Inpatient Job Doing My Own Billing

[BiscoDisco]

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I'm entertaining an inpatient job where I would be reimbursed through my own billings of patients I see. I've been told my patient load can be 14-20, "whatever you pick up". Does this imply I could see more patients if I wanted - not sure how that would even work though.

Generally speaking, I know outpatient billing codes have a wide variety of reimbursements based on locale, payor, etc. When entertaining an inpatient job where I do my own billings, how do I even get a vague sense of how much I could earn. I recall @Shufflin saying finding these type of jobs was how he did so well...but I'm totally lost as to what I can expect income to be. Thanks.

 

[Stagg737]

I'm confused about this billing setup. Are you billing insurance/whoever yourself instead of the hospital and expected to chase down collections yourself? I don't understand how that could be more productive than the hospital submitting billing...

 

[Sushirolls]

Income = volume X payer mix X collection rate

As you get enrolled in insurance panels with every company, make an excell spread sheet that has all the CPT codes you will bill for while doing inpatient work.

Then make columns for each insurance company and what their reimbursement rate is for each of those codes.

Then you will need to keep track on another excell spread sheet your payer mix for each month, or quarter, or whatever. You need to know what % medicare, medicaid, Regence, Cigna, UHC, etc you are seeing.

Then you can create another excell spread sheet that will autocompute your level 2 follow ups and new pt codes and discharge codes into a blended average. With this key sheet, you can then see exactly what your rate of earnings can be when you calculate with different volume numbers.

Inpatient psychiatry has so many insurance companies that will show up. You will have a % that you simply aren't paneled with. Who will do the paneling for you? is it even worth it for 1 patient? or 5 patients per year? There will still be out of pocket expenses for inpatient stays. Count on 20% kicked to the patient.

You will need your own billing person (employee to do all of this for you) or you will need to contract with a billing company that will take 5-10% of collected dollars. I've seen as low as 3-4%, but harder to find, and quality may be ... outsourced, even though CMS says you can't use international sources...

It's possible this could work out well and be a more efficient means to capture the highest rate of pay. But I suspect for most this is a way of the hospital to punt the headaches and cost burden on to you until you get fed up and leave after 1-2 years. You end up being a cheaper locums...

We did even get into the DRG / capitated payment insurances. Some companies will give a lump sum to the hospital that will be inclusive of the physician professional fees and simply won't look at your claim submissions. So how do you negotiate with this hospital to get paid for these capitated insurances?

Outpatient psychiatry can already have collections concerns. Image the population more typical of inpatient. Phone number? are the phones VM full? Or even working? Is the address their's or the parents that just kicked them out? Did they just lose their job for the crisis that lead to be in the hospital?

 

[Sushirolls]

To compensate for all these issues, you'll need more patients/volume. Are you prepared for the mindset that the answer to everything is more volume? You can't control the payer mix, and unlikely the rates with the insurance companies, too.

 

[jbomba]

Sounds like directly billing the hospital is the answer here. Do hospitals pay you the fee they collect minus facility fees?

 

[Sushirolls]

Billing the hospital then is simply a 1099 contractor job where you submit for a blended average.
Some time back I saw one of these contracts where it was $ for intake, $ follow up.

They did their own math to assign a dollar value of blended payer mix for each of those submissions. Naturally, they were likely less than what it would be if you did it yourself.

In summary, is this headache worth the squeeze? Might be? Odds are, maybe not.

 

[jbomba]

Billing the hospital then is simply a 1099 contractor job where you submit for a blended average.
Some time back I saw one of these contracts where it was $ for intake, $ follow up.

They did their own math to assign a dollar value of blended payer mix for each of those submissions. Naturally, they were likely less than what it would be if you did it yourself.

In summary, is this headache worth the squeeze? Might be? Odds are, maybe not.

I see, thanks. Are there alternate codes one uses inpatient to increase billing (legitimately of course). I'm aware of 99231/232/233. Are there others out there than can be "add ons"?

 

[Sushirolls]

tobacco cessation, 99407 I think?
90833 therapy add on
Could maybe do a PHQ/GAD at start, bill those 96127 and again at discharge?
99417 if appropriate? or what ever is similar for inpatient?

I think those are about it for real world 'extras'

 

[BiscoDisco]

I'm confused about this billing setup. Are you billing insurance/whoever yourself instead of the hospital and expected to chase down collections yourself? I don't understand how that could be more productive than the hospital submitting billing...

So it was recommended to use a billing company to bill. Is this atypical for inpatient jobs/not worth taking because of the hassle?

 

[Sushirolls]

That will be the best way to approach this job.
If you have a quality billing company, there is a chance this could be sweet setup where you have maximized what you take home.
Keep your stats on those excell. After 6 months or so, you should be able to reflect if this is a good set up or one that's just not worth the efforts.
A positive though, the contracts you get while doing inpatient, can be easily converted over, to outpatient.
It's how I started my private practice. I had this setup up, walked away from the hospital as fast as I could, and then dropped the less ideal insurances as time went on.

 

[Stagg737]

tobacco cessation, 99407 I think?
90833 therapy add on
Could maybe do a PHQ/GAD at start, bill those 96127 and again at discharge?
99417 if appropriate? or what ever is similar for inpatient?

