hourly rate

[whopper]

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They are associated with a big academic center. Do they really receive most of this fee or is some of it going to the academic center? Are most psychiatrists at academic centers paid by salary or by production? BTW, i just want to state for the record that I doubt any psychiatrist is actually worth this ludicrous rate. And I imagine all of their pts have to be loaded to even consider being seen by these docs.

It depends on the institution. I'm at U. of Cincinnati. We currently have a few psychiatrists here are ranked in the top 100 doctors in the country. Douglas Mossman, Paul Keck, Susan Mcelroy, and we unfortunately recently lost Henry Nasrallah (St. Louis's gain, where he is now the head of psychiatry and neurology). There are several other notables here, maybe not top 100, but certainly well respected on a national level. At this institution, they take a slice of what you bring in.

Others, they don't take a slice of what you bring in.

As bad as having to pay the "man" some of your money, the department does provide very good benefits. You have collegial support among top doctors, if you are sued, the program will fight tooth and nail to defend you, while some institutions and insurance companies I've seen drop their doctor to the wolves. A colleague of mine was sued and the legal fees to protect him went to around $300K and the department paid for all of it. Being in here also opens the door to several academic opportunities.

From what I've seen, expect to have to pay the department at least something of what you bring in though if you become big, you can start negotiating these things with more bargaining power.

I've seen some institutions build a name, be very expensive, and while physically so, the care they gave was not significantly superior.

 

[PikminOC]

actual numbers aside, it's important to realize that a psychiatrist(or psychologist) listed cash rate is often very different from their average effective rate, which is also different from there actual collected rate.

For example, I know one analyst whose rate is listed at 200/hr, but with discounts to certain pts and such her effective charges come out to about 160-165/hr. And what she actually ends up collecting is more like 140-145/hr gross.

I th0ught by effective rate you meant how effective their treatment is. 🤣

 

[PikminOC]

well perhaps....although many cash pay practitioners will do this for less than that

So will many insurance docs who are overloaded with patients anyway...and don't have time to argue...and are concerned with press gancey and complaints to their admins...
I have psych docs at the local hospital who see their patients every five to twelve months..
Antipsychotics and controlled substances are some of the meds these patients are on.

 

[Thewonderer]

Wow...this is like my first post in 7 years!

A few comments:

1) It is very hard to fill your cash only practice. VERY hard. Like a few years hard. Like it can take up to 5 years. And if you are ok with it, then go ahead and do it. That's why a lot of the younger, new graduates keep their moonlighting gigs (such as working for the county clinic or weekend inpatient coverage) for many years before quitting those moonlighting gigs.

2) It depends on your definition of being "full." I can guarantee you if you want to see 30-hours of face-to-face with patients based on cash only, it will take a long long time to build. If you considering working part-time for 15 hours a week and handling some paperwork on the side, you might be able to get full in a year or two.

3) Someone made a comment on "advertised rates," "effective rates" and "collected rates." And those observations are 100% accurate. Many people advertise their rates to be $300/hour but they only have a handful of patients who pay that. The rest of the patients get sliding scale rates of as low was $150/hour. Then some psychiatrists are also not good at billing and collecting the money so their collected rates might even go down to $200/hour, far less than $300/hour they advertise. I am really wary of people stating that they charge this much and that much. Let us be honest. Most people have ego's. They advertise their rates to be $300/hour (and the higher the rate, the more other people think these psychiatrists are the best). Honestly they don't collect that rates. That is for sure.

4) Cash only does give you more autonomy.

5) academic centers usually take 50% off of your collection for overhead purpose. 17-25% is way too low. Academic health centers will lose money if they ONLY take 17-25% off your billing. Overhead is high.

 

[notdeadyet]

academic centers usually take 50% off of your collection for overhead purpose. 17-25% is way too low. Academic health centers will lose money if they ONLY take 17-25% off your billing. Overhead is high.

If I was at an academic place taking 50% billing, I'd start looking elsewhere. This may highlight regional variation. Out west 17-25% is very much the norm. My place takes 22% and they most definitely do not lose money on the deal.


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[Thewonderer]

If I was at an academic place taking 50% billing, I'd start looking elsewhere. This may highlight regional variation. Out west 17-25% is very much the norm. My place takes 22% and they most definitely do not lose money on the deal.


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I think it depends. Many academic places also guarantee part of your salary (taken from the department, taken from the hospital revenue, etc.) so that part of the salary is guaranteed (say that's $75,000 per year). Then the other part of the salary that is based on your collection, it is not out of the ordinary to take 50% of your collection.

I am really really not sure what you are talking about in terms of overhead. Many places (private practice groups) might do a revenue split with the doc. 55% to the doc, 45% to the group, or even 50/50. If the group is really desperate, they might do 60/40 (60% to the doc and 40% to the group). And these private practice groups are a lot more efficient and much better with overheads than academic health centers.

