, school, etc that you can use 99358 potentially...but these extended service codes are highly scrutinized and depending on various factors sometimes not reimbursed.

The kicker is the orthopedist can see 4 new patients in an hour and he's already ahead of the child psychiatrist who is seeing 1 new patient in 90 minutes from an RVU standpoint, and it's even worse if insurance doesn't reimburse the extended service 99354/99358 codes.

 

[budda10000]

An orthopedist can see you for a bad shoulder in 10 minutes and review radiology reports/imaging in 5-10 minutes, and that's a 99203 (1.42 RVUs), full new patient evaluation.

A child psychiatrist see the kid/parents alone and together over 90+ minutes and that's a full patient eval 99205+99354 (5.5 RVUs), plus more time coordinating with therapist, school, etc that you can use 99358 potentially...but these extended service codes are highly scrutinized and depending on various factors sometimes not reimbursed.

The kicker is the orthopedist can see 4 new patients in an hour and he's already ahead of the child psychiatrist who is seeing 1 new patient in 90 minutes from an RVU standpoint, and it's even worse if insurance doesn't reimburse the extended service 99354/99358 codes.

Could you not structure additional cash fees for additional work. If insurance only reimburses the initial evaluation why not just charge FFS for the rest? In this way you could have a hybrid insurance/cash practice. Or has this conveniently been regulated out of possibility? I know a few CAP that do cash only and charge for all this, needless to say they cater to the more affluent. But couldn't a hybrid practice cater to more middle class? I don't see how this would be unethical if the pricing structure was discussed up front.

 

[wolfvgang22]

Could you not structure additional cash fees for additional work. If insurance only reimburses the initial evaluation why not just charge FFS for the rest? In this way you could have a hybrid insurance/cash practice. Or has this conveniently been regulated out of possibility? I know a few CAP that do cash only and charge for all this, needless to say they cater to the more affluent. But couldn't a hybrid practice cater to more middle class? I don't see how this would be unethical if the pricing structure was discussed up front.

Yes, it is against regulations.

 

[Merovinge]

Could you not structure additional cash fees for additional work. If insurance only reimburses the initial evaluation why not just charge FFS for the rest? In this way you could have a hybrid insurance/cash practice. Or has this conveniently been regulated out of possibility? I know a few CAP that do cash only and charge for all this, needless to say they cater to the more affluent. But couldn't a hybrid practice cater to more middle class? I don't see how this would be unethical if the pricing structure was discussed up front.

Because of insurance, most outpatient CAP falls into a few categories:
1) Academic or large non-profit health care systems that take Medicaid and provide good care - these are getting overrun with demand, huge waiting lists and places are moving towards never having permanent patients (stabilize for a few visits and return to PCP)
2)Community NP's, possibly "supervised", likely not, likely without any peds psych experience, to take most or all insurance
3)Private insurance CAP (actually relatively small group for the reasons mentioned here with billing), may be in a behavioral health group for cost-sharing, supervisor revenue stream, and referral streams
4)Cash pay CAP

With the increasing demand, limited increase in CAPs to meet the demand, there will be an increasing fissure of #2 for medicaid, #3 for working class with decent insurance and #4 for upper-middle and upper class who are fine spending some money to get the best care for their children. If you know anyone who needs care and doesn't have good insurance options, get on the wait list for any academic place ASAP as many are around a year out.

 

[dl2dp2]

They do, but they don't take insurance and hence don't sign contracts with insurance companies.

Private child psych do 360-degree evals end up charging 2-3k per eval. They end up making a ton.

That said, if you want to medicate my child with anything beyond Concerta 18mg, I think 2-3k out of pocket for a quality eval is fair game and worth every penny. People are paying 50k for private school. Adolescents routinely kill themselves or fail out of school for mental health reasons. This service is anything but optional and more mission-critical than many other areas of medicine.

 

[Sushirolls]

So I have heard many CAP complaining about the excessive burden of administrative work in this field. My question to you practicing in this field. Why don't you bill for this work? Lawyers and most other professional charge for all labor rendered, shouldn't you as well?

You need to have a basic understanding of insurance. Cash only practice, yes you can set your fees and in theory get paid for all the time you spend - in theory.

