Expected earnings from 70/30 outpatient split job?

[futuredo32]

Hi. I interviewed with a clinic that takes most insurance plans except Medicaid. He said working 40 hours with 5 weeks off a year, I could expect to make 400 k a year. This sounds like BS to me. Is this likely? Southeast Michigan area. My psychiatrist has a 70/30 job but he does a lot of therapy so he doesn't make this and isn't a good comparison.

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[AD04]

Most likely BS. Have him show you the math. Maybe he's projecting earnings based on 6x 99214 per hour with 100% show rate and 100% collection rate, collecting only from the highest-paying insurance.

 

[futuredo32]

Most likely BS. Have him show you the math. Maybe he's projecting earnings based on 6x 99214 per hour with 100% show rate and 100% collection rate, collecting only from the highest-paying insurance.

Thank you. That's what I thought. I asked him how much each insurance paid and he said it's illegal to disclose that.
What would be reasonable to expect?

 

[AD04]

Thank you. That's what I thought. I asked him how much each insurance paid and he said it's illegal to disclose that.
What would be reasonable to expect?

Basically he can't back up his numbers. If your patient panel is full and if you take a variety of insurances except Medicaid, I anticipate $250k - $300k as 1099. To get higher, you have to be selective with insurance and really be on top of no-show fees and prune the patient panel, such as what @clausewitz2 does.

 

[Stagg737]

Thank you. That's what I thought. I asked him how much each insurance paid and he said it's illegal to disclose that.
What would be reasonable to expect?

He should be able to tell you how many patients per hour/day you see as well as frequency of which codes are used. That should be enough to calculate an average income as well as workload.

 

[calvnandhobbs68]

Thank you. That's what I thought. I asked him how much each insurance paid and he said it's illegal to disclose that.
What would be reasonable to expect?

I mean sure, technically insurance companies want to keep their negotiated rates “confidential” (mostly so they can **** everyone over so nobody knows what anyone else is getting). But in real life, unless he thinks you’re an insurance company plant that’s gonna to tell them, he’d share the rates with you. He can at least give you an average mix of insurance panels he has and their average reimbursement rate for various codes, since that then obscures each specific rate and he’s technically not “disclosing” any specific rate if that’s what he’s so worried about.

But he’s not. He just doesn’t want you to know what a 70/30 split would actually look like. Don’t agree to a split of anything until you know what exactly it is you’re splitting

 

[Sushirolls]

Work backwards the numbers:
$400,000 / 0.7 = $571,000 in total billing/collections per year

$571,000 / 47 weeks = $12,149 per week billing/collections

$12,149 / 40 clinical hours per week = $303.73 per hour

~$150 per 30 minute follow up encounter

So, yes this is very doable but the crux to this figure is working 40 clinical hours per week and 47 weeks per year. This is likely a truthful number, if in an area with some greater than Medicare paying insurance.

 

[Bartelby]

Though with the catch that those calculations presume 40 *billed* hours per week. I suspect you would have to work well over 40 hours to consistently generate that level of billing.

 

[clausewitz2]

Though with the catch that those calculations presume 40 *billed* hours per week. I suspect you would have to work well over 40 hours to consistently generate that level of billing.

Heck, if OP was anticipating doing 3 20 min med appts per hour, $100 per encounter seems very doable.

Seeing 24 patients a day 5 days a week -forever- would make my head explode, but to each their own...

 

[futuredo32]

Work backwards the numbers:
$400,000 / 0.7 = $571,000 in total billing/collections per year

$571,000 / 47 weeks = $12,149 per week billing/collections

$12,149 / 40 clinical hours per week = $303.73 per hour

~$150 per 30 minute follow up encounter

So, yes this is very doable but the crux to this figure is working 40 clinical hours per week and 47 weeks per year. This is likely a truthful number, if in an area with some greater than Medicare paying insurance.

I don't get reimbursed that much for therapy and med management for a 45 minute appointment from Bluecross. And what about the no shows?

