How good can you have it after residency?

[randomdoc1]

If insurance based PP is paying $350/hr (based on average reimbursement of most common codes) how the hell isn't every psychiatrist out there killing it making 500k a year working 4 days a week?

Ok, so let’s say average 99213+90833 is $130. You do three an hour =$390. Your work 7h a day = $2730. X 4 days = $10,920 x 48 weeks = $524,160.
Two employees added together, no benefits, at 40h a week (e.g. one works 20h and so does the other) at 17.50*8h*5d a week*50 weeks=35k.
My first suite rent for 5 rooms was 26k a year.
marketing + software + phone system per year were about 50k
So per year about $111,000 in expenses
$524,160-111,000=$413,160 baby. That’s with the remaining 4 rooms unused,
THEN you get 1099 working for you, that brings you up to exceeding the 500k.

What insurance panel is paying $90 for a 90833 add-on...are you billing the world's best insurance?

I have two panels specific to my state that somehow I managed to negotiate that upon contracting and then tried to figure out how to attract more members with that insurance. They work for one of the hospitals nearby and so I built more relationships there.
the first year for me, was the worst. But it was a wise investment. I just worked more and exceeded 400k.

Most billers I worked with were pathetic. Leave it to most, they lose you a lot of money and try to take 6% of the pathetic amount they collected. I do my own billing and trained staff myself. Set up a system in your emr that can generate aging reports. You can easily see where the money is not coming in and either fix it or nip it. Patients not paying is 99% of the problem. What do you do? Collect at time of service. Many will conveniently swear they have no copay or deductible, print them a copy of their benefits. End of discussion. They can pay or go elsewhere.

Shufflin nailed it. No guarantee you have well of patients to infinitely draw from immediately, and this beast called overhead. Mine with 0.5FTE employee and all the other stuff comes out to 72-80K per year. Fixed cost.

I spend 30k a year for rockstar SEO. It is worth it. We got an endless stream of new patients angling to get in for meds but also for therapy. And it’s a good panel, minimal train wrecks. But I started by building up my panel as a 1099 and then most followed when I branched off.

It takes many months to ramp up to filling 8 hrs a day of seeing patients. Of those, around 5 to 6hrs will be actually seeing patients because of no-shows, delays, and time to write notes. That puts you, with 4 weeks vacation a year, at around $400K. You need an office manager, so subtract $50K. You need a biller, that's 5% to 10%. You're down to $320K. Still a great income. But then there's overhead. Rent, supplies, etc.

Ramping up with the proper marketing and networking takes time.

Write notes during visit. Set up strict late cancellation and no show policies and enforce. Bill insurance for phone calls and electronic communication. Yes, they do pay. Not always, but about 60% of the time, the contract allows it. 🙂

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[TexasPhysician]

Ok, so let’s say average 99213+90833 is $130. You do three an hour =$390. Your work 7h a day = $2730. X 4 days = $10,920 x 48 weeks = $524,160.
Two employees added together, no benefits, at 40h a week (e.g. one works 20h and so does the other) at 17.50*8h*5d a week*50 weeks=35k.
My first suite rent for 5 rooms was 26k a year.
marketing + software + phone system per year were about 50k
So per year about $111,000 in expenses
$524,160-111,000=$413,160 baby. That’s with the remaining 4 rooms unused,
THEN you get 1099 working for you, that brings you up to exceeding the 500k.

I have two panels specific to my state that somehow I managed to negotiate that upon contracting and then tried to figure out how to attract more members with that insurance. They work for one of the hospitals nearby and so I built more relationships there.
the first year for me, was the worst. But it was a wise investment. I just worked more and exceeded 400k.

Most billers I worked with were pathetic. Leave it to most, they lose you a lot of money and try to take 6% of the pathetic amount they collected. I do my own billing and trained staff myself. Set up a system in your emr that can generate aging reports. You can easily see where the money is not coming in and either fix it or nip it. Patients not paying is 99% of the problem. What do you do? Collect at time of service. Many will conveniently swear they have no copay or deductible, print them a copy of their benefits. End of discussion. They can pay or go elsewhere.



I spend 30k a year for rockstar SEO. It is worth it. We got an endless stream of new patients angling to get in for meds but also for therapy. And it’s a good panel, minimal train wrecks. But I started by building up my panel as a 1099 and then most followed when I branched off.


