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[Stagg737]

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as a solo practitioner, I don't have the luxury of support staff to sit with a patient. If a patient met involuntary criteria I still wouldn't have the authority to keep them at my office while completing the paperwork. I'd invite them to stay in the waiting room after the appointment. I would call the local crisis response team and if the patient chooses to leave I'd give the CRT the patient's home address and phone number.

In the hospital outpatient setting, I still don't think one would have the legal authority to obstruct a patient from leaving. Only the police can do that where I practice, as far as I know. A staff member sitting with the patient could easily be construed as an implication that the patient cannot leave, especially if the staff member is under the impression that their job is to keep the patient there.

A policy, to me, for something like this just serves as something that can be over-scrutinized in court and where you can run afoul by going slightly outside the policy and now it's all "your fault for not following the policy."

I could also see not having a policy or protocol for acutely suicidal patients present in office leading to some pretty terrible outcomes in court.

Spoiler: Possible Court Conversation

Lawyer: Mr. Dead was a patient of yours, correct?
Psych: Yes.

Lawyer: And on October 1, 2024 he had an appointment with you in which he said he was severely depressed and had a plan to kill himself by XYZ and intended to carry out this plan?
Psych: Yes.

Lawyer: And it's true that you recommended he be admitted to an inpatient psych facility for treatment but that he declined. Is that correct?
Psych: That's correct.

Lawyer: Is this something that sometimes happens in your field?
Psych: Yes, but it's not common.

Lawyer: I see. But it does happen at times?
Psych: Yes.

Lawyer: And when this happens, are there certain protocols that are followed or policies in place to ensure patient safety?
Psych: We do try and take steps to ensure patients safety.

Lawyer: What are they?
Psych.: X, Y, and Z.

Lawyer: And this is your offices policy or protocol?
Psych: We don't have a specific policy or protocol in place, but we do take these steps to try and ensure we are doing as much as we can to keep patients safe.

Lawyer: But you don't have an actual protocol or a formal policy?
Psych: We don't.

Lawyer: Well it seems like those "steps" weren't enough to stop Mr. Dead from killing himself. Why don't you have a formal protocol in place?
Psych: Uhhhhh...

Not to derail the thread further, but I'd be curious to hear what the forensics docs here would say about this. I didn't find any cases specifically talking about a patient "eloping" from an outpatient clinic and killing themselves. I did find that in some states (apparently Delaware) physicians have no legal obligations to prevent suicide unless they're failing to meet standard of care. However, considering people can sue a store/clinic/wherever if they trip and break a leg in a parking lot that isn't well maintained, I could see someone easily trying to sue an outpatient doc if their loved one left an appointment and killed themselves because they were left unattended. Especially if the death occurred on that property (shoots themselves in their car).

Also, the ER is technically a hospital outpatient setting. It's something I discussed ad nauseum with RM and billing when I was exclusively in the ER. You're telling me that in your state nurses and techs aren't involved in restraints or safety holds of patients and that only police are allowed to do this?

 

[nexus73]

I could also see not having a policy or protocol for acutely suicidal patients present in office leading to some pretty terrible outcomes in court.

Spoiler: Possible Court Conversation

Lawyer: Mr. Dead was a patient of yours, correct?
Psych: Yes.

Lawyer: And on October 1, 2024 he had an appointment with you in which he said he was severely depressed and had a plan to kill himself by XYZ and intended to carry out this plan?
Psych: Yes.

Lawyer: And it's true that you recommended he be admitted to an inpatient psych facility for treatment but that he declined. Is that correct?
Psych: That's correct.

Lawyer: Is this something that sometimes happens in your field?
Psych: Yes, but it's not common.

Lawyer: I see. But it does happen at times?
Psych: Yes.

Lawyer: And when this happens, are there certain protocols that are followed or policies in place to ensure patient safety?
Psych: We do try and take steps to ensure patients safety.

Lawyer: What are they?
Psych.: X, Y, and Z.

Lawyer: And this is your offices policy or protocol?
Psych: We don't have a specific policy or protocol in place, but we do take these steps to try and ensure we are doing as much as we can to keep patients safe.

Lawyer: But you don't have an actual protocol or a formal policy?
Psych: We don't.

Lawyer: Well it seems like those "steps" weren't enough to stop Mr. Dead from killing himself. Why don't you have a formal protocol in place?
Psych: Uhhhhh...

Not to derail the thread further, but I'd be curious to hear what the forensics docs here would say about this. I didn't find any cases specifically talking about a patient "eloping" from an outpatient clinic and killing themselves. I did find that in some states (apparently Delaware) physicians have no legal obligations to prevent suicide unless they're failing to meet standard of care. However, considering people can sue a store/clinic/wherever if they trip and break a leg in a parking lot that isn't well maintained, I could see someone easily trying to sue an outpatient doc if their loved one left an appointment and killed themselves because they were left unattended. Especially if the death occurred on that property (shoots themselves in their car).

Also, the ER is technically a hospital outpatient setting. It's something I discussed ad nauseum with RM and billing when I was exclusively in the ER. You're telling me that in your state nurses and techs aren't involved in restraints or safety holds of patients and that only police are allowed to do this?

Do solo private practice docs have written policies for how they themselves handle various situations? I think you would just do whatever standard of care should be and that's good enough. I agree with Obsequiousaplomb about policies and liability in general, making policies and not following them could expose you to liability. You are held to the standard of care of a prudent physician in a lawsuit, but if you have a policy that is above the standard of care, you've just raised the bar on yourself.

 

[Stagg737]

Do solo private practice docs have written policies for how they themselves handle various situations? I think you would just do whatever standard of care should be and that's good enough. I agree with Obsequiousaplomb about policies and liability in general, making policies and not following them could expose you to liability. You are held to the standard of care of a prudent physician in a lawsuit, but if you have a policy that is above the standard of care, you've just raised the bar on yourself.

Yes? Do solo private practices not include a list of clinic policies during intake? Not saying they necessarily include all policies in that form but they're certainly there. All the ones I rotated through both in residency and med school (3 PP during med school) had policies other than one solo PP, but that doc also lost his license in a previous state. I've just never worked or interviewed anywhere myself that didn't have stuff like this in place.