 

[futuredo32]

Heck, if OP was anticipating doing 3 20 min med appts per hour, $100 per encounter seems very doable.

Seeing 24 patients a day 5 days a week -forever- would make my head explode, but to each their own...

Except 15 minute appointments dont reimburse that well from the best insurance companies.

 

[calvnandhobbs68]

Except 15 minute appointments dont reimburse that well from the best insurance companies.

You continue to have this weird perspective on what insurance companies reimburse that I guess applies to your own limited experience but definitely isn’t the norm.

people definitely knock out 99214 visits in 15-20 minutes. Is it good psychiatry? Probably not but it happens. 99214s in two different markets I’ve looked at across different insurance companies (actually both in the Midwest so pretty similar to you) consistently pay >100 each, some more like 130. I know there are people on here in even better markets that get reimbursed more than that.

If your best insurance company isn’t paying you at least 100 bucks for a 99214, that’s an issue.

 

[futuredo32]

You continue to have this weird perspective on what insurance companies reimburse that I guess applies to your own limited experience but definitely isn’t the norm.

people definitely knock out 99214 visits in 15-20 minutes. Is it good psychiatry? Probably not but it happens. 99214s in two different markets I’ve looked at across different insurance companies (actually both in the Midwest so pretty similar to you) consistently pay >100 each, some more like 130. I know there are people on here in even better markets that get reimbursed more than that.

If your best insurance company isn’t paying you at least 100 bucks for a 99214, that’s an issue.

Maybe it's because I am practicing just outside of Ann Arbor where there are more psychiatrists than any other city in Michigan? Because I am not a big clinic affiliated with a large hospital system and can't negotiate larger reimbursement? But most of my appointments are med management with therapy and for those I always use 99213.

 

[rjs2131]

Don’t know of many PP folks consistently working 40 patient hrs/week…that gets to be a grind fairly quickly, especially if your visits are 15-20 min (thats like 24+ patients/day)

 

[Sushirolls]

If in a part of the country where 99214 isn't hitting well in excess of $100; then there is no point in taking any insurance! The insurance companies just made that decision for you. You can't run a practice on that. You just can't, unless you are doing 15min med check model.

Either A join a Big Box shop, or B do cash only, or C move to better paying region in the country.

For instance I have some insurance paying ~$180-$220 for a 99214. The local Big Box shops are getting $305 for a 99214 down the street from me.

I recently considered relocating to another state with an area that was wide open for Psychiatry needs, but the insurance rates in that area were markedly less than my current location. It could have penciled out once full or at higher volume to compensate. The inertia to relocate, start over, etc, etc, I decided against it and will continue my slow trudge forward. Positively the rates are overall well/good here - but who knows how long that will last. Especially considering the reports here of abysmal rates elsewhere in the country. I figure its only a matter of time they start cutting rates downs and I have no choice but to flip to cash only.

 

[Stagg737]

Maybe it's because I am practicing just outside of Ann Arbor where there are more psychiatrists than any other city in Michigan? Because I am not a big clinic affiliated with a large hospital system and can't negotiate larger reimbursement? But most of my appointments are med management with therapy and for those I always use 99213.

Well that’s a huge mistake. I’d estimate 80% or more of all psych med appointments hit a 99214. If you’re billing 99213 the majority of the time, you either have the most stable patient population in existence or you’re grossly under billing.

For example, in my whole PGY-3 year I think only 2 patients out of a couple hundred got billed as 99213. I legitimately billed more 99215s than 213s and that’s excluding Clozapine patients.

 

[MedMan80]

If in a part of the country where 99214 isn't hitting well in excess of $100; then there is no point in taking any insurance! The insurance companies just made that decision for you. You can't run a practice on that. You just can't, unless you are doing 15min med check model.

Either A join a Big Box shop, or B do cash only, or C move to better paying region in the country.

For instance I have some insurance paying ~$180-$220 for a 99214. The local Big Box shops are getting $305 for a 99214 down the street from me.