 

[Leo Aquarius]

Wow...this is like my first post in 7 years!

A few comments:

1) It is very hard to fill your cash only practice. VERY hard. Like a few years hard. Like it can take up to 5 years. And if you are ok with it, then go ahead and do it. That's why a lot of the younger, new graduates keep their moonlighting gigs (such as working for the county clinic or weekend inpatient coverage) for many years before quitting those moonlighting gigs.

2) It depends on your definition of being "full." I can guarantee you if you want to see 30-hours of face-to-face with patients based on cash only, it will take a long long time to build. If you considering working part-time for 15 hours a week and handling some paperwork on the side, you might be able to get full in a year or two.

3) Someone made a comment on "advertised rates," "effective rates" and "collected rates." And those observations are 100% accurate. Many people advertise their rates to be $300/hour but they only have a handful of patients who pay that. The rest of the patients get sliding scale rates of as low was $150/hour. Then some psychiatrists are also not good at billing and collecting the money so their collected rates might even go down to $200/hour, far less than $300/hour they advertise. I am really wary of people stating that they charge this much and that much. Let us be honest. Most people have ego's. They advertise their rates to be $300/hour (and the higher the rate, the more other people think these psychiatrists are the best). Honestly they don't collect that rates. That is for sure.

4) Cash only does give you more autonomy.

5) academic centers usually take 50% off of your collection for overhead purpose. 17-25% is way too low. Academic health centers will lose money if they ONLY take 17-25% off your billing. Overhead is high.

In the popular cities in California grads from residency fill their practices in under 1 year. I've seen as little as 6 months to fill. And I'm in an area where the NORM is $300 and some $400 per hour.

Work in academia or hospital, you make $200,000. Do solo private, $400,000.

 

[Leo Aquarius]

$400,000 is very reasonable even AFTER discounting for sliding scales and missed appointments.

At $400 per hour, working 8 hours a day but factoring 3 hours of lost income due to paperwork and sliding scales and people not paying, lets say you end up billing a mere 5 hours a day for your work. 5 days a week.

Take one whole month off for vacation. You're at $440,000.

 

[F0nzie]

And yet we are still near the bottom of the pay scale, Leo. When you have your own private practice after some experience, accepting a new patient feels like a game of Russian roulette. Then you will know why. 🙂 Think of a private practice as a place of autonomy, tax benefits, and free time as opposed to a place to 1up orthopedic surgeons.

 

[PikminOC]

And yet we are still near the bottom of the pay scale, Leo. When you have your own private practice after some experience, accepting a new patient feels like a game of Russian roulette. Then you will know why. 🙂 Think of a private practice as a place of autonomy, tax benefits, and free time as opposed to a place to 1up orthopedic surgeons.

??

 

[F0nzie]

??

Oh no I'm not going there. I'm in a good mood right now 😉

 

[Shikima]

Fonzie has Lady Gaga playing...

 

[Thewonderer]

And yet we are still near the bottom of the pay scale, Leo. When you have your own private practice after some experience, accepting a new patient feels like a game of Russian roulette. Then you will know why. 🙂 Think of a private practice as a place of autonomy, tax benefits, and free time as opposed to a place to 1up orthopedic surgeons.

I agree with F0nzie. Cash-only private practice does not generate $400,000 or anywhere close to that in the first 8 years. I can guarantee you that. I don't feel like going into the details either. Just go out, practice and find out for yourself.

Doing cash-only private practice is for autonomy purpose. If you want to have some resemblance of an "attending" life-style, don't quit your moonlighting gigs. You need it to pay the bill.

 

[PikminOC]

I agree with F0nzie. Cash-only private practice does not generate $400,000 or anywhere close to that in the first 8 years. I can guarantee you that. I don't feel like going into the details either. Just go out, practice and find out for yourself.

Doing cash-only private practice is for autonomy purpose. If you want to have some resemblance of an "attending" life-style, don't quit your moonlighting gigs. You need it to pay the bill.

I don't know what Fonzie means by Russian Roulette? Can someone help me understand his comment regarding that?
Tax breaks? 1099 is always higher tax than W2...

 

[Thewonderer]

I don't know what Fonzie means by Russian Roulette? Can someone help me understand his comment regarding that?
Tax breaks? 1099 is always higher tax than W2...