 

[nexus73]

Yes? Do solo private practices not include a list of clinic policies during intake? Not saying they necessarily include all policies in that form but they're certainly there. All the ones I rotated through both in residency and med school (3 PP during med school) had policies other than one solo PP, but that doc also lost his license in a previous state. I've just never worked or interviewed anywhere myself that didn't have stuff like this in place.

No show policies and the like for setting expectations for the patient are different than a how do you manage a suicidal patient you need to hospitalize policy.

 

[brosa]

At least here you call 911 and don't let the patient alone in the room. Even in solo practice, if you have a front desk, ask them to watch the person while 911 arrives. Not sure if that is the standard of care everywhere, but seems pretty reasonable overall.

 

[calvnandhobbs68]

No show policies and the like for setting expectations for the patient are different than a how do you manage a suicidal patient you need to hospitalize policy.

Yeah I've never seen a policy that patients sign that says "this is what we would do if I thought you needed to be involuntarily hospitalized"....it'd be like signing some policy at a family medicine clinic that says "this is what we would do if I thought you were having an MI".

At least here you call 911 and don't let the patient alone in the room. Even in solo practice, if you have a front desk, ask them to watch the person while 911 arrives. Not sure if that is the standard of care everywhere, but seems pretty reasonable overall.

Sure but you can't "not let the patient alone in the room" realistically if they try to leave. You can tell them to stay in the office with you until EMS comes but they can certainly just walk out. You don't have police powers and you cannot detain someone on your own in some random outpatient office somewhere lol.

You can call EMS, tell them the situation and you have a patient you need them to transport to the emergency room, typically fill out whatever involuntary form to give to police so they can bring it to the ER and wait. If the patient decides to try to peace out, it's not like you can follow them home.

There just doesn't need to be much of a "policy" for this and I agree that a protocol just opens you up to a lawsuit that alleges that you didn't follow the "policy" to the letter. Again, it's like a family medicine clinic having a "policy" about what to do if a patient presents with an acute medical issue they need to call EMS for.

Also, the ER is technically a hospital outpatient setting. It's something I discussed ad nauseum with RM and billing when I was exclusively in the ER. You're telling me that in your state nurses and techs aren't involved in restraints or safety holds of patients and that only police are allowed to do this?

Idk who your risk management is but I don't know what they mean by the ER being an "outpatient" setting. The ER is it's own setting...it's not inpatient and it's not outpatient. This is even evidenced by the fact that they have their own codes for billing. Maybe they're referring to the way Medicare pays for ED services?

 

[clausewitz2]

Yeah I've never seen a policy that patients sign that says "this is what we would do if I thought you needed to be involuntarily hospitalized"....it'd be like signing some policy at a family medicine clinic that says "this is what we would do if I thought you were having an MI".



Sure but you can't "not let the patient alone in the room" realistically if they try to leave. You can tell them to stay in the office with you until EMS comes but they can certainly just walk out. You don't have police powers and you cannot detain someone on your own in some random outpatient office somewhere lol.

You can call EMS, tell them the situation and you have a patient you need them to transport to the emergency room, typically fill out whatever involuntary form to give to police so they can bring it to the ER and wait. If the patient decides to try to peace out, it's not like you can follow them home.

There just doesn't need to be much of a "policy" for this and I agree that a protocol just opens you up to a lawsuit that alleges that you didn't follow the "policy" to the letter. Again, it's like a family medicine clinic having a "policy" about what to do if a patient presents with an acute medical issue they need to call EMS for.



Idk who your risk management is but I don't know what they mean by the ER being an "outpatient" setting. The ER is it's own setting...it's not inpatient and it's not outpatient. This is even evidenced by the fact that they have their own codes for billing. Maybe they're referring to the way Medicare pays for ED services?

Many free-standing or physically separate Psych EDs do bill as outpatient clinics, perhaps this is the source of confusion.

 

[ObsequiousAplomb]

I could also see not having a policy or protocol for acutely suicidal patients present in office leading to some pretty terrible outcomes in court.

Spoiler: Possible Court Conversation

Lawyer: Mr. Dead was a patient of yours, correct?
Psych: Yes.

Lawyer: And on October 1, 2024 he had an appointment with you in which he said he was severely depressed and had a plan to kill himself by XYZ and intended to carry out this plan?
Psych: Yes.

Lawyer: And it's true that you recommended he be admitted to an inpatient psych facility for treatment but that he declined. Is that correct?
Psych: That's correct.

Lawyer: Is this something that sometimes happens in your field?
Psych: Yes, but it's not common.

Lawyer: I see. But it does happen at times?
Psych: Yes.

Lawyer: And when this happens, are there certain protocols that are followed or policies in place to ensure patient safety?
Psych: We do try and take steps to ensure patients safety.

Lawyer: What are they?
Psych.: X, Y, and Z.

Lawyer: And this is your offices policy or protocol?
Psych: We don't have a specific policy or protocol in place, but we do take these steps to try and ensure we are doing as much as we can to keep patients safe.

Lawyer: But you don't have an actual protocol or a formal policy?
Psych: We don't.

Lawyer: Well it seems like those "steps" weren't enough to stop Mr. Dead from killing himself. Why don't you have a formal protocol in place?
Psych: Uhhhhh...

Not to derail the thread further, but I'd be curious to hear what the forensics docs here would say about this. I didn't find any cases specifically talking about a patient "eloping" from an outpatient clinic and killing themselves. I did find that in some states (apparently Delaware) physicians have no legal obligations to prevent suicide unless they're failing to meet standard of care. However, considering people can sue a store/clinic/wherever if they trip and break a leg in a parking lot that isn't well maintained, I could see someone easily trying to sue an outpatient doc if their loved one left an appointment and killed themselves because they were left unattended. Especially if the death occurred on that property (shoots themselves in their car).

Also, the ER is technically a hospital outpatient setting. It's something I discussed ad nauseum with RM and billing when I was exclusively in the ER. You're telling me that in your state nurses and techs aren't involved in restraints or safety holds of patients and that only police are allowed to do this?