I recently considered relocating to another state with an area that was wide open for Psychiatry needs, but the insurance rates in that area were markedly less than my current location. It could have penciled out once full or at higher volume to compensate. The inertia to relocate, start over, etc, etc, I decided against it and will continue my slow trudge forward. Positively the rates are overall well/good here - but who knows how long that will last. Especially considering the reports here of abysmal rates elsewhere in the country. I figure its only a matter of time they start cutting rates downs and I have no choice but to flip to cash only.

Nice that we do have that option to jump to cash only.

 

[Sushirolls]

I'm about 82-85% 99214
10-15% 99213
Tiny fraction 99215

 

[robellis]

Maybe it's because I am practicing just outside of Ann Arbor where there are more psychiatrists than any other city in Michigan? Because I am not a big clinic affiliated with a large hospital system and can't negotiate larger reimbursement? But most of my appointments are med management with therapy and for those I always use 99213.

>90 percent of your visits should be 99214 so I’m not sure why you’re under coding, you do realize undercoding could also be considered fraud right?

 

[futuredo32]

>90 percent of your visits should be 99214 so I’m not sure why you’re under coding, you do realize undercoding could also be considered fraud right?

With therapy for the same med they have been taking for three years? No 99213 is appropriate.

 

[futuredo32]

Well that’s a huge mistake. I’d estimate 80% or more of all psych med appointments hit a 99214. If you’re billing 99213 the majority of the time, you either have the most stable patient population in existence or you’re grossly under billing.

They are therapy patients and I am refilling the same medicine they have been on for years. very stable on meds.

 

[Sushirolls]

Its not just about stability and refills but also number of diagnoses.

GAD + MDD + Insomnia; all stable with 2 meds; = 99214

 

[robellis]

With therapy for the same med they have been taking for three years? No 99213 is appropriate.

Yes..it’s still 99214…I strongly recommend you learn to bill properly, you just need 2 diagnoses and a medication prescription

 

[trixter888]

If in a part of the country where 99214 isn't hitting well in excess of $100; then there is no point in taking any insurance! The insurance companies just made that decision for you. You can't run a practice on that. You just can't, unless you are doing 15min med check model.

Either A join a Big Box shop, or B do cash only, or C move to better paying region in the country.

For instance I have some insurance paying ~$180-$220 for a 99214. The local Big Box shops are getting $305 for a 99214 down the street from me.

I recently considered relocating to another state with an area that was wide open for Psychiatry needs, but the insurance rates in that area were markedly less than my current location. It could have penciled out once full or at higher volume to compensate. The inertia to relocate, start over, etc, etc, I decided against it and will continue my slow trudge forward. Positively the rates are overall well/good here - but who knows how long that will last. Especially considering the reports here of abysmal rates elsewhere in the country. I figure its only a matter of time they start cutting rates downs and I have no choice but to flip to cash only.

How did you find out what the rates are/were in another state? Curious about Nevada (Las Vegas) if anyone has experience in that market.

 

[futuredo32]

Its not just about stability and refills but also number of diagnoses.

GAD + MDD + Insomnia; all stable with 2 meds; = 99214

It takes no thought to write for 20 mg Lexapro and 50 mg trazodone. I refill every 3 months. The rest of the appointments are therapy only. 1 appointment of 12 I write for meds.

 

[futuredo32]

Yes..it’s still 99214…I strongly recommend you learn to bill properly, you just need 2 diagnoses and a medication prescription

Most appointments aren't for med refills just therapy

 

[clausewitz2]

Most appointments aren't for med refills just therapy

I bet dollars to donuts that's not going to be true of the new position. Look, it's true that just mindlessly refilling standing scripts is not cognitively difficult. But are you checking after side effects, trying to gauge how well these medications are actually working even when someone says they're fine, determining the impact of whatever you are prescribing them for on their psychosocial functioning?

Refills can be mindless or they can be thoughtful. Just because the script ends up being the same doesn't mean there wasn't medical decision-making.

