Inpatient private practice questions

[BlackBantie]

Currently I'm a board-certified 100% inpatient adult faculty member at an academic institution on a clinician-educator track. I drank the academic Kool-Aid when I was a chief resident, have been working at the academic institution for a few years, and will likely be here for the next couple of years for a few different reasons.

I love inpatient psychiatry, inpatient >>>>> outpatient in my opinion. My current job would be a great job if it weren't for the education/academic portion. Unfortunately at my hospital you are only allowed to work here if you are affiliated with the academic institution.

I want to work in an inpatient setting but I'm picky. I don't like the VA and I don't like academics. That seems to leave me with state hospitals and private practice. The area where I'm looking to relocate doesn't have any state hospitals nearby so that's off the list. So I guess I'm left with private practice inpatient.

Unfortunately I never had any private practice inpatient experience as a resident so I know nothing about it. I know the nuances vary depending on the hospital, contract terms, etc. but I do have some general questions:

• Is there an average number of patients that one usually sees in a private inpatient setting? I usually see ~12-13 patients a day but I have all of my academic responsibilities in addition to patient care. Honestly I'd rather see a few more patients a day instead of doing academic stuff.

• Is it typical for private inpatient attendings to manage billing? At my hospital there's a separate department that goes through the records and codes for RVUs but I know of a private hospital nearby that has the attendings fill out coding. I didn't know if that's the norm or not.

• I'm assuming weekend call is typical in the private hospital setting? Do you usually have to round on all of the patients in the hospital?

Like I said, I know specifics will vary but if anyone can provide any general information about the daily routine of an inpatient private psychiatrist I would greatly appreciate it!! I need some light at the end of the tunnel...

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[splik]

There are different types of private hospitals. Also the models at different hospitals are different. Some will have qX weekend call, whereas others might have moonlighters who cover basically every weekend. At some it will be part of your job and others it will be optional extra for additional pay. I have worked at a for-profit inpatient psych hospital before. It was terrible. There will always be coders but we still had to provisionally bill for each encounter. At my current academic institution, we only have to see 6-8 patients lol and that is considered full time with a full complement of residents, psychology interns, and medical students. We don't have to take weekend call but can for additional compensation. If someone is on vacation etc then the number of pts increases of course. You definitely want to find out how leave coverage works...

I have to say if you have 12-13pts and you also have a whole bunch of academic responsibilities it is no wonder you are burnt out. you might find (unless you hate all the teaching/admin stuff) that you actually like doing that stuff when you have the time and receive credit for doing that stuff. I would say 10-12 patients would be a reasonable amount of patients to see per day, but there are some hospitals that make you see more than that (for which you should be appropriately compensated). Many private hospitals work on an RVU model so you get paid $x per wRVU and may have a minimum requirement for your base salary, and make extra for additional. Many will have you move to an RVU model exclusively after 1-2 yrs (at which point you would usually make more than guaranteed). Be careful of hospitals that are for profit, have minimal ancillary services, cut costs, keep pts who don't need to be there, and kick out patients who do need to be there but whose insurance won't pay anymore. Some places will have a person who will talk to the UR person for extra authorization, whereas at others you will have to do it. Some psych hospitals now have a "hospitalist model" (of which there are several models including the 7 or 14 on/off or working long hours for 3-4 days at a stretch).

 

[OldPsychDoc]

There are various models in many private hospitals. In my region, they largely belong to non-profit health care systems. Some follow a hospitalist model, 7-on/7-off, whereas others do M-F with rotating weekend call. The sustainability of both of these models depends on staff willingness to "play well with others", work as a team, and communicate. Censuses at the places I'm most familiar with range from 10 beds/day (which easily amounts to a census of 12-13 due to daily turnover) to 20 beds/day covered with a PA/NP assist. We enter our own billing codes in the EMR, but it's internally audited so we don't overbill, and we have an army of admins who actually submit it to the various payors, and our pay is salary plus production over base.

 

[PistolPete]

Somewhat related question: if I work inpatient in PP in the mornings at a place that accepts commercial insurance and Medicare/Medicaid, can I then work outpatient in the evenings and do cash only? Or do I also have to accept commercial insurance and Medicare/medicaid in my evening outpatient practice?

 

[Armadillos]

How do admissions work at most private hospitals? At my academic center residents are seeing possible admissions in ER during the night, but I understand most private hospitals have non-MD (MSW?) admissions staff and the psychiatrist sees pts in the morning? I would worry about this leading to medically unstable/inappropriate admissions?

 

[michaelrack]

'Is it typical for private inpatient attendings to manage billing? At my hospital there's a separate department that goes through the records and codes for RVUs but I know of a private hospital nearby that has the attendings fill out coding. I didn't know if that's the norm or not."

several ways to do it including: 1. the attending is a hospital employee and the hospital does the billing. 2. the attending is a contractor and bills the patients himself. 3. the attending is a contractor, and the hospital bills for his professional services, and pays the attending a fixed amount for each service (for example $200 per psych eval and 50 per follow up note). 4. the attending is a contractor and the hospital pays him a fixed amount for managing a unit, and the hospital bills the patients for his servies.

 

[Jules A]

Somewhat related question: if I work inpatient in PP in the mornings at a place that accepts commercial insurance and Medicare/Medicaid, can I then work outpatient in the evenings and do cash only? Or do I also have to accept commercial insurance and Medicare/medicaid in my evening outpatient practice?

My understanding is you are credentialed for the location. I have a couple of friends who do cash practices and moonlight in hospitals. The only time I heard of an issue was when one started picking up hours at another clinic and upon learning this some cash patients wanted to go there for services.