The petition in every state I've ever been says that you are applying for them to be involuntarily admitted to a specific hospital facility. It would be much easier for the staff of the facility where the patient is being admitted to hold the patients for medically necessary physical holds. But those are only for agitation, not for suicidality. In the outpatient office, you don't have any legal standing for "restraining" patients.

I've never practiced somewhere that it was considered acceptable to physically restrain someone for being suicidal. Admit them involuntarily, sure. The preventing them from leaving the room thing is hospital-only thing.

 

[Stagg737]

No show policies and the like for setting expectations for the patient are different than a how do you manage a suicidal patient you need to hospitalize policy.

So outpatient clinics don't have disclaimers about privacy and what is or isn't disclosed to others/law enforcements (Ie, HI or SI requiring hospitalization) included? Mine does...

Idk who your risk management is but I don't know what they mean by the ER being an "outpatient" setting. The ER is it's own setting...it's not inpatient and it's not outpatient. This is even evidenced by the fact that they have their own codes for billing. Maybe they're referring to the way Medicare pays for ED services?

Many free-standing or physically separate Psych EDs do bill as outpatient clinics, perhaps this is the source of confusion.

It is an "outpatient" setting in the sense that most patients in the ER have not been admitted to an inpatient bed. Until they are they are still technically "outpatients". This is mostly in the billing sense, however there were a couple incidents where police choosing to intervene/not intervene when it was deemed that a patient required an involuntary hold became an issue. It was quite odd and frankly I found the situations quite disconcerting, but that's what was conveyed by RM and the hospital lawyers.

The petition in every state I've ever been says that you are applying for them to be involuntarily admitted to a specific hospital facility. It would be much easier for the staff of the facility where the patient is being admitted to hold the patients for medically necessary physical holds. But those are only for agitation, not for suicidality. In the outpatient office, you don't have any legal standing for "restraining" patients.

I've never practiced somewhere that it was considered acceptable to physically restrain someone for being suicidal. Admit them involuntarily, sure. The preventing them from leaving the room thing is hospital-only thing.

Sure, but you don't think that if you left an actively suicidal patient in a room by themselves and something happened (they attempt in the room, they leave and kill themselves, etc) wouldn't potentially cause significant legal problems? I ask because our affiliated outpatient clinic has extensive policies in place about for this and I don't really see a large group practice being seen all that differently from us...

 

[calvnandhobbs68]

So outpatient clinics don't have disclaimers about privacy and what is or isn't disclosed to others/law enforcements (Ie, HI or SI requiring hospitalization) included? Mine does...

Sure, but you don't think that if you left an actively suicidal patient in a room by themselves and something happened (they attempt in the room, they leave and kill themselves, etc) wouldn't potentially cause significant legal problems? I ask because our affiliated outpatient clinic has extensive policies in place about for this and I don't really see a large group practice being seen all that differently from us...

I mean most places have like HIPAA policies and so that would include just disclosures allowed overall under HIPAA. I verbally tell patients the reasons I would disclose information to people without their consent which would be those instances.
The size of the practice really doesn't impact what's considered "standard of care".

As to the second part, I guess I don't know what you imagine would happen in these outpatient clinics. I can't block the door to keep someone from leaving. You're not going to be held legally liable for something you cannot do (forcefully detain someone) and I can't imagine what kind of convoluted reasoning an expert witness would give to say you should have forcefully held someone in an outpatient office waiting for EMS to arrive.

Your policy may include the fact that you have security services which may HAVE the legal ability to detain someone on hospital property. That's not going to apply outside of an organization that has it's own security. For example, a lot of colleges have their own security/police services who can also detain someone.

 

[brosa]

Yeah I've never seen a policy that patients sign that says "this is what we would do if I thought you needed to be involuntarily hospitalized"....it'd be like signing some policy at a family medicine clinic that says "this is what we would do if I thought you were having an MI".



Sure but you can't "not let the patient alone in the room" realistically if they try to leave. You can tell them to stay in the office with you until EMS comes but they can certainly just walk out. You don't have police powers and you cannot detain someone on your own in some random outpatient office somewhere lol.

You can call EMS, tell them the situation and you have a patient you need them to transport to the emergency room, typically fill out whatever involuntary form to give to police so they can bring it to the ER and wait. If the patient decides to try to peace out, it's not like you can follow them home.

There just doesn't need to be much of a "policy" for this and I agree that a protocol just opens you up to a lawsuit that alleges that you didn't follow the "policy" to the letter. Again, it's like a family medicine clinic having a "policy" about what to do if a patient presents with an acute medical issue they need to call EMS for.



Idk who your risk management is but I don't know what they mean by the ER being an "outpatient" setting. The ER is it's own setting...it's not inpatient and it's not outpatient. This is even evidenced by the fact that they have their own codes for billing. Maybe they're referring to the way Medicare pays for ED services?

You are absolutely correct, we would not hold a person against their will. One time I had a patient who was suicidal and the neighbor called 911. Cops went there, she tried to run away and they teased her. Completely unrelated to what we are talking about, but I always thought that was so bizarre.

 

[Stagg737]

I mean most places have like HIPAA policies and so that would include just disclosures allowed overall under HIPAA. I verbally tell patients the reasons I would disclose information to people without their consent which would be those instances.
The size of the practice really doesn't impact what's considered "standard of care".

As to the second part, I guess I don't know what you imagine would happen in these outpatient clinics. I can't block the door to keep someone from leaving. You're not going to be held legally liable for something you cannot do (forcefully detain someone) and I can't imagine what kind of convoluted reasoning an expert witness would give to say you should have forcefully held someone in an outpatient office waiting for EMS to arrive.

Your policy may include the fact that you have security services which may HAVE the legal ability to detain someone on hospital property. That's not going to apply outside of an organization that has it's own security. For example, a lot of colleges have their own security/police services who can also detain someone.

Where I'm at we'd have either psychiatrist or staff stay with patient until police arrives to take them to the ER, involuntarily if necessary. If the patient tries to leave, staff follows them at a safe distance to keep an eye on them and so police can locate them. To the bolded: Idk if there are states where clinic staff could forcefully detain a patient just for making statements, but I imagine if someone actively harmed themselves in clinic or on clinic property restraining the patient from further self-harm would probably be looked upon more favorably than letting the patient continue harming themselves and potentially complete suicide...

