How do some psychiatrists make more than others?

Discussion in 'Psychiatry' started by ima4ltrwrd, Sep 27, 2014.

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  1. ima4ltrwrd

    ima4ltrwrd 7+ Year Member

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    Greetings everyone, I had a question about billing and income. My understanding of how reimbursement works is that everything is based off the note written and the subsequent code submitted based on the level of care. With that being said, I have heard people say "go into child" or "go into forensics" because the money is amazing. Outside of maybe being booked for extended periods of time down the road, I don't see how this claim is possible? If they are billing for the same codes as everyone else, how would they make more money than the general psychiatrist? It seems that the variable for income would be the number of patients someone sees per day, not the level of training. I also understand that some of these people do cash only and can charge whatever the market will pay, but my question is mostly for psychiatrists who work with insurance. Are my assumptions generally right or am I missing something? If specialists are making more income, how are they doing it outside of seeing more patients? Thanks!
     
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  3. Trismegistus4

    Trismegistus4 Worried Wellologist 10+ Year Member

    1. Forensic psychiatrists don't make big bucks seeing and treating patients in a treatment setting (i.e., forensic unit of a state hospital) and billing insurance. They do it by providing services like evaluation of compentency to stand trial, expert witnessing, etc., which are contracted out on a private basis and for which, if they have made a good name for themselves among lawyers and in the court system, they can charge hundreds of dollars per hour like lawyers can.

    2. As you said, some psychiatrists do cash only and charge whatever the market will pay. Because of the extra-high demand for child psychiatrists, the market will usually pay more for cash-on-the-barrelhead child/adolescent than adult.

    3. If a doctor is in high demand, and provides some other benefit to a medical center/hospital system than the revenue he generates directly (e.g., allowing a psych unit to stay open at all, because without a psychiatrist it would close,) the employer may subsidize his pay with money garnered from elsewhere in the system's budget. Again because of the greater demand for child/adolescent psychiatrists, they may benefit more from this.
     
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  4. Shikima

    Shikima 10+ Year Member

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    DaTruMD likes this.
  5. IN321

    IN321 2+ Year Member

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  6. wolfvgang22

    wolfvgang22 10+ Year Member

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    Also, child psychiatrists usually don't usually make a lot more than adult psychiatrists. Yeah, you can charge cash if you do private practice, and are in higher demand, but child psychiatry requires that extra year of fellowship. It will take you a while to recoup your lost year of being in practice (at least $150,000). That doesn't take into account the cost putting off paying your student loans if you have any.
    Child psychiatry is not for everyone. Don't do the fellowship unless you really love treating these patients and the disorders that are seen more often by child psychiatrists. You will be spending lots of extra time gathering collateral information from schools, obtaining psychological and academic testing scores. You will be seeing more disorders such as ADHD, Autistic Spectrum Disorders, and developmental disorders than most adult psychiatrists. If you are in it just for the money, you will hate it after a while. Also, You will be dealing with parents that have just as many or more problems than the patients. I actually kind of got burned out in fellowship seeing lots of parents that would not do the simplest things to help their children, all across the socioeconomic spectrum, so I'm not seeing children and adolescents for a while. I found it took a lot more energy than seeing adults.
    I will probably get back into seeing children and adolescents more in the future.
     
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  7. Leo Aquarius

    Leo Aquarius Anxiety.org Schizophrenia.com DepressionHealth.net 5+ Year Member

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    I'm did my Child rotation and it convinced me NOT to pursue C&A as a practice. It's 50% or more glorified social work. The children are mostly beyond reasonable help quite unfortunately (unless you could replace their parents, friends, and trauma history). The parents need work, plus they urge you to give meds. I hated that pressure especially when it involves kids who mostly can't vouch for themselves. It's a messy field that you need to have a real heart for. I do well at it. But it's just not my cup of tea.
     
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  8. ima4ltrwrd

    ima4ltrwrd 7+ Year Member

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    I don't plan on doing child either, I just wanted to make sure I wasn't missing something regarding generating revenue. Thanks for the responses everyone.
     
  9. DaTruMD

    DaTruMD 7+ Year Member

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  10. Frazier

    Frazier Emergentology Lifetime Donor 7+ Year Member

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    MDApps:
    I'm guessing related to employee's prior experience, the job's location, how quick they need the position filled, etc.

    For example:

    there will be an opening in 6 months at the VA in San Diego when Dr. XYZ retires. Applicant is months out of residency. Offer: in line with tier 1 figures.

    there is an emergency opening today at the VA in Backwoods Montana since Dr, XYZ unexpectedly passed away. Applicant has 20 years experience. Offer: in line with tier 2-3.
     
  11. Trismegistus4

    Trismegistus4 Worried Wellologist 10+ Year Member

    Federal employee salaries are a matter of public record. You can go to this website and find out exactly what all these fools at the VA make.
     
  12. Shikima

    Shikima 10+ Year Member

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    Not quite. It has to do with the job you do. Not all specalties are created equal. That said Psychiatry is Tier 2. More than likely you'll start off as a GS15 step 1 coming out of residency. Each year of service roughly will grant you another step increase.
     
  13. Shikima

    Shikima 10+ Year Member

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    Just remember that the VA may offer good benefits, but the benefits are going to be the same at any job location within a standard deviation. You will be punching a clock. You will have metric ***t-ton of taxes taken out with the chance to reclaim a fraction through tax refund. And if you say no to any work they give you, be prepared to put up a fight if you want to stand your ground.
     