Simple. What F0nzie means is, when you are cash only psychiatrist, you sometimes do not know what the ulterior motives of the new patients are when they first sign up to see you. When they are paying you so much, are they expecting you to prescribe Xanax, Adderall, or all of the above? Other than the cash-only practice being a Russian Roulette in terms of meds and expectations from the cash-paying clients, there are also questions regarding if your patients will EVER pay you. Don't forget, Anthem BlueCross, United HealthCare, etc. are big companies. They will pay you IF the benefits checked out (and sometimes that is a big IF. People can walk around with their insurance ID from last year so you might mistakenly think that insurance plan is still active). I am very sure most insurance companies are more credit worthy than half of your cash paying patients. Finally, once these cash paying patients like you and they sign up, what is stopping them from asking you for a rate decrease and a sliding scale because "something" all of the sudden changed in their environments? Now you are their doctor, what is your moral and ethical obligation now?

Anyway, I have been practicing for many years. There are pro's and con's to a cash-only practice. Don't get me wrong. I enjoy cash-paying patients. It gives me autonomy away from the insurance company. It is just, well, cash-only practice is also not what it is cracked up to be unless you are a good business man and are not afraid to talk to your patients about finances. If you think doing a cash-only practice will take money out of the equation, then you are mistaken. And most of the people who advise residents on cash-only practice are their supervisors in the academic settings, i.e. they have not done a single day of private practice in their lives. Take their advice with a grain of salt.

When you are self-employed you can write down a lot of stuff that you cannot write down as an employee. Well, as an employee, you cannot even write down anything pretty much. When I worked for a system (i.e. VA, County, Academic Center, etc.), they denied a part of my CME expenses when that CME pot of money to be used came from my own collection. They were ******ed.

 

[PikminOC]

Simple. What F0nzie means is, when you are cash only psychiatrist, you sometimes do not know what the ulterior motives of the new patients are when they first sign up to see you. When they are paying you so much, are they expecting you to prescribe Xanax, Adderall, or all of the above? Other than the cash-only practice being a Russian Roulette in terms of meds and expectations from the cash-paying clients, there are also questions regarding if your patients will EVER pay you. Don't forget, Anthem BlueCross, United HealthCare, etc. are big companies. They will pay you IF the benefits checked out (and sometimes that is a big IF. People can walk around with their insurance ID from last year so you might mistakenly think that insurance plan is still active). I am very sure most insurance companies are more credit worthy than half of your cash paying patients. Finally, once these cash paying patients like you and they sign up, what is stopping them from asking you for a rate decrease and a sliding scale because "something" all of the sudden changed in their environments? Now you are their doctor, what is your moral and ethical obligation now?

Anyway, I have been practicing for many years. There are pro's and con's to a cash-only practice. Don't get me wrong. I enjoy cash-paying patients. It gives me autonomy away from the insurance company. It is just, well, cash-only practice is also not what it is cracked up to be unless you are a good business man and are not afraid to talk to your patients about finances. If you think doing a cash-only practice will take money out of the equation, then you are mistaken. And most of the people who advise residents on cash-only practice are their supervisors in the academic settings, i.e. they have not done a single day of private practice in their lives. Take their advice with a grain of salt.

When you are self-employed you can write down a lot of stuff that you cannot write down as an employee. Well, as an employee, you cannot even write down anything pretty much. When I worked for a system (i.e. VA, County, Academic Center, etc.), they denied a part of my CME expenses when that CME pot of money to be used came from my own collection. They were ******ed.

So if cash only, then why are the insurances involved?
Aldo don't you have to pay ss and the percentage that the employer usually covers if you are 1099?

 

[zxg]

You do have to pay self-emplyment taxes, but half of it (the portion that your employer would cover as a W-2 employee) is deductible. As are a host of other things, from business cards to your office furniture to half of any business related meals. And business expenses are deducted from gross employment income, so they reduce self-employment income and therefore SE tax as well.

 

[Thewonderer]

The quote, bold lined referred to a practice that relies on insurance company's reimbursement. What I was saying is, sometimes it is better to take insurance because at least many of the insurance companies are more credit worthy than half of your cash paying patients. Seriously, cash paying patients sometimes don't pay (or often don't pay if you are not good with talking money with your patients upfront). On the other hand, if you take insurance, just as long as the benefits checked out (and that is a big IF), you will pretty much get paid. These insurance companies are credit worthy after all.

 

[DJspreadsheet]

The quote, bold lined referred to a practice that relies on insurance company's reimbursement. What I was saying is, sometimes it is better to take insurance because at least many of the insurance companies are more credit worthy than half of your cash paying patients. Seriously, cash paying patients sometimes don't pay (or often don't pay if you are not good with talking money with your patients upfront). On the other hand, if you take insurance, just as long as the benefits checked out (and that is a big IF), you will pretty much get paid. These insurance companies are credit worthy after all.

A simple policy would require payment before service. It's not rocket surgery.

 

[mgdsh]

The quote, bold lined referred to a practice that relies on insurance company's reimbursement. What I was saying is, sometimes it is better to take insurance because at least many of the insurance companies are more credit worthy than half of your cash paying patients. Seriously, cash paying patients sometimes don't pay (or often don't pay if you are not good with talking money with your patients upfront). On the other hand, if you take insurance, just as long as the benefits checked out (and that is a big IF), you will pretty much get paid. These insurance companies are credit worthy after all.