 

[MedMan80]

Most of my visits are 99214, i'm in a medicaid clinic seeing kids/adolescents with often >2 diagnosis. I feel alot of my old school colleagues also code as 99213, many weren't educated that visits aren't just about time spent but rather complexity. The higher rate for complex patients invariably makes up for the greater amount of work we have to do coordinating care and calling the patient when in crisis that we cannot bill for.

 

[Candidate2017]

Don’t know of many PP folks consistently working 40 patient hrs/week…that gets to be a grind fairly quickly, especially if your visits are 15-20 min (thats like 24+ patients/day)

I personally know a couple psychiatrists who see 22-24 patients a day and make $400k+ (as well as hearing about others doing the same). One is finished and out the door at 5 pm, the other takes a little longer with notes. 22-24 per day is in the minority, but not rare.

Anyway, it seems to be a pattern that OP asks a question, the hive mind gives a consensus answer (i.e., most visits are 99214), and OP declines to accept the answer because of [insert perceived unique situation].

 

[rjs2131]

It takes no thought to write for 20 mg Lexapro and 50 mg trazodone. I refill every 3 months. The rest of the appointments are therapy only. 1 appointment of 12 I write for meds.

Doesn't matter how stable the patient is or how straightforward the appointment...2 stable diagnoses + med prescription = 99214 per the new guidelines.

 

[futuredo32]

I personally know a couple psychiatrists who see 22-24 patients a day and make $400k+ (as well as hearing about others doing the same). One is finished and out the door at 5 pm, the other takes a little longer with notes. 22-24 per day is in the minority, but not rare.

Anyway, it seems to be a pattern that OP asks a question, the hive mind gives a consensus answer (i.e., most visits are 99214), and OP declines to accept the answer because of [insert perceived unique situation].

Actually I am just saying I personally don't get the reimbursement that the rest of you seem to. My psychiatrist NEVER charges for meds, he only charges for therapy with me. I see him 5x a week and every three months he refills meds, he says he doesn't code for 999213 or 99214 because he doesn't want to trigger an audit.. I obviously need to read up on the new coding guidelines and will. They use a time based model for 99213- 15 minutes and 99214 - 30 minutes but because I don't spend nearly that much time on med management in my private practice, I was using 99213. Because she's worried about an audit or insurance fraud is what you can put in the parenthesis. But I got a job I posted about (I think I posted about) that is salary, so I'm all set. Thanks

 

[futuredo32]

CPT Code 99214 - Moderate Complexity E/m Billing Guide [+Reimbursements] This is where I got my information from

 

[Sushirolls]

How did you find out what the rates are/were in another state? Curious about Nevada (Las Vegas) if anyone has experience in that market.

Arrange meetings with local PCPs, express interest in moving there. Offer to take them and their spouse out to dinner. Share knowledge. Any numbers they mention, subtract/reduce for the usual poor treatment Psychiatry gets. If they say they get paid 5 acorns from Tree Insurance, assume you'll only get 3-4 Acorns from Tree Insurance.

Tupperware Container Insurance might pay all specialists the same and not discount Psychiatry, so pay attention to Tupperware Container Insurance rates in that locality and it can be a good source to extrapolate. Also look up Medicare in that area. Consolidate your numbers and chin stroke the value of what you have learned.

 

[futuredo32]

I bet dollars to donuts that's not going to be true of the new position. Look, it's true that just mindlessly refilling standing scripts is not cognitively difficult. But are you checking after side effects, trying to gauge how well these medications are actually working even when someone says they're fine, determining the impact of whatever you are prescribing them for on their psychosocial functioning?

Refills can be mindless or they can be thoughtful. Just because the script ends up being the same doesn't mean there wasn't medical decision-making.

Do you have a link on a how to bill? My biller sent me the above link that I posted. She said I was overbilling and I could get audited and she said she had one doctor have to pay back tens of thousands of dollars to the insurance company and another doctor had to undergo some physician training program or lose his license.

