Intake Process Best Practices - Private Practice

[sighchiatry]

I have an out of network private practice. I'm trying to make my intake process more efficient and streamlined. I am very interested to hear how everyone else does it.

Here is my process:
1. Get an inquiry from a potential patient (email, call, referral, etc)
2. Brief screening phone call with the patient during which I also explain my fees, process, etc. Get their email and basic contact info. Schedule an appointment.
3. Email the patient a patient portal invite on Luminello where they are instructed to e-sign forms, fill out a few rating scales, input their credit card info, input their emergency contact, etc
4. See the patient

I am running into trouble at step 3. I rely heavily on my EMR. Some patients just don't want to create a patient portal. Or if they do, they can't figure out what to do once they have accessed it - despite my including specific instructions with pictures. This isn't just an age issue, I have 26-year-old software engineers who just aren't interested in making a patient account.

I am curious to hear how everyone gets their forms signed and collects payment info prior to the first appointment, especially in the era of telemedicine where you can't just print forms at the office and have the patient complete them at the first in-person visit.

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[CalmAndCollected]

I have an out of network private practice. I'm trying to make my intake process more efficient and streamlined. I am very interested to hear how everyone else does it.

Here is my process:
1. Get an inquiry from a potential patient (email, call, referral, etc)
2. Brief screening phone call with the patient during which I also explain my fees, process, etc. Get their email and basic contact info. Schedule an appointment.
3. Email the patient a patient portal invite on Luminello where they are instructed to e-sign forms, fill out a few rating scales, input their credit card info, input their emergency contact, etc
4. See the patient

I am running into trouble at step 3. I rely heavily on my EMR. Some patients just don't want to create a patient portal. Or if they do, they can't figure out what to do once they have accessed it - despite my including specific instructions with pictures. This isn't just an age issue, I have 26-year-old software engineers who just aren't interested in making a patient account.

I am curious to hear how everyone gets their forms signed and collects payment info prior to the first appointment, especially in the era of telemedicine where you can't just print forms at the office and have the patient complete them at the first in-person visit.

Not anywhere near this point in my career myself, but most PP doctors (not just psychiatrists) I have met take the payment at the time of service and make the patient fill out forms in person. You can make them fill it out on a tablet if you want to save to paper, and you can offer them the option of setting up payment through a patient portal for convenience.

Just to give general advice though, If I were trying to get a consulting service (say, with a legal firm) and their first request was to ask me to fill out online forms with personal information and credit card info, I would probably think it’s sketchy. In my mind, I have never met you, don’t trust you, and I have no reason to believe I will be seeing you more than once. The fact that you place so much importance on me doing this process so fast and before I ever see you would probably make me think “SCAM!”.

If a friend told me a psychiatrist was asking for such personal info so long before and appointment, I would probably tell them that I have only encountered large medical systems having those portals, never heard of anyone asking you to send payment info before service, and they should probably go with someone who is a little less sketchy.

That’s just my two cents.

 

[Sushirolls]

I have a website that clearly shows who I am and allays any fears of mistrust. Clearly identifies my degree, my training, and links to look up board certifications, too.

I use Luminello and understand your work flow issues. It's really a bell curve I've experienced, some people just don't like the tech, and the other half 'LOVE' it and I routinely get praises form the ease of use and operations from patients. It pains me to know that I am potentially losing patients by not doing the paper intake process in the office as Calm notes above. However, the patients I am getting are much easier to interact with for future billing, treatment issues, prescription issues, ROIs etc. My patients also have handled the Covid-19 in stride, and very little attrition of my patient panel, and I largely attribute it to their ability to be open/receptive to the Luminello tech intake process.

My assistant and I have had several discussions about going toward the paper intake route, and the few people we've sampled with were lost to follow up, didn't pay bills, and didn't complete other requests. More time and effort was extended on these patients. No thanks, I'm willing to endure the slower growth.

I also won't open up or permit scheduling until all the forms are signed, and the pre-consultation questionnaires are completed. My assistant is proactive in calling people when their rate of completion slows, and that usually helps. Other people are just on different time lines and take more than a month to get things done. Others simply drop off and aren't heard from again.

In summary, you should delay scheduling until after they complete your forms. I go and check the box in their profile, and then send a simple message thanking for completing everything and to then do the online scheduling and pick their own consult slot. When people first get the message of instructions on what's expected for forms, etc, I will also enter the date range of when to expect being to get an appointment "...once all this is complete you can expect to be able to schedule a consult in 1-3 business days." I've had to increase that number at times depending on the schedule.

 

[sighchiatry]

I have a website that clearly shows who I am and allays any fears of mistrust. Clearly identifies my degree, my training, and links to look up board certifications, too.

I use Luminello and understand your work flow issues. It's really a bell curve I've experienced, some people just don't like the tech, and the other half 'LOVE' it and I routinely get praises form the ease of use and operations from patients. It pains me to know that I am potentially losing patients by not doing the paper intake process in the office as Calm notes above. However, the patients I am getting are much easier to interact with for future billing, treatment issues, prescription issues, ROIs etc. My patients also have handled the Covid-19 in stride, and very little attrition of my patient panel, and I largely attribute it to their ability to be open/receptive to the Luminello tech intake process.