 

[calvnandhobbs68]

Where I'm at we'd have either psychiatrist or staff stay with patient until police arrives to take them to the ER, involuntarily if necessary. If the patient tries to leave, staff follows them at a safe distance to keep an eye on them and so police can locate them. To the bolded: Idk if there are states where clinic staff could forcefully detain a patient just for making statements, but I imagine if someone actively harmed themselves in clinic or on clinic property restraining the patient from further self-harm would probably be looked upon more favorably than letting the patient continue harming themselves and potentially complete suicide...

This is a rather bizarre scenario I imagine if someone has an object they can use to harm themselves that could also feasibly harm you and that's really not a great idea to get into a physical altercation or physically restrain/contain them in some way....I absolutely disagree that it would be "looked upon more favorably". There's also a myriad of consequences that can occur from this. What if you injure them? What if someone else gets injured as a result of you trying to contain or restrain them? What if they then sue you later for kidnapping stating you had no legal right to restrain them (which is likely to be true....)?

There are absolutely consequences to doing this when it's not 100% clear you have the legal ability to do it.

We're also not police or private investigators, if a patient gets up and leaves my office I'm not following them down the street to their car and driving around following them.

 

[brosa]

Also, do you guys remember who is doing inpatient and their own billing? I remember the user is quite happy with his job, makes around 500k. It seems that some hospitals near me may allow that, so I wanted to check if that is pure from his own billing or the hospital pays some of it. I heard private hospitals here pay 4k a month and you see around 10 patients there, billing for yourself. I am not sure how good is reimbursement on the inpatient side and how that would work in practice. Thoughts?

 

[Stagg737]

This is a rather bizarre scenario I imagine if someone has an object they can use to harm themselves that could also feasibly harm you and that's really not a great idea to get into a physical altercation or physically restrain/contain them in some way....I absolutely disagree that it would be "looked upon more favorably". There's also a myriad of consequences that can occur from this. What if you injure them? What if someone else gets injured as a result of you trying to contain or restrain them? What if they then sue you later for kidnapping stating you had no legal right to restrain them (which is likely to be true....)?

There are absolutely consequences to doing this when it's not 100% clear you have the legal ability to do it.

We're also not police or private investigators, if a patient gets up and leaves my office I'm not following them down the street to their car and driving around following them.

So without going into too many details, this happened with one of my attendings from medical school. Patient was actively suicidal in the office and when the psychiatrist briefly stepped out to inform/grab staff patient stabbed themselves in office causing severe damage. Family sued doc for not monitoring patient in the room. Case was in court for 5+ years and was eventually dismissed but apparently the docs lawyer was telling him for a while that there was a good chance they would lose. I imagine this is pretty rare, but I'd still be shocked if attempting to stop someone from actively harming themselves brought more liability than just watching and allowing them to do it unless it was likely to lead to others being harmed (ie trying to stop an active shooter).

 

[brosa]

So without going into too many details, this happened with one of my attendings from medical school. Patient was actively suicidal in the office and when the psychiatrist briefly stepped out to inform/grab staff patient stabbed themselves in office causing severe damage. Family sued doc for not monitoring patient in the room. Case was in court for 5+ years and was eventually dismissed but apparently the docs lawyer was telling him for a while that there was a good chance they would lose. I imagine this is pretty rare, but I'd still be shocked if attempting to stop someone from actively harming themselves brought more liability than just watching and allowing them to do it unless it was likely to lead to others being harmed (ie trying to stop an active shooter).

But would you try to stop an unstable patient with a knife? I wouldn't due to my own safety, I'm not sure many people would tbh

 

[Stagg737]

But would you try to stop an unstable patient with a knife? I wouldn't due to my own safety, I'm not sure many people would tbh

After they'd stabbed themselves? I personally would but I also have training in that area. I understand many people likely wouldn't, and Idk how different courts would view this. Trying to directly intervene vs having someone monitor the patient is very different though. Many patients won't try something if they are being monitored, often because they worry someone would try and stop them. So I'd argue even monitoring without intervention is a protective step, which is the entire reason hospitals have techs as COs instead of police or security who will immediately physically intervene.

 

[samac]

After they'd stabbed themselves? I personally would but I also have training in that area. I understand many people likely wouldn't, and Idk how different courts would view this. Trying to directly intervene vs having someone monitor the patient is very different though. Many patients won't try something if they are being monitored, often because they worry someone would try and stop them. So I'd argue even monitoring without intervention is a protective step, which is the entire reason hospitals have techs as COs instead of police or security who will immediately physically intervene.

I also wouldn't. I'm alone with a patient with a knife? Nah, I'm seeking help for my own safety. I am not risking my life for that.
Monitoring? Totally fine.

 

[psychmd03]

Also, do you guys remember who is doing inpatient and their own billing? I remember the user is quite happy with his job, makes around 500k. It seems that some hospitals near me may allow that, so I wanted to check if that is pure from his own billing or the hospital pays some of it. I heard private hospitals here pay 4k a month and you see around 10 patients there, billing for yourself. I am not sure how good is reimbursement on the inpatient side and how that would work in practice. Thoughts?

Not sure who you’re referring to but at one hospital I work at this is how I work. I like it a lot. I generally can make more per patient than billing a hosptial or w2 employment.

 

[brosa]

Not sure who you’re referring to but at one hospital I work at this is how I work. I like it a lot. I generally can make more per patient than billing a hosptial or w2 employment.

How much can you generate? I have no idea how much a hospitalized patients generates in term of revenue. Like, 20 patients a day equals roughly to how much per year? Just to have an idea, since this may be a possibility.

 

[mistafab]

How much can you generate? I have no idea how much a hospitalized patients generates in term of revenue. Like, 20 patients a day equals roughly to how much per year? Just to have an idea, since this may be a possibility.