 

[robellis]

Do you have a link on a how to bill? My biller sent me the above link that I posted. She said I was overbilling and I could get audited and she said she had one doctor have to pay back tens of thousands of dollars to the insurance company and another doctor had to undergo some physician training program or lose his license.

you see a psychiatrist 5x per week? That seems..excessive…like really excessive

 

[futuredo32]

you see a psychiatrist 5x per week? That seems..excessive…like really excessive

Psychoanalysis. But that has nothing to do with this thread.

 

[TexasPhysician]

CPT Code 99214 - Moderate Complexity E/m Billing Guide [+Reimbursements] This is where I got my information from

This is outdated. Following this could have you lose an audit.

That said - If you are coding correctly, worrying about an audit is a waste of time. You should bill correctly and invite them to audit you.

 

[futuredo32]

This is outdated. Following this could have you lose an audit.

That said - If you are coding correctly, worrying about an audit is a waste of time. You should bill correctly and invite them to audit you.

Do you have an updated one? My psychiatrist says audits are terrible. My biller has me scared of them. My biller sent this to me in January.

 

[calvnandhobbs68]

Do you have an updated one? My psychiatrist says audits are terrible. My biller has me scared of them. My biller sent this to me in January.

Your psychiatrist says audits are terrible but you’re doing psychoanalysis with him 5x a week….

Interesting self disclosure for an analyst.

 

[Psych19]

Doesn't matter how stable the patient is or how straightforward the appointment...2 stable diagnoses + med prescription = 99214 per the new guidelines.

Now I thought moderate level MDM required 2 out of 3: Problem Points, Data or Risk

Either 2 stable diagnoses or a med prescription gets you there on risk, but not for problem points or data.

Help me understand what I’m missing

 

[robellis]

Now I thought moderate level MDM required 2 out of 3: Problem Points, Data or Risk

Either 2 stable diagnoses or a med prescription gets you there on risk, but not for problem points or data.

Help me understand what I’m missing

2 diagnoses is the problem points lol

 

[Psych19]

2 diagnoses is the problem points lol

I think you need 3 problem points for moderate level. 2 stable diagnoses gets you only 2

 

[robellis]

I think you need 3 problem points for moderate level. 2 stable diagnoses gets you only 2

No..you need 2/3 for 99214

 

[futuredo32]

Your psychiatrist says audits are terrible but you’re doing psychoanalysis with him 5x a week….

Interesting self disclosure for an analyst.

I belong to several physician groups online. The consensus is avoid audits because they are horrible.

 

[futuredo32]

Apparently I am not the only one confused about billing. If anyone has a current link it would help many.

 

[clausewitz2]

I think you need 3 problem points for moderate level. 2 stable diagnoses gets you only 2

Read the AMA guide document again. Two chronic stable diagnoses qualifies for level 4/moderate on problems addressed.

 

[clausewitz2]

Apparently I am not the only one confused about billing. If anyone has a current link it would help many.

https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf&ved=2ahUKEwjmuLG5g9_xAhUdGVkFHf8EAqwQFnoECA8QAQ&usg=AOvVaw1HW8hiID4UVLFjWnC4YQgv

 

[calvnandhobbs68]

I think you need 3 problem points for moderate level. 2 stable diagnoses gets you only 2

Apparently I am not the only one confused about billing. If anyone has a current link it would help many.

There are no longer "points" as in the old 992xx CPT codes. There are 3 elements of Medical Decision Making which you have to say you hit 2/3 in a given level to get to an overall level of MDM. 2 stable chronic illnesses and prescription management fulfill 2/3 of these criteria. However, if you'd like to consistently downcode yourself, be my guest. Just means those of us who actually code correctly will keep getting the stupid insurance letters talking about how other psychiatrists are coding 50% 99213s.

AMA literally lays it out as clearly as possible here. APA and AACAP have similar tables. Save this PDF please because this keeps coming up.

https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

 

[futuredo32]

Thank you for the links.

 

[calvnandhobbs68]

Thank you for the links.

I mean I appreciate that you're thankful but you've been talking about this stuff on this forum for quite a while now and this is the first time you've seen this table? I literally googled "ama cpt office codes 2021 table" to find the table I have saved. I think there's a bit of learned helplessness going on here.