My assistant and I have had several discussions about going toward the paper intake route, and the few people we've sampled with were lost to follow up, didn't pay bills, and didn't complete other requests. More time and effort was extended on these patients. No thanks, I'm willing to endure the slower growth.

I also won't open up or permit scheduling until all the forms are signed, and the pre-consultation questionnaires are completed. My assistant is proactive in calling people when their rate of completion slows, and that usually helps. Other people are just on different time lines and take more than a month to get things done. Others simply drop off and aren't heard from again.

In summary, you should delay scheduling until after they complete your forms. I go and check the box in their profile, and then send a simple message thanking for completing everything and to then do the online scheduling and pick their own consult slot. When people first get the message of instructions on what's expected for forms, etc, I will also enter the date range of when to expect being to get an appointment "...once all this is complete you can expect to be able to schedule a consult in 1-3 business days." I've had to increase that number at times depending on the schedule.

That's an interesting point - a patient's comfort with engaging in electronic intake and registration serves as a layer of screening for practice fit. Thank you.

 

[Basis]

I also have a solo private practice, and I don't take insurance. I'm a computer guy, but everything in my practice is extremely low-tech by design.

Since I don't take insurance, don't use an EMR, and don't do e-prescribing, (and a few other things), I'm not a covered entity under HIPAA which is nice. I don't have any sort of portal, messaging system, email for patients, etc.

My process is basically like this:
1. Potential patient calls and leaves a voicemail
2. I call them back and get an idea of what they're wanting treatment for. I also give them a quick rundown of my practice, some of the policies (no controlled subs, etc), my hours, fees, and how the first visit is an evaluation/consultation and that I don't take everyone on as a patient. This takes like 5 minutes usually. If I can instantly tell I don't want this person as a patient, I tell them about community resources and don't even bother with the whole speech.
3. If they want to schedule an evaluation, I only take credit cards, and they have to pay part of the fee up front over the phone as a deposit. While I'm on the phone with them I log into the merchant account on my computer or you can even do it on the browser on your phone. I let them know I keep cards on file for billing (you need verbal permission to keep cards on file, per policies from most card issuers).
4. I write down their appointment in my physical schedule book.

99% of people who have actually become ongoing patients have said on that first phone call 'Ok that sounds great' and given their credit card info.

Most people say "Ok well let me think about it" or "Let me ask my spouse" or "Ok that sounds great but let me call you back tomorrow because I'm [insert weird excuse here]". These people NEVER call back. I think maybe one person actually called back after a week and I did not take him as a patient after the evaluation.

Having the credit card on file for billing is key. I didn't want to waste my time tracking down balances because someone forgot their checkbook again.

(Also: I'm not a lawyer and this isn't legal advice, but what I've learned and was told from my lawyer from day 1, is that you need to be extremely careful how you word things both on your website and over the phone to any potential patient. Offering what could be construed as medical advice, making any sort of verbal promise to accept them as a patient, etc, you need to avoid all of that if you have a 'consultative' model like me. Otherwise you can prematurely create a patient-physician treatment relationship.)

I try to have everything set up so that I would be comfortable if I was the patient. I honestly would not want to see a psychiatrist or any kind of doctor where I'd have all my stuff in an EMR or some portal system, but that's the unfortunate reality of most modern practices and it's not avoidable usually. It's annoying enough they want your social security #, now they want your email and everything else.

When they show up for the evaluation, I actually do have a few simple pieces of paperwork for them to fill out and sign. But it's mostly like demographics info, treatment/consultation agreement, policies, etc. All worded correctly from the lawyer.

 

[TexasPhysician]

some patients do online and others do paperwork in person. Either way I charge in advance. Patients that don’t want to provide a cc in advance can go elsewhere.

 

[CalmAndCollected]

I also have a solo private practice, and I don't take insurance. I'm a computer guy, but everything in my practice is extremely low-tech by design.

Since I don't take insurance, don't use an EMR, and don't do e-prescribing, (and a few other things), I'm not a covered entity under HIPAA which is nice. I don't have any sort of portal, messaging system, email for patients, etc.

My process is basically like this:
1. Potential patient calls and leaves a voicemail
2. I call them back and get an idea of what they're wanting treatment for. I also give them a quick rundown of my practice, some of the policies (no controlled subs, etc), my hours, fees, and how the first visit is an evaluation/consultation and that I don't take everyone on as a patient. This takes like 5 minutes usually. If I can instantly tell I don't want this person as a patient, I tell them about community resources and don't even bother with the whole speech.
3. If they want to schedule an evaluation, I only take credit cards, and they have to pay part of the fee up front over the phone as a deposit. While I'm on the phone with them I log into the merchant account on my computer or you can even do it on the browser on your phone. I let them know I keep cards on file for billing (you need verbal permission to keep cards on file, per policies from most card issuers).
4. I write down their appointment in my physical schedule book.

99% of people who have actually become ongoing patients have said on that first phone call 'Ok that sounds great' and given their credit card info.