Insurance on the other hand is a contract and the contract with that company is what dictates what you get paid for and how much. The what is E&M codes. 99213 or 92214; 99203 or 99204 or 99205; 90792; 99354 and even 99358. Some insurance companies will pay less than your worth. However, because you signed the contract, you (or your employer) have declared that is what you are worth. The second issue, some insurance companies simply say, "Nope" and won't reimburse for 99354 or 99358. So there you are needing to decide if spending the time and performing the level or work you were trained to do in the purest academic sense is your decision for the day knowing you will get paid only for some of the E&M codes you put down, and for less than your worth ... or will you do less work and simply see more patients more quickly.

Insurance contracts will show 99354 as billed $200, paid $0, patient responsibility $0, and you have no contractual legal means to BALANCE BILL the patient the $200. Your contract with the insurance clearly says, no, you aren't owed that.

These are the realities of insurance.

 

[budda10000]

Yes, it is against regulations.

Are you sure about that? If it isn't part of the initial evaluation it doesn't seem like it would constitute insurance fraud ect, and other specialties do this,

Should You Charge For It?

With paperwork piles getting ever higher, more physicians have been trying to buck the trend by charging their patients administrative fees.

www.physicianspractice.com

They do, but they don't take insurance and hence don't sign contracts with insurance companies.

Private child psych do 360-degree evals end up charging 2-3k per eval. They end up making a ton.

That said, if you want to medicate my child with anything beyond Concerta 18mg, I think 2-3k out of pocket for a quality eval is fair game and worth every penny. People are paying 50k for private school. Adolescents routinely kill themselves or fail out of school for mental health reasons. This service is anything but optional and more mission-critical than many other areas of medicine.

How important is it to have a good pedigree in these private practice cash only models(i.e. go to an IVY for CAP ect)? It goes without saying that you would need to set up shop in a community that can actually pay cash, so maybe they care? I am asking these questions because I do love working with adolescents but the idea of being a slave to uncompensated administrative work really turns me off. I have been self-employed my whole life, never had a supervisor until medical school. One thing I am unwilling to compromise on is quality of work, I always put my best in. But I also want to be compensated for that work appropriately, not line someone else's pocket... especially insurance companies.

 

[dl2dp2]

How important is it to have a good pedigree in these private practice cash only models(i.e. go to an IVY for CAP ect)? It goes without saying that you would need to set up shop in a community that can actually pay cash, so maybe they care? I am asking these questions because I do love working with adolescents but the idea of being a slave to uncompensated administrative work really turns me off. I have been self-employed my whole life, never had a supervisor until medical school. One thing I am unwilling to compromise on is quality of work, I always put my best in. But I also want to be compensated for that work appropriately, not line someone else's pocket... especially insurance companies.

Pedigree is a necessary but insufficient aspect. Pedigree is a marketing instrument, but you need to actually market yourself to stand out. Plenty of ivy people unsuccessfully set up their practice, and people who are not ivys can succeed (albeit with more barriers), and depends on where you are. In the Midwest, you generally don't need ivy, but something name brand is *still* helpful.

Realizing that full-on cash subspecialty psych is one of the cushiest gigs in all of medicine, it's probably best for you to plan to gun as much as possible during training and pretend that you are shooting for derm or retinal surgery, if this is what you want to do with your life.

 

[budda10000]

Pedigree is a necessary but insufficient aspect. Pedigree is a marketing instrument, but you need to actually market yourself to stand out. Plenty of ivy people unsuccessfully set up their practice, and people who are not ivys can succeed (albeit with more barriers), and depends on where you are. In the Midwest, you generally don't need ivy, but something name brand is *still* helpful.

Realizing that full-on cash subspecialty psych is one of the cushiest gigs in all of medicine, it's probably best for you to plan to gun as much as possible during training and pretend that you are shooting for derm or retinal surgery, if this is what you want to do with your life.

Gun in what aspect? I am a psych resident. Already aced my prite, lots of publications, excellent board scores, excellent evals. The only thing I can think to add to the resume is more specific CAP research since its a newer interest.

 

[dl2dp2]

Gun in what aspect? I am a psych resident. Already aced my prite, lots of publications, excellent board scores, excellent evals. The only thing I can think to add to the resume is more specific CAP research since its a newer interest.

If you are not at a name program, do your fellowship at a name program. This is also a good time to start looking for mentors, who have successfully established cash practices in your market.

 

[budda10000]

If you are not at a name program, do your fellowship at a name program. This is also a good time to start looking for mentors, who have successfully established cash practices in your market.

Yes this was my plan, to fast-track somewhere with a name. People at my program generally match pretty well for fellowship