Write notes during visit. Set up strict late cancellation and no show policies and enforce. Bill insurance for phone calls and electronic communication. Yes, they do pay. Not always, but about 60% of the time, the contract allows it. 🙂

How do you see 3 patients/hr with only 1 FTE staff? What are you automating?

My cash only practice between 2 of us has 3 FTE staff to answer phones, schedule, faxes, record requests, PA’s, get vitals, respond to messages, etc.

 

[randomdoc1]

How do you see 3 patients/hr with only 1 FTE staff? What are you automating?

My cash only practice between 2 of us has 3 FTE staff to answer phones, schedule, faxes, record requests, PA’s, get vitals, respond to messages, etc.

The set up is sooooooo.....important. Try to keep everything electronic and integrated. Have as much as you can integrated with your emr.

Answer phones: yes, the staff do that. They were trained what they can take care of and what can be forwarded to me. They are trained to take clinical messages and message me in the EMR which turns into a note for good record keeping. I used to give them the ability to forward to my office VM but...people got lazy. Everyone. End of day I'd have like 15 voicemails it was a lot of things the staff could handle. So changing the workflow helps.

Fax is all electronic. You log in on a browser and click a button to upload it to the chart. You can also send records out of the chart, just click on which notes, put in fax number and done.

PA's, I use covermymeds and do it myself. Takes me about 3 minutes to do one.

Vitals, I do mine.

Responding to messages, the EMR has a portal where patients can make accounts, in similar way to major healthcare systems. Patient sends a message through there.

Sending statements, I can generate through the EMR with a few clicks and a few other clicks to send the bills out.

Scheduling, I encourage but don't mandate all providers to schedule their follow ups at end of the visit. That 1) helps you keep your schedule full, wherever there is a chance for something to fall through the cracks, it will. so make is easy as possible for patient to schedule and 2)promotes patient follow through.

Staff, that is super important. Probably the most important factor or a close second. Hire good staff. I'm not saying you should micromanage but spot check and see how they are approaching the work. How efficient and accurate are they? What is their work ethic? A lot of times, there are aspects beyond remediation. But you can find people who are good at multitasking, interpersonal skills, actually have common sense and good problem solving. Here's a secret: hire EMTs. Especially the highly trained ones, paramedic level. They have good clinical knowledge, do not get overwhelmed over distressed patients, and have good working memory. At least in my state, they get paid crappy. So they were super excited to work here and knocked out a lot of work. And then that, will create the right culture in the office. A friendly but go getter attitude.

 

[TexasPhysician]

The set up is sooooooo.....important. Try to keep everything electronic and integrated. Have as much as you can integrated with your emr.

Answer phones: yes, the staff do that. They were trained what they can take care of and what can be forwarded to me. They are trained to take clinical messages and message me in the EMR which turns into a note for good record keeping. I used to give them the ability to forward to my office VM but...people got lazy. Everyone. End of day I'd have like 15 voicemails it was a lot of things the staff could handle. So changing the workflow helps.

Fax is all electronic. You log in on a browser and click a button to upload it to the chart. You can also send records out of the chart, just click on which notes, put in fax number and done.

PA's, I use covermymeds and do it myself. Takes me about 3 minutes to do one.

Vitals, I do mine.

Responding to messages, the EMR has a portal where patients can make accounts, in similar way to major healthcare systems. Patient sends a message through there.

Sending statements, I can generate through the EMR with a few clicks and a few other clicks to send the bills out.

Scheduling, I encourage but don't mandate all providers to schedule their follow ups at end of the visit. That 1) helps you keep your schedule full, wherever there is a chance for something to fall through the cracks, it will. so make is easy as possible for patient to schedule and 2)promotes patient follow through.

Staff, that is super important. Probably the most important factor or a close second. Hire good staff. I'm not saying you should micromanage but spot check and see how they are approaching the work. How efficient and accurate are they? What is their work ethic? A lot of times, there are aspects beyond remediation. But you can find people who are good at multitasking, interpersonal skills, actually have common sense and good problem solving. Here's a secret: hire EMTs. Especially the highly trained ones, paramedic level. They have good clinical knowledge, do not get overwhelmed over distressed patients, and have good working memory. At least in my state, they get paid crappy. So they were super excited to work here and knocked out a lot of work. And then that, will create the right culture in the office. A friendly but go getter attitude.

Billing three 90833/hour involves 16 min of therapy or more during each appointment. That leaves 0-4 minutes for meds if you spend 0 time doing anything else each hour. If you take vitals and room patients, you are burning those 4 minutes. I don’t see how that is sustainable.