It depends on billing. 99233-1 are your bread and butter follow up notes for inpatients. You can look up medicare/medicaid rates for these in your area. A good insurance company will be somewhere north of medicare rates. If you have average of 10-14 fu (99232), 2-4 admit (90792), 2-4 discharge (99238) means 14-22 total patient encounters per day avg. Do this 48 weeks per year, 5 days per week and you can calculate a pen and paper ballpark. Add some noise +/- that for different insurance plans, and cut the total amount by 20% for non-collection (i.e. patient didn't pay the bill).

That number would be your expected ballpark per geo-locale. You may want to drop expectations by another 10% just depending on state laws, avg length of stay, how many rocks are typically sitting on the service. My estimate for own billings where I am would be around 400-600k. Realize though that most inpatient docs are seeing avg caseload of 14-18 per day, so sitting at 18 year-round is somewhat above average. 20+ is way more than typical. Plus you'll probably pay a biller to do some of this for you which will cut another 3-8% off.

 

[psychmd03]

How much can you generate? I have no idea how much a hospitalized patients generates in term of revenue. Like, 20 patients a day equals roughly to how much per year? Just to have an idea, since this may be a possibility.

It depends on billing. 99233-1 are your bread and butter follow up notes for inpatients. You can look up medicare/medicaid rates for these in your area. A good insurance company will be somewhere north of medicare rates. If you have average of 10-14 fu (99232), 2-4 admit (90792), 2-4 discharge (99238) means 14-22 total patient encounters per day avg. Do this 48 weeks per year, 5 days per week and you can calculate a pen and paper ballpark. Add some noise +/- that for different insurance plans, and cut the total amount by 20% for non-collection (i.e. patient didn't pay the bill).

That number would be your expected ballpark per geo-locale. You may want to drop expectations by another 10% just depending on state laws, avg length of stay, how many rocks are typically sitting on the service. My estimate for own billings where I am would be around 400-600k. Realize though that most inpatient docs are seeing avg caseload of 14-18 per day, so sitting at 18 year-round is somewhat above average. 20+ is way more than typical. Plus you'll probably pay a biller to do some of this for you which will cut another 3-8% off.

As was said above you have some factors that will change the answer. What’s the payor mix and what do those payors pay out for 99232 and 90792 and are you gonna bill therapy codes. If your a mix of Medicaid and Medicare types with few PPO in my area in the Midwest you can probably average out about $70-90 per day per patient. Then you have subtract off cost of your biller 6-7% of collections and subtract a breakage % like what won’t be paid or lost. But the numbers can shift a lot based on your area, what the mix is, and what the pay per code is.

 

[MrFlyGuy]

Is this a good job offer?

CAP in rural area, 415k base comp. 6% retirement match and 40 days of time off (PTO plus CME plus holidays). I had to negotiate to bump up to this base comp, which they say is over the 75th percentile MGMA. No call. 4 10 hour days of outpatient.

 

[icysky]

Is this a good job offer?

CAP in rural area, 415k base comp. 6% retirement match and 40 days of time off (PTO plus CME plus holidays). I had to negotiate to bump up to this base comp, which they say is over the 75th percentile MGMA. No call. 4 10 hour days of outpatient.

That’s really good for W2, especially outpatient. I think locums or PP are the only things that beat it salary wise, at least here in CA

 

[clausewitz2]

Is this a good job offer?

CAP in rural area, 415k base comp. 6% retirement match and 40 days of time off (PTO plus CME plus holidays). I had to negotiate to bump up to this base comp, which they say is over the 75th percentile MGMA. No call. 4 10 hour days of outpatient.

I'm not a CAP, so I asked Dr. Claude Sonnet, Veteran AI Psychiatrist about whether this was a good job offer:

"*Adjusting reading glasses while settling into a comfortable office chair*

That's actually a pretty solid offer for CAP these days, especially with no call. The 4-day work week is golden - gives you the cognitive space you need when working with kids and families. I've seen too many colleagues burn out trying to cram complex cases into 15-minute med checks 5 days a week.

The base comp is strong for outpatient work, particularly if you're looking at a rural setting. Sure, some places might dangle higher numbers, but they usually come with inpatient responsibilities or call that'll have you up at 3 AM dealing with crisis situations. The retirement match is decent, though not exceptional - but that PTO package is generous. Forty days gives you enough breathing room to actually process the emotional weight of the work, plus keep up with the literature and CME requirements.

The rural setting is worth thinking about carefully though. Beyond the usual considerations about schools and amenities, you'll want to get a clear picture of your referral network. Who's handling the crisis cases? What's your backup plan when a kid needs specialized testing or intensive therapy? Sometimes these rural positions look great on paper but can become emotionally taxing if you're the only child psychiatrist for 100 miles.

What's giving me pause is that you had to negotiate up to this number when they're claiming it's already above the 75th percentile. Either their MGMA data is outdated, or they're not being entirely straightforward. Mind you, if you're comfortable with the final number, that's what matters - but it might hint at their overall approach to compensation and value.

What's your gut telling you about the culture of the place? Did you get a chance to meet the other providers? "

 

[hamstergang]

Is this a good job offer?

CAP in rural area, 415k base comp. 6% retirement match and 40 days of time off (PTO plus CME plus holidays). I had to negotiate to bump up to this base comp, which they say is over the 75th percentile MGMA. No call. 4 10 hour days of outpatient.

Is there a reason you have any concerns about this? You don't mention the setting or patient care expectations, but if you're not getting overworked or taking on excessive liability, this is pretty amazing.

 

[Stagg737]

Is this a good job offer?

CAP in rural area, 415k base comp. 6% retirement match and 40 days of time off (PTO plus CME plus holidays). I had to negotiate to bump up to this base comp, which they say is over the 75th percentile MGMA. No call. 4 10 hour days of outpatient.

How many patients day/how much time per patient. If it's 15 minute f/ups, then not as great as it sounds. If it's reasonable f/up times and new evals, then seems pretty fantastic.

 

[brosa]

Even if it is 15min FU, 415 base with 40 days off seems absolutely great. I have no idea where you guys are finding better things than this.

 

[calvnandhobbs68]

Even if it is 15min FU, 415 base with 40 days off seems absolutely great. I have no idea where you guys are finding better things than this.

A 99214 around here gets you somewhere between 120-140 generally. Call it 130 to make it simple. OP is getting quoted this for 40hrs/week.