I think those are about it for real world 'extras'

99406 and 99407 are tobacco cessation codes. The former is for 3-10 minutes of counseling and 99407 is for counseling >10 minutes. Documentation needs to include patients' motivation for behavioral change and a plan for behavioral modification. A specific quit date and including the use of any medications or techniques is typically adequate. RVUs are 0.24 and 0.5 respectively.

You can also bill 99408 and 99409 for alcohol or other substance counseling. 99408 is 15-30 minutes of counseling, 99409 is >30 minutes. They're not covered by Medicare but are reimbursed by state Medicaid. Idk updated RVU values for these but they reimburse somewhere around $30 and $60 respectively.

99406-99409 can be billed 4 times per treatment/cessation attempt and up to 8x per year. I've never billed 408-409, but did do 406 and 407 add-ons for SA rotations in residency.

So it was recommended to use a billing company to bill. Is this atypical for inpatient jobs/not worth taking because of the hassle?

I guess I'm confused on whether this is an employed position or contract position. I'm assuming contract-based since the hospital isn't handling billing.

 

[michaelrack]

I do this type of work currently. It's very hard for a solo doc to do well, although it is possible if they are already in network with most insurers in the area and are working with an experienced biller. Some things to consider are : "I've been told my patient load can be 14-20, "whatever you pick up"."- you likely pick up those patients by being on call. some places have a call supplement, and some don't. You will likely have some choice in picking patients, but be limted by walk-ins and EMTALA requirements. You may end up getting a lot of self-pays/out of network patients

Another factor to consider is how patients are assigned: at one hospital I work at, a doctor who has seen a patient in the last several years can get the patient admitted to him, regardless who is on call. You may find yourself on call nights giving admission orders for another doctor's patient with chronic schizophrenia who is back for his 3rd admission of the year.

How often are you required to round? some places require 6 days a week. What are the arrangements if you are gone on vacation?

At one hospital I work at, we bill for most patients; at another we invoice the hospital for a fixed rate for medicaid/capitated insurance plans.

I would forget about add on codes in the inpatient setting.

Do you work with an NP to help with rounding? Would you be able to bill for his/her services? What are they allowed to do (?admissions?) at that hospital.

To the OP: by the way you ask your question, I can 99% guarantee you are not going to make it if you rely on this position as your only job. You could try it out as a side job, and you would learn a lot about the business aspects of IP psychiatry.

By the way, I was a solo doc who did a mix of employed (and at different hospitals) and private practice/independent contractor work. I left my employed job 11/2021 and on January 1st 2022 became a partner in a Psychiatric group. I currently do non-W2 work at several hospitals.

 

[comp1]

Oh I hope you can find a salaried inpatient job. That whole billing thing sounds so very, very complicated even with a biller. Inpatient rocks, of course!

 

[psychmd03]

So I normally just read but truly had to make an account just to talk about this. I’ll give a short response and can expand if needed.

I do this at one hospital and it’s much more lucrative than my w2 position. I am unsure how rare this type of job is but I am not affiliated with the hospital in any way other than I pay yearly dues.

I work most days of the month and someone covers me when I’m gone and I give some coverage when others are gone. My payer mix is more Medicaid type insurers than not yet still easily this pays better per hour than a w2.

I show up and round when I want and when works for my scheduled and generally leave and do notes at home. Because I enjoy it I have some students that round with me but they just watch. We talk a bit and that’s it.

Personally I’d only do jobs like this if they can be found. If you’re not efficient then don’t do this type of job.

 

[Sushirolls]

In response to someone above, this type of job isn't 1099 contractor and isn't W2.
It's 'old school' traditional.
You are your own private practice entity, have privilege's at the hospital, and service the clinical needs. This type of arrangement use to be the only arrangement many decades ago for all physicians and specialties.

It wasn't until the last 30-40 years that hospitals went from being shell organizations that housed the practicing physicians who sorted things out amongst themselves via med staff bylaws, to what we see now; Big Box shops that employ and push out any independent groups they can.

 

[AD04]

So I normally just read but truly had to make an account just to talk about this. I’ll give a short response and can expand if needed.

I do this at one hospital and it’s much more lucrative than my w2 position. I am unsure how rare this type of job is but I am not affiliated with the hospital in any way other than I pay yearly dues.

I work most days of the month and someone covers me when I’m gone and I give some coverage when others are gone. My payer mix is more Medicaid type insurers than not yet still easily this pays better per hour than a w2.

I show up and round when I want and when works for my scheduled and generally leave and do notes at home. Because I enjoy it I have some students that round with me but they just watch. We talk a bit and that’s it.

Personally I’d only do jobs like this if they can be found. If you’re not efficient then don’t do this type of job.

My attendings from residency did something like this. Do you do your own billing? Or do you hire your own staff to do it? Or do you contract out?

I would forget about add on codes in the inpatient setting.

Why do you say this? Does the insurance companies not pay for the add-on?

 

[psychmd03]

My attendings from residency did something like this. Do you do your own billing? Or do you hire your own staff to do it? Or do you contract out?



Why do you say this? Does the insurance companies not pay for the add-on?

I have a biller. I collect the face sheets and send the dates and codes and they do the rest. They take 6.25%. The collection rate is quite good. We hold billing at the start of the year to let people hit their deductibles which helps not chasing people to pay.

I also agree you can very easily have a normal 90833 add on as long as you know how to document it