 

[calvnandhobbs68]

Billing three 90833/hour involves 16 min of therapy or more during each appointment. That leaves 0-4 minutes for meds if you spend 0 time doing anything else each hour. If you take vitals and room patients, you are burning those 4 minutes. I don’t see how that is sustainable.

Yeah I'm surprised you don't get audited by insurance for this. Two 99213+add-on per hour passes the sniff test...three 99213+add-on per hour not as much.

 

[randomdoc1]

Billing three 90833/hour involves 16 min of therapy or more during each appointment. That leaves 0-4 minutes for meds if you spend 0 time doing anything else each hour. If you take vitals and room patients, you are burning those 4 minutes. I don’t see how that is sustainable.

Yeah I'm surprised you don't get audited by insurance for this. Two 99213+add-on per hour passes the sniff test...three 99213+add-on per hour not as much.

I do 2 visits an hour, so 30 min for 99213 and 90833.
8 hours a day, 5 days a week, 50 weeks a year at $140 per visit gives me 560k gross revenue. for the first year. Alternatively, you can have one super long day and 3 shorter days where you get the 4 days a week. If someone was an independent contractor as a psychiatrist with a 75/25 split, the 1099 can walk home with 420k a year. So back to the OP, in a well structure PP, 200k is totally feasible and on a very comfortable schedule. The most important question? Ask them about their damn collections.

I scaled down to 3 days a week now since I have 1099 working here too, there is TMS, and my panel has evolved to more of the better paying insurance that gives $156-$200 a follow up. Yes, from insurance.

 

[Merovinge]

Lol all of you are so business minded. I don’t even know how money works.

Find the white coat investor sooner rather than later then or your apt to regret not understanding basic personal finance. I'm constantly pained by the number of brilliant doctors who have worse understanding of money then some high school students on my panel.

 

[NontradCA]

Is it possible to do something similar, but only on weekends? Would love to find a locums job requiring weekend coverage 1-2 weekends a month to supplement the primary job.

You probably don’t have to do locums to get a weekend only gig paying 300+

 

[Psychresy]

You probably don’t have to do locums to get a weekend only gig paying 300+

How would I find that if not locums?

 

[Copper_Tracker]

@randomdoc - what EHR do you recommend? Seems like there is a lot of cluttered ones out there that don't appear too streamlined

 

[randomdoc1]

@randomdoc - what EHR do you recommend? Seems like there is a lot of cluttered ones out there that don't appear too streamlined

Icanotes

 

[Psychresy]

How's Athena?

 

[Armadillos]

I hear of a lot of private practices routinely billing these EM with therapy add on codes for essentially every patient.

Seems like at some point the medical necessity of that is going to come into question. Seems strange that patients would require the exact same frequency of 16min therapy as 99213 Med management.

Seems patients in that model are getting some permutation of not frequent enough therapy or too frequent Med management depending on their situation.

 

[randomdoc1]

I hear of a lot of private practices routinely billing these EM with therapy add on codes for essentially every patient.

Seems like at some point the medical necessity of that is going to come into question. Seems strange that patients would require the exact same frequency of 16min therapy as 99213 Med management.

Seems patients in that model are getting some permutation of not frequent enough therapy or too frequent Med management depending on their situation.

That's a legit argument. Although, there is a ton of crappy therapy taking place, so I take it on to myself to offer what I can. Therapy is still my most powerful tool (promoting helpful changes, differential diagnosis, etc.) and helps avoid polypharmacy. So...I consider it necessary. Sure, there's conflict of interest but the 15 min med checks seem to not have the greatest outcomes. Maybe someone will collect data on outcomes? I'd be interested to see the results. I suspect the outcomes would be better and longterm healthcare costs would be lower with the 30 minute visit. And insurances would like that. Then hopefully there's less push for 15 minute med checks. But that's just me dreaming but it's not to say it is impossible.

 

[Armadillos]

That's a legit argument. Although, there is a ton of crappy therapy taking place, so I take it on to myself to offer what I can. Therapy is still my most powerful tool (promoting helpful changes, differential diagnosis, etc.) and helps avoid polypharmacy. So...I consider it necessary. Sure, there's conflict of interest but the 15 min med checks seem to not have the greatest outcomes. Maybe someone will collect data on outcomes? I'd be interested to see the results. I suspect the outcomes would be better and longterm healthcare costs would be lower with the 30 minute visit. And insurances would like that. Then hopefully there's less push for 15 minute med checks. But that's just me dreaming but it's not to say it is impossible.