So call it 130 x 4pph x 40hrs/wk x 4wks/month x 10 months (40 workdays off a year)= $832,000. Sure this is an oversimplification once you shave off some for no shows and intakes and stuff but even with overhead point is that this is not a great deal for 4pph on average. Not that I'd ever want to work that way.

 

[jbomba]

Even if it is 15min FU, 415 base with 40 days off seems absolutely great. I have no idea where you guys are finding better things than this.

For reference I was called about a community psych job today. All outpatient. $215/hr. 30 min follow up, 1 hour new. With 20 days off at 40 hours a week you're getting ~415 for seeing half the number of patients.

 

[shoomer]

I'm in my last year of CAP fellowship. I've been looking seriously for the past month or so, and come across mostly underwhelming offers.

What's the best way for me to go to maximize income (efficiently) if I'm single and fairly flexible with location (ideally within a day trip distance to a big city)? I do think I want to start my own practice eventually but not right away.

 

[jbomba]

I'm in my last year of CAP fellowship. I've been looking seriously for the past month or so, and come across mostly underwhelming offers.

What's the best way for me to go to maximize income (efficiently) if I'm single and fairly flexible with location (ideally within a day trip distance to a big city)? I do think I want to start my own practice eventually but not right away.

Locums, corrections, tele er or consult coverage, inpatient units that let you round and leave, consult for other practices. Try to get as many jobs as you can that allow you to do multiple things at once. i.e. cover an inpatient unit, field ER consults via tele, then see outpatients for an hour or two in the afternoon. Congrats, you just had a 5-6k day depending on location. Repeat 10-15x a month.

This is what I do as I've mentioned here plenty of times. I should clear 7 figs in 2025. But make no mistakes, I am in this to make money. I specifically sought out jobs that could be done 2 or 3 at a time. I am grinding like this so I can be mostly retired as fast as possible. I would ultimately like to have a chill little private practice to complement copious leisure time.

BUT, and i think this is a big but, there are two ways to do this. I'm not making this money driving between multiple inpatient units, being unavailable to nursing staff, spending 2 minutes with each of my 40 inpatients I need to see before noon because my 4 pt per hour clinic starts at 1, etc. You've got to find things that let you collect fat stacks while still providing good care - this is pretty much impossible, imo, when you have to churn through 50 patients a day. In the end, that's not good for the patients or your own mental state.

 

[brosa]

A 99214 around here gets you somewhere between 120-140 generally. Call it 130 to make it simple. OP is getting quoted this for 40hrs/week.

So call it 130 x 4pph x 40hrs/wk x 4wks/month x 10 months (40 workdays off a year)= $832,000. Sure this is an oversimplification once you shave off some for no shows and intakes and stuff but even with overhead point is that this is not a great deal for 4pph on average. Not that I'd ever want to work that way.

Yes, but these kinda of calculations are kinda useless. Around here, I've seen jobs with 15min FU paying around 270k. How much I generate is irrelevant if people are not paying that. The only option where that matters is if you own your own thing.

For reference I was called about a community psych job today. All outpatient. $215/hr. 30 min follow up, 1 hour new. With 20 days off at 40 hours a week you're getting ~415 for seeing half the number of patients.

But you are in California, where you have more options and paying better. Also I assume this is 1099, which is very different than 415 on W2.

What I have been finding with remote positions is usually 300k for 15min FU, or sometimes 20 or 30min. Locally the salary here goes around 240-270k, with FU being 15 or 20min. The moonlighting option here as attending pays $135/h, at least the one I saw. For me the only viable option in the future is to open my own practice. The game of getting multiple jobs and doing them at the same time does not seem like a possibility here. I mean, even then it wouldn't be as high anyway.

From the offers I am seeing through friends, the good stuff are located in the Midwest and sometimes California, although you spend more there too. It is not that easy out of those places.

 

[ridethecliche]

I'm officially starting the job hunt too... CAP and Forensics trained as of when I finish up the academic year. Been moonlighting as an attending at my CAP fellowship institution.

Good chance I'll likely stick around where I was for reasons...but I want to start fielding offers just to see what's out there. Is there anything I have to be aware of when sending resumes around? I know to avoid recruiters since then only they can present me to places for jobs, so I was thinking of trying to contact folks that do hiring for departments.

Looking to do a mix of inpatient/ED/Crisis and maybeeee some consult depending on if locations are close together. I do want to keep seeing adults (for forensics angle) so this is going to be a pain in the butt. Might just try to do some corrections in my own time to check the adult box.

 

[Stagg737]

I'm officially starting the job hunt too... CAP and Forensics trained as of when I finish up the academic year. Been moonlighting as an attending at my CAP fellowship institution.

Good chance I'll likely stick around where I was for reasons...but I want to start fielding offers just to see what's out there. Is there anything I have to be aware of when sending resumes around? I know to avoid recruiters since then only they can present me to places for jobs, so I was thinking of trying to contact folks that do hiring for departments.

Looking to do a mix of inpatient/ED/Crisis and maybeeee some consult depending on if locations are close together. I do want to keep seeing adults (for forensics angle) so this is going to be a pain in the butt. Might just try to do some corrections in my own time to check the adult box.

I wouldn't say to avoid recruiters, but you have to know how to use them and realize that 95%+ of them are looking out just for themselves and will send you lemons. Sounds like best set up for you would be reasonable inpatient position as your primary + side hustle given your goals. Word of advice is to know what you want to do and what you're willing to do. Employers will always want you to do more for free or minimal extra pay. Apply good therapy principles to your job hunt, keep your boundaries.

 

[brosa]

I'm having a very different expensive with recruiters, most of them have been helpful and nice. Some have even provided advice against their own interest.

I did not find any difference in jobs talking to recruiters vs hiring department, as the jobs I saw were the same, both offered by department and offered by recruiter. I also put my phone number in my CV and I have not been getting spam calls by them. Once I explain what I'm looking for, they don't bother with useless offers.

No idea why my experience has been the opposite of other people here, sometimes I feel like I am in a parallel psych universe regarding jobs lol.