I'd say out of all my cash paying patients, everyone is up to date on their tabs except 2 people. I did get one check that bounced and I had the fee waived (This patient never came back) and another patient who came up with every excuse in the book when it came time to pay. This patient also did not come back. In the aggregate this has been significantly less than 1% of total revenue (100% cash practice).

A simple policy would require payment before service. It's not rocket surgery.

That's possible. I'd imagine that might be a barrier to obtaining new patients in some cases.

 

[PikminOC]

I'd say out of all my cash paying patients, everyone is up to date on their tabs except 2 people. I did get one check that bounced and I had the fee waived (This patient never came back) and another patient who came up with every excuse in the book when it came time to pay. This patient also did not come back. In the aggregate this has been significantly less than 1% of total revenue (100% cash practice).



That's possible. I'd imagine that might be a barrier to obtaining new patients in some cases.

Good for you!
Can you tell us more about your billing practices to help us other docs please?

 

[NickNaylor]

What are the ethical ramifications for terminating patients due to non-payment? Are there any guidelines anywhere?

I would imagine that if a patient is significantly past due (e.g., 60+ days) on their payments in a cash setting, giving them written warning that they will be terminated in x days wouldn't be unreasonable as long as they are informed of what's going and have the opportunity to find a new provider. I imagine that this is very situation-dependent, of course, as terminating someone who is seriously ill probably wouldn't be a wise thing to do.

 

[jl lin]

What are the ethical ramifications for terminating patients due to non-payment? Are there any guidelines anywhere?

I would imagine that if a patient is significantly past due (e.g., 60+ days) on their payments in a cash setting, giving them written warning that they will be terminated in x days wouldn't be unreasonable as long as they are informed of what's going and have the opportunity to find a new provider. I imagine that this is very situation-dependent, of course, as terminating someone who is seriously ill probably wouldn't be a wise thing to do.

Yea. Like turning off the electric for defaulting on the electric bill. 😛🙄😉

 

[dl2dp2]

What are the ethical ramifications for terminating patients due to non-payment? Are there any guidelines anywhere?

I would imagine that if a patient is significantly past due (e.g., 60+ days) on their payments in a cash setting, giving them written warning that they will be terminated in x days wouldn't be unreasonable as long as they are informed of what's going and have the opportunity to find a new provider. I imagine that this is very situation-dependent, of course, as terminating someone who is seriously ill probably wouldn't be a wise thing to do.

You are worried about immaterial things way too early. When these complex situations come up, I usually consult the expert at the malpractice insurance company and they can help guide you on a case-by-case basis.

 

[doctorpilgrim]

Medical board usually publish guidelines to do it properly in timely, ethical and legal manner.

 

[Gavanshir]

Who are you vistaril? You almost always have negative things to say about the field. Are you an unsatisfied psychiatrist who regrets his/her career choice? I'm genuinely curious.

 

[Mad Jack]

Who actually pays this? Seriously? If you have insurance, wouldn't you just find someone on the insurance plan?

Less than half of psychiatrists accept insurance, and those typically either have full practices or waitlists that stretch on for months.

 

[Mad Jack]

this isn't quite true. its a little over half of psychiatrists in private practice that don't accept insurance. this figure does not include psychiatrists working in community mental health, academics, HMOs (like Kaiser) etc etc. this figure also doesn't take into account the significant distribution differences. which is to say, most of these cash only psychiatrists live in particular major metropolitan areas (like most psychiatrists) and outside of these areas there is a much smaller proportion of psychiatrists who don't take insurance. in most parts of the country patients expect to be able to use their insurance.

Sorry, I mixed up my stats. Just over half accept insurance overall. I'd copy and paste the page I got the data from, but ever since the last Android update my copy function is completely broken.

 

[PikminOC]

Sorry, I mixed up my stats. Just over half accept insurance overall. I'd copy and paste the page I got the data from, but ever since the last Android update my copy function is completely broken.

I'd be interested in this if you can post later

 

[Thewonderer]

The number and stat is not that hard to find. 55% of psychiatrists (across United States of America) in 2010 accept insurance while 88% of other specialties accept insurance. That is a decline of 17% since 2006.

JAMA Psychiatry. 2014 Feb;71(2):176-81. doi: 10.1001/jamapsychiatry.2013.2862.
Acceptance of insurance by psychiatrists and the implications for access to mental health care.
Bishop TF, Press MJ, Keyhani S, Pincus HA.

 

[PistolPete]

I think the stat is also 55% of psychiatrists in the US are over the age of 55 (or in that ballpark). Not a bad time to be in psychiatry!