  14. Anduin

    Anduin

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    I dont see any physician salaries. What is the occupation?
     
  15. Trismegistus4

    Trismegistus4 Worried Wellologist 10+ Year Member

    "Medical Officer." Or you can just enter names of attendings you know.
     
  16. Extralong

    Extralong 5+ Year Member

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    Thanx for the info Tris! I have always wondered where I can see and compare info on VA salaries to their medical officers. When you look at their website for open positions, they always say 98,000 to whatever, so you really cannot know unless there is a link like the one Tris provided.
     
  17. Armadillos

    Armadillos 2+ Year Member

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    wow, if that fed salary thing is accurate the inpatient psychiatrists at my school associated VA make 20k/year more than the inpatient IM attendings
     
  18. jaymon

    jaymon ASA Member 5+ Year Member

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    The ones at our school associated VA are making like 50k more than the IM attendings.
     
  19. psych md jd

    psych md jd Better safe than sorry. 2+ Year Member

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    1. Forensic psychiatrists don't make big bucks seeing and treating patients in a treatment setting (i.e., forensic unit of a state hospital) and billing insurance. They do it by providing services like evaluation of compentency to stand trial, expert witnessing, etc., which are contracted out on a private basis and for which, if they have made a good name for themselves among lawyers and in the court system, they can charge hundreds of dollars per hour like lawyers can.

    Let me clarify a bit. I am a forensic psychiatrist, fellowship trained. I see patients in an outpatient setting, under contract. I don't make bug bucks, but I can't complain.

    Depending on the state, state hospitals and corrections can pay in the $240-280K/year range. These are state jobs and have pretty good benefits along with a lot of bureaucracy and paperwork. County jails usually pay a little less. A forensic fellowship is not required to work in a state hospital or corrections, but may open the door to more senior/supervisory roles at the institution.

    I don't do competency evaluations. Usually, the court pays a set fee and psychologists and psychiatrists on a rotating panel perform the evals. The fee is about $200-$250 per eval. That entails travel to the jail, time to get into the jail through the sally port, time to have the inmate brought to the interview area, reviewing the records, interviewing the inmate, and writing the report. If you have to appear in court that may be part of the fee. The time to get into the jail may be minutes, or may be hours, or not at all if the jail is in lockdown. And, of course, taxes take about 1/3 off the top. I did the math: in my circumstances the net pay is slightly above minimum wage. I see a lot of competency evals on my patients, few are written by psychiatrists.

    Most of the patients a forensic psychiatrist deals with are indigent. Rarely, a client can pay out of pocket. More prominent forensic psychiatrists can attract more clients that can pay out of pocket.

    AFAIK, no forensic psychiatry services are covered by insurance.

    How do some psychiatrists make more than others? They work harder and usually have more than 1 gig.
     
    Last edited: Oct 12, 2014
  20. Trismegistus4

    Trismegistus4 Worried Wellologist 10+ Year Member

    Good to know. I sort of suspected the "OMG BIG $$$" reputation of forensics was somewhat overstated. I guess if you're one of the top few names in the field, and you can get away with charging $600 per hour to serve as an expert witness in the latest celebrity murder trial, that's one thing, but most people who do a forensics fellowship aren't going to be in that position.
     
  21. DJspreadsheet

    DJspreadsheet inside the box 2+ Year Member

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    It's similar to becoming an architect. Everyone imagines designing Notre Dame, when in reality they end up designing the bathroom for cul-de-sac suburbia.
     
  22. Ceke2002

    Ceke2002 Purveyor of Strange 7+ Year Member

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    Just going by the salary packages being offered on jobs down this way (Australia, South Australia specifically) I'd say as a Lead Clinician/Consultant Psychiatrist/Senior Lecturer (with a separate Psychotherapy job at another clinic) my Psych would be on around 300-600K per annum (AUD). I've seen other jobs advertised with a pay rate as low as $60k a year though, so it would seem the pay rates are pretty broad ranging depending on seniority, experience, hours worked etc etc.
     
  23. TexasPhysician

    TexasPhysician SDN Moderator 7+ Year Member

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    Just to compare, 1 county I know uses the same forensic psychiatrist for all competency evals and other types of evals. The psychiatrist bills $3000/eval and gets a bonus if testifying. Offering to save the county money and offering services for $2400 were politely denied.

    In some instances, forensic pay is quite good, but it is all about who you know. Attorneys, judges, etc like known entities with strong years of experience, and they will pay for it. Breaking in is very hard.
     
  24. whopper

    whopper Former jolly good fellow 10+ Year Member

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    It definitely is. I could be making a lot more than what I make now but I've chosen to stick with academia for now, and the method to the money that I could easily do doesn't require fellowship.

    There are also headaches with making even the big money in forensic psychiatry. Sometimes a lawyer could hire you, you do the work, and then they don't pay you. So then they do pay you ahead of time, and it turns out your opinion isn't anything that lawyer wanted. Yes-they still need to pay you. You aren't supposed to just take the money and do anything they want, but that's what a lot of them expect, and unfortunately that's what a lot of mental health providers do, even ones I've seen that are considered high up in some institutions.

    Wish I had a secret camera running where I noticed some people being hired guns.
     

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