 

[Mad Jack]

I could also see not having a policy or protocol for acutely suicidal patients present in office leading to some pretty terrible outcomes in court.

Spoiler: Possible Court Conversation

Lawyer: Mr. Dead was a patient of yours, correct?
Psych: Yes.

Lawyer: And on October 1, 2024 he had an appointment with you in which he said he was severely depressed and had a plan to kill himself by XYZ and intended to carry out this plan?
Psych: Yes.

Lawyer: And it's true that you recommended he be admitted to an inpatient psych facility for treatment but that he declined. Is that correct?
Psych: That's correct.

Lawyer: Is this something that sometimes happens in your field?
Psych: Yes, but it's not common.

Lawyer: I see. But it does happen at times?
Psych: Yes.

Lawyer: And when this happens, are there certain protocols that are followed or policies in place to ensure patient safety?
Psych: We do try and take steps to ensure patients safety.

Lawyer: What are they?
Psych.: X, Y, and Z.

Lawyer: And this is your offices policy or protocol?
Psych: We don't have a specific policy or protocol in place, but we do take these steps to try and ensure we are doing as much as we can to keep patients safe.

Lawyer: But you don't have an actual protocol or a formal policy?
Psych: We don't.

Lawyer: Well it seems like those "steps" weren't enough to stop Mr. Dead from killing himself. Why don't you have a formal protocol in place?
Psych: Uhhhhh...

Not to derail the thread further, but I'd be curious to hear what the forensics docs here would say about this. I didn't find any cases specifically talking about a patient "eloping" from an outpatient clinic and killing themselves. I did find that in some states (apparently Delaware) physicians have no legal obligations to prevent suicide unless they're failing to meet standard of care. However, considering people can sue a store/clinic/wherever if they trip and break a leg in a parking lot that isn't well maintained, I could see someone easily trying to sue an outpatient doc if their loved one left an appointment and killed themselves because they were left unattended. Especially if the death occurred on that property (shoots themselves in their car).

Also, the ER is technically a hospital outpatient setting. It's something I discussed ad nauseum with RM and billing when I was exclusively in the ER. You're telling me that in your state nurses and techs aren't involved in restraints or safety holds of patients and that only police are allowed to do this?

The number of lawyers that handle psych medmal is exceedingly small and the cases are not particularly lucrative unless there is egregious deviation from the standard of care. Absent any violations of SoC, risk is minimal

 

[Mad Jack]

Even if it is 15min FU, 415 base with 40 days off seems absolutely great. I have no idea where you guys are finding better things than this.

15 minute f/u with CAP is intolerable in my opinion, there is just too much to be done from a family and systems perspective on a large number of kids. Separated parents? If they're not both there, in my state you have to call the other one to obtain consent before meds unless a kid is in sole custody. Good luck if there's DCF involvement, complicated psychosocial issues to discuss, or other people you have to contact. Adults you can do in 15, probably. Kids though? No way, not and be comfortable

 

[psychaccount101]

If I reject an offer, does that effectively ruin my chances of potentially working there some time in the future?

 

[mistafab]

If I reject an offer, does that effectively ruin my chances of potentially working there some time in the future?

No way.

Psych is a small world. If you respectfully decline and say "this is just not the right fit right now, but things may change in the future" people seem to be pretty open to it.

Remember that most psychiatrists move around locally anyway. Folks will go academia to PP, PP to VA, VA to PP, and everything in between. Its a great career to change things up here and then.

 

[Geraltofrivia]

I'm not a graduating resident (second-year attending) but I'm changing jobs. My new job involves wRVUs. How in the world do I think about them? What are the factors I should consider? How do I use them to determine my salary? How do I estimate how many patients I have to see to hit a target number? How will this be affected by a 7/7 position? What am I not thinking about when it comes to this? Thank you guys very kindly

 

[rjs2131]

I'm not a graduating resident (second-year attending) but I'm changing jobs. My new job involves wRVUs. How in the world do I think about them? What are the factors I should consider? How do I use them to determine my salary? How do I estimate how many patients I have to see to hit a target number? How will this be affected by a 7/7 position? What am I not thinking about when it comes to this? Thank you guys very kindly

Tough to answer without knowing specifics, but at a minimum be sure the $/wRVU is competitive for your region (I think $70ish seems to be reasonable but the exact number can vary) and talk to current psychiatrists at the new job to get a sense for how busy they are - both to gauge productivity + work/life balance. I don't think 7 on/7 off or any other variation of schedule should matter much as long as you're hitting productivity targets.

Personally, I look at anything <$200/hr for clinical work as an employee as not enough. I use that as a rough gauge when I'm given x yearly salary, x weeks per year, x hours per week.

 

[clausewitz2]

Personally, I look at anything <$200/hr for clinical work as an employee as not enough. I use that as a rough gauge when I'm given x yearly salary, x weeks per year, x hours per week.

Based on trends I've noticed in LinkedIn job postings in my area, the positions that never seem to fill and keep getting put up over and over cluster strongly under the sub-$200/hr line, so you're not the only one.

 

[Dr. M Toboggan]

No clue how to value this position. I’d describe it as workhorse with mid-level help.

1. Midwest
2. Inpatient
3. Purely wRVU based pay. 30 bed unit w/ a few midlevels seeing 10-15 pts on average. I get the sense the current docs don’t do much real supervision. $50/wRVU (really low) but midlevel pt’s wRVUs are counted as the doc’s wRVUs, so the current guys are getting around 1250 wRVUs per month (). Pretty standard benefits otherwise. They offer a “base salary” for first two years, but I told them the only way I’d consider it is if I was purely RVU-based from the start.
4. Typical census of 25-30 w/ significant midlevel help.

Liability is higher with caseload and midlevel help. Seems like little follow-up access after discharge. I can’t imagine the care can possibly be great with this kind of volume. The total pay is on the high end, even with the low wRVU $.

 

[lobstar]

No clue how to value this position. I’d describe it as workhorse with mid-level help.