This is a good point, guess in a perfect world they would just reimburse 30 minute worth of E&M at a higher rate. I’m never criticizing someone for providing good care, just wondering if insurance going to allow to continue if gets to point that just becomes the standard billing for psychiatric follow up

 

[Candidate2017]

you’re the reason pay is low for others, if they can exploit one person they can exploit us all eventually

CMH-type Drs make less pay than PP Drs, but their ratio of $ to actual work is a lot higher due to fewer pts (lots of no-shows) and their pay being decoupled from fee for service (their pay comes from taxes not the pt or pt's employer/insurance).

 

[Candidate2017]

This is a good point, guess in a perfect world they would just reimburse 30 minute worth of E&M at a higher rate. I’m never criticizing someone for providing good care, just wondering if insurance going to allow to continue if gets to point that just becomes the standard billing for psychiatric follow up

Four med checks an hour reimburses about the same as two combined med+therapy, so it's not costing insurance any more. Insurance would save more money by not paying for 15 med checks and sending them to their PCP.

 

[TexasPhysician]

CMH-type Drs make less pay than PP Drs, but their ratio of $ to actual work is a lot higher due to fewer pts (lots of no-shows) and their pay being decoupled from fee for service (their pay comes from taxes not the pt or pt's employer/insurance).

This is highly variable. A friend of mine at a CMH is booked 4 follow-ups/hour. Sometimes 0 show, sometimes all 4. He is expected to see all that show even if 4 x 8 hours.

 

[Stagg737]

A friend of mine from residency took a job with UWorld. She essentially reads articles and writes questions for the qBank.

Is this just a side hustle or is this her primary job. Would be curious about how many hours she works and what she gets paid.

If the money is good and that person is happy, then it's not a waste. 🙂

I think they were referring to the person being able to get that job with just a med school education and not residency.

If insurance based PP is paying $350/hr (based on average reimbursement of most common codes) how the hell isn't every psychiatrist out there killing it making 500k a year working 4 days a week?

Because many doctors are financially stupid and some would just rather be employed and take what they get than have to try and run a business themselves.

Shufflin nailed it. No guarantee you have well of patients to infinitely draw from immediately, and this beast called overhead. Mine with 0.5FTE employee and all the other stuff comes out to 72-80K per year. Fixed cost.

Overhead can be hugely variable though. I rotated through a cash only clinic that did paper charting. $200 per hour + flat fees for various forms. Overhead was ~1200 per month for office space and hired one person part time at $35k per year to do scheduling and run patient's credit cards. If patient didn't pay at the visit, they could schedule but wouldn't be seen again until they paid. His total overhead was less than $50k per year and he took home everything else which came out to almost $350k.

How's Athena?

Used it 2 rotations in med school, not intuitive at all and clunky. Maybe better now if there were updates as that was 4 years ago. Best systems I've used are Epic (though not really ideal for smaller practices) and CareCloud which seemed pretty ideal for smaller private practices.

 

[Sushirolls]

Athena takes ~7% of collections and not a fixed cost EMR...

 

[Sushirolls]

I took 8 weeks last year, with intent to only take 6 weeks. This year I should be on track to only take 6 weeks.

Last year when on a 1 week vacation I checked my messages/EMR at noon, and in the evening, messaged some to receptionist in AM, and took phone calls from receptionist during her working hours if needed. I was in the woods with poor reception. Worked out well. Called one crisis patient, needed admission for psychosis in evening and coordinated with the family. This year planning another 1 week vacation, and will only check messages once a day.

I have my assistant work during these days to help put out fires if needed.

 

[wolfvgang22]

I took 8 weeks last year, with intent to only take 6 weeks. This year I should be on track to only take 6 weeks.

Last year when on a 1 week vacation I checked my messages/EMR at noon, and in the evening, messaged some to receptionist in AM, and took phone calls from receptionist during her working hours if needed. I was in the woods with poor reception. Worked out well. Called one crisis patient, needed admission for psychosis in evening and coordinated with the family. This year planning another 1 week vacation, and will only check messages once a day.

I have my assistant work during these days to help put out fires if needed.

When you say assistant, do you mean a PA?

 

[Sushirolls]

When you say assistant, do you mean a PA?

I mean receptionist/clerk/assistant, not PA.