Cash Only Group Practice?

[yoloswagpoop42069]

Are cash only no insurance group practices a thing?

Ideally
1. MD/DOs only
2. MD/DO + PAs
3. MD/DO + NPs (kill me now)

+ Therapists

If so, what would such a structure look like in terms of founder/founding partners and then younger employees or therapists added over time?

Insurance based group practices make more sense in my mind as people struggle with the idea of setting up their own with billing services and what not. Also since it’s more affordable, insurance based probably fills quicker than cash only.

Does this not exist?
Also can you have a cash based practice but only take commercial insurance for TMS?

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[splik]

Yes there are cash based group practices, either MD only or with therapists. There might be some people who use NPs but I don't think NPs work well in this sort of model where people are paying for a premium service.

And yes it is possible to only take insurance for TMS. But you'd do a single case agreement each time which is a bit of a nuisance.

 

[yoloswagpoop42069]

Thank you splik.

While I have you here since you’re forensically trained do you have a personal view on concierge psychiatry or such a model?

Don’t know if there’s a running thread for it already. Not quite sure what concierge would provide, aside from extensive / unlimited time, appointment freedom, home appointments?

I wonder what liability issues home appointments would provide, ignoring boundary issues? Almost like an ACT service but for those higher functioning / wealthier, who want the privacy of their home?

Wish I knew someone in person who practices such a thing if it exists.

 

[Sushirolls]

Telemedicine basically killed, or satisfied the niche of what was or could have ever been home appointments.
Concierge, from the SDN collective here typically summarizes it as not viable.

Briefly thought about this concept when I was a spring chicken, but beyond the chin stroking of youthful vigor... probably just a bad idea. Others I'm sure will elucidate the why of it being a bad idea with more tact than I.

 

[Ironspy]

A lot of cash practices advertise that they are “concierge” and it basically just means increased access to the psychiatrist, longer appointments etc. Most still bill fee for service.

 

[hamstergang]

I work at a group practice with 6 MDs, 1 APN, and 1 LCSW/LCADC (and 2 admin staff). We don't accept any insurance. We all get paid a percentage of our collections and are W2s so can get benefits. The owner has been in the area a long time and has many connections, so he helps generate more referrals than we likely could on our own. I think he also comes with some clout that justified higher rates than I could charge on my own.

 

[smalltownpsych]

I run a group practice that is cash only. We also have a “wrap-around” services package that we offer that is not fee for service and is just a flat monthly rate. It is actually a little more profitable for us to do the monthly rate and is essential for some of our more severe patients. If we had a psychiatrist, then I could probably tack another 1k onto the monthly bill. For this group we are looking at psychiatry follow-ups every couple weeks and a little bit of outside the appointment work. Since I have six of these right now, thats like another 6k in revenue. I’d probably give the psychiatrist a big percentage of that.

 

[Stagg737]

I work at a group practice with 6 MDs, 1 APN, and 1 LCSW/LCADC (and 2 admin staff). We don't accept any insurance. We all get paid a percentage of our collections and are W2s so can get benefits. The owner has been in the area a long time and has many connections, so he helps generate more referrals than we likely could on our own. I think he also comes with some clout that justified higher rates than I could charge on my own.

Interesting. This is the only time I've ever heard of a prescribing mid-level in a larger cash only practice. The only times I've seen NPs doing cash only were when they were running their own practices.

Does the APN get paid as much as the psychiatrists if they submit the same codes? Aka, same appointment length +/- therapy if done is paid the same?

Don’t know if there’s a running thread for it already. Not quite sure what concierge would provide, aside from extensive / unlimited time, appointment freedom, home appointments?

I wonder what liability issues home appointments would provide, ignoring boundary issues? Almost like an ACT service but for those higher functioning / wealthier, who want the privacy of their home?

A home visit itself wouldn't be a boundary issue, but it could make them far more likely or at the very least increase the likelihood of being accused of one more likely. It also would also change the therapeutic dynamic significantly and make the patient more likely to violate boundaries. ACT teams avoid those by working in teams, working 1-on-1 with patients is different though.

As to the concierge aspect itself, I feel like it should be very obvious why giving patients access to their psychiatrist/therapist 24/7 is problematic. Unless it's part of a system with significant structure like DBT it can foster dependence and horrible coping skills. It's very different from concierge medicine.

 

[hamstergang]

Interesting. This is the only time I've ever heard of a prescribing mid-level in a larger cash only practice. The only times I've seen NPs doing cash only were when they were running their own practices.

Does the APN get paid as much as the psychiatrists if they submit the same codes? Aka, same appointment length +/- therapy if done is paid the same?

This is a quite experienced APN. Her rates are less than the psychiatrists'. Not everyone wants to see her but plenty are fine with it and even like spending less.

 

[hamstergang]

Also, there's another OON practice not far from me that has a psychiatrist, two therapists, and a recently hired APN as well.

 

[clozareal]

There are many group practices that accept cash only who are all MDs.

You can set up a separate TMS practice that takes only insurance.

There are a few concierge models in my area:

1. Monthly/annual membership fee only. They can see you and contact you as much as they want within this time, but of course it would need to be agreed upon that it is worthwhile.
2. Monthly/annual membership fee + fee per appointment.
3. One time membership fee to join + fee per appointment.

Usually it means 24/7 access to the psychiatrist, same day appointments available, longer and more frequent appointments.

 

[annoyedpsychiatrist]

these telehealth places like cerebral are basically conceirge, they pay a monthly fee and get access to their "team".

i would not want someone to have 24/7 access to me at all.

 

[FlowRate]

Seems like, unless you are trained in- and practicing- a rigorous form of DBT that does 24/7 availability within very specific boundaries, being that available to patients is likely to foster unhelpful dependent behaviors.

 

[smalltownpsych]

Seems like, unless you are trained in- and practicing- a rigorous form of DBT that does 24/7 availability within very specific boundaries, being that available to patients is likely to foster unhelpful dependent behaviors.

Exactly the type of practice I operate and we have multiple therapists and mentors to share the load and structure things. I have found that when I am more available to my patients they tend to be less needy or demanding of my time and typically become more respectful of my time. What I do is communicate to them how to reach me and other team members and under which circumstances so that they are reassured that they can access help if and when they need it. A standalone psychiatry practice, this probably wouldn’t make much sense unless you are heavy into psychotherapy and well versed in utilizing and maintaining the therapeutic frame which is an essential foundation for effective psychotherapy that tends to get overlooked. I will also typically increase frequency of sessions when patient is in crisis because I want them to learn to make use of emotional support from healthy relationships as that is typically something that is missing from the more personality disordered patients.

 

[Merovinge]

Seems like, unless you are trained in- and practicing- a rigorous form of DBT that does 24/7 availability within very specific boundaries, being that available to patients is likely to foster unhelpful dependent behaviors.

Yup, but I guess if you are being paid $600/hour, having unhealthy dependent behaviors might be the point. Easier to sell that you are "doing everything you can for the patient" with this type of model as opposed to pimping yourself out for 50 Addy/Xanny scripts a day.

 

[FlowRate]

Yup, but I guess if you are being paid $600/hour, having unhealthy dependent behaviors might be the point. Easier to sell that you are "doing everything you can for the patient" with this type of model as opposed to pimping yourself out for 50 Addy/Xanny scripts a day.

I was thinking along the same lines. The patient is dependent on their psychiatrist for excessive emotional support and the psychiatrist is dependent on $600/hr patients to maintain a lavish lifestyle.