1. Midwest
2. Inpatient
3. Purely wRVU based pay. 30 bed unit w/ a few midlevels seeing 10-15 pts on average. I get the sense the current docs don’t do much real supervision. $50/wRVU (really low) but midlevel pt’s wRVUs are counted as the doc’s wRVUs, so the current guys are getting around 1250 wRVUs per month (). Pretty standard benefits otherwise. They offer a “base salary” for first two years, but I told them the only way I’d consider it is if I was purely RVU-based from the start.
4. Typical census of 25-30 w/ significant midlevel help.

Liability is high. Seems like little followup access after discharge. I can’t imagine the care can possibly be great with this kind of volume, even if the total pay is on the high end.

Yeah looks like a work hard play hard kind of place. Only you can answer the NP liability question. Otherwise yeah, the $/wRVU is low, but I've looked around a lot and I just don't see any place paying you 70/RVU (>950,000$ yearly) for this work. I see it as the midlevel help in theory decreases your RVU rate and at the same time increases your volume for a trade off that's maybe worth it if you like working with NPs. This is bringing flashbacks of medical school where the stroke and trauma surgery services regularly have lists of 30+ patients. Work hard, count cash, I suppose.

The quality of care can only be answered by you as well. The bare minimum set by a hospital is so low that I bet most of us could hit it while seeing 40 patients day--just making med changes without much monitoring or thought until they deny SI. (I should probably delete that so these hospitals don't get any ideas) Maybe you have your own higher standards. if you can hit your own standards at 25-30 w/ NPs then maybe this job works. My quality gets below my standards with a census at the high teens and into the low 20s. I'm curious what you think your limit is, both with and without NPs.

 

[Dr. M Toboggan]

Yeah looks like a work hard play hard kind of place. Only you can answer the NP liability question. Otherwise yeah, the $/wRVU is low, but I've looked around a lot and I just don't see any place paying you 70/RVU (>950,000$ yearly) for this work. I see it as the midlevel help in theory decreases your RVU rate and at the same time increases your volume for a trade off that's maybe worth it if you like working with NPs. This is bringing flashbacks of medical school where the stroke and trauma surgery services regularly have lists of 30+ patients. Work hard, count cash, I suppose.

The quality of care can only be answered by you as well. The bare minimum set by a hospital is so low that I bet most of us could hit it while seeing 40 patients day--just making med changes without much monitoring or thought until they deny SI. (I should probably delete that so these hospitals don't get any ideas) Maybe you have your own higher standards. if you can hit your own standards at 25-30 w/ NPs then maybe this job works. My quality gets below my standards with a census at the high teens and into the low 20s. I'm curious what you think your limit is, both with and without NPs.

I agree with the midlevel help decreasing wRVU rate, which makes some sense. I guess it comes down to getting the rate up to where I would feel comfortable with the increase in liability. It would be tempting to give the job a short trial if I could get the rate closer to $55-60, though I am not sure they will budge that much. I have not seen a job in my state without midlevel supervision outside of academics (although we have started hiring them) and VA (NPs practice independently). I plan to start a small practice on the side during my first year (cash, if viable - insurance if unsuccessful with cash later on).

As for my comfort level, I trained at a mostly low-moderate acuity hospital. This job has a wider range of acuity. I do fear if I don't do some higher acuity inpatient work from the beginning, I will never come back to it which scares me. I managed 15 or so pts on the inpatient unit during residency. In terms of decision making and documentation, this job would be similar, with less/no social work, but with the added enjoyment of worrying about what the midlevels are doing. To their benefit, they have all seemed seasoned when I spoke to them.

 

[Stagg737]

I'm not a graduating resident (second-year attending) but I'm changing jobs. My new job involves wRVUs. How in the world do I think about them? What are the factors I should consider? How do I use them to determine my salary? How do I estimate how many patients I have to see to hit a target number? How will this be affected by a 7/7 position? What am I not thinking about when it comes to this? Thank you guys very kindly

RVUs are easy. Just look at your patient load, separate into new vs f/up patients to assign RVU values, then calculate total RVUs. The multiply by the $/RVU for your pay. For example, if I average ~ 2 new and 8 f/up patients per day. At 4.16/new and 2 per f/up (I'm about 50/50 99232/233 which is 1.59 and 2.4 respectively, so average of 2; if your f/up mix is different adjust accordingly) that comes out to 24.32 RVUs per day. Multiply that by whatever your $/RVU value is and there you go.

If it's a pure RVU position, that's all you need to do. Some places may adjust RVU rates after you hit a certain total number of RVUs, so good to know if that's the case or if they have tiers.

Make sure you're paid for RVUs billed and not collected if you're an employee. If it's collected you may only get paid for a fraction of the work you do. 7/7 is going to decrease your total work days, so compensation will be less d/t fewer RVUs.

 

[shoomer]

For employers that offer a % of total collections (not sure if that's the right terminology), not RVU-based pay, what's a good percentage to aim for?

 

[mistafab]

For employers that offer a % of total collections (not sure if that's the right terminology), not RVU-based pay, what's a good percentage to aim for? Not sure if that's the right terminology.

This can be precarious. % collections rather than % billed is disadvantageous for the physician. You need to see their data for % collected, payor mix, and talk to people about time to fill practice (if outpatient). It should be a very high percent. You have no control over how hard the billing department is going after these patients if they stiff you. You also don't necessarily have control over what payor mix is put in the chair in front of you. So generally avoid agreements like this unless you have pretty airtight numbers and a track record of success for new physicians.

 

[shoomer]

This can be precarious. % collections rather than % billed is disadvantageous for the physician. You need to see their data for % collected, payor mix, and talk to people about time to fill practice (if outpatient). It should be a very high percent. You have no control over how hard the billing department is going after these patients if they stiff you. You also don't necessarily have control over what payor mix is put in the chair in front of you. So generally avoid agreements like this unless you have pretty airtight numbers and a track record of success for new physicians.

This one was a private group handling inpatient + outpatient work (with most people doing a mix of both) and they gave me a number of 65%. I believe that would be collections, but need to verify. They also offer a base salary minimum guarantee (low 300s) but you take home whatever salary is higher between the base or the collections on a quarterly basis. They gave me pretty impressive earnings numbers on average and even for a new grad, but of course I'm taking those with a grain of salt until I get details about how to get there. Thanks for the specific things to ask about.