Most people say "Ok well let me think about it" or "Let me ask my spouse" or "Ok that sounds great but let me call you back tomorrow because I'm [insert weird excuse here]". These people NEVER call back. I think maybe one person actually called back after a week and I did not take him as a patient after the evaluation.

Having the credit card on file for billing is key. I didn't want to waste my time tracking down balances because someone forgot their checkbook again.

(Also: I'm not a lawyer and this isn't legal advice, but what I've learned and was told from my lawyer from day 1, is that you need to be extremely careful how you word things both on your website and over the phone to any potential patient. Offering what could be construed as medical advice, making any sort of verbal promise to accept them as a patient, etc, you need to avoid all of that if you have a 'consultative' model like me. Otherwise you can prematurely create a patient-physician treatment relationship.)

I try to have everything set up so that I would be comfortable if I was the patient. I honestly would not want to see a psychiatrist or any kind of doctor where I'd have all my stuff in an EMR or some portal system, but that's the unfortunate reality of most modern practices and it's not avoidable usually. It's annoying enough they want your social security #, now they want your email and everything else.

When they show up for the evaluation, I actually do have a few simple pieces of paperwork for them to fill out and sign. But it's mostly like demographics info, treatment/consultation agreement, policies, etc. All worded correctly from the lawyer.

Just out of curiosity, as someone who is still starting his career: why not charge at the time of service? I feel there isn't much to gain, but a lot to lose, by asking for a deposit up front (unless you have an extremely high rate of no-shows for first appointments).

Even then, I just feel that asking for payment ahead of time, or allowing you to keep their cc on file if they agree, would work just as well without alienating patients who don't like giving cc over the phone.

 

[randomdoc1]

I hold my boundaries firm. I instruct the patient that legally I cannot see them until they sign the consents. Instruct them that doing it electronically is fastest and most efficient but if they rather do it on pen and paper, they can come in and do it. That was pre-covid. During covid, I use adobe where patients do not have to make an account. If they do not complete the paperwork, I just won't see them. Also, to secure an intake slot, I require a $20 safety deposit. If for any reason we have to do a cancellation with less than 24h notice, it cannot be refunded. But if they give notice, it can be refunded if they decide to go elsewhere. If they just want to reschedule, that's fine. What happens when the pt shows up for the appointment AND they did their intake papers? The $20 gets applied to deductible/copay/coinsurance. That $20 safety deposit really reduced the no show rate of new patients.

 

[Jules A]

I have a brief discussion on phone and take enough info to set up e-chart and email them the documents. They have all except 1 brought the completed documents with them and the one who didn't had everything printed and used part of their appointment time filling it out. I do not collect my fee up front, get very few cancellations and so far have not had a no-show for the intake although I'm only doing this one day a week so my sample size is small.

 

[sighchiatry]

I hold my boundaries firm. I instruct the patient that legally I cannot see them until they sign the consents. Instruct them that doing it electronically is fastest and most efficient but if they rather do it on pen and paper, they can come in and do it. That was pre-covid. During covid, I use adobe where patients do not have to make an account. If they do not complete the paperwork, I just won't see them. Also, to secure an intake slot, I require a $20 safety deposit. If for any reason we have to do a cancellation with less than 24h notice, it cannot be refunded. But if they give notice, it can be refunded if they decide to go elsewhere. If they just want to reschedule, that's fine. What happens when the pt shows up for the appointment AND they did their intake papers? The $20 gets applied to deductible/copay/coinsurance. That $20 safety deposit really reduced the no show rate of new patients.

I didn't know you could do that with Adobe.

I was thinking about adding something like DocuSign to my g suite for a somewhat similar outcome.

 

[watto]

Because I treat mainly sleep disorders and am cash only, I have asked patients to fill out an exhaustive sleep evaluation beforehand and get it back to me two days before their appointment. They are incentivized to do so because their initial appt can then be spent in discussing treatment plan / education rather than data collection. They feel they get a free appointment.

 

[romanticscience]

1) I have a "request appointment" link on my website for a google form, asking prospective patients for basic demographic info, basic past treatment history, prospective payment type (insurance # or cash), availability, and preferred modality for scheduling (phone v. email). An excel spreadsheet is compiled with this info. Callers to my office also are informed that due to call volume, new patient requests are only taken online. This probably is the first screen for tech-oriented patients.

2) Verify coverage and reach out to the patient by email with that week's available times. I don't have a waiting list, trying to catch people at their peak motivation. I believe this is why my rate of portal registration/intake form completion/show-rate has been so high.

3) When they pick a time, I reply with a confirmation and instructions on how to complete new patient forms in my portal. I set up their profile with the original info from the google form, so no redundant work on their part.

4) 9/10 patients complete the online registration and related forms.

5) See the patient for consultation. As part of the agreed-upon frame, reinforcing communication through the portal/work out registration issues.

I RARELY screen or schedule people by phone. Usually, it's only for VIPs and good potential clients who prefer to schedule by phone. I really feel the whole scheduling by phone/initial screen is an unreimbursed time-suck.

This system has lead to being consistently full (40 clinical hours/week) with minimal time spent on the phone (<1h week, maybe even <30-min week).

 

[dl2dp2]

I would avoid step 3. I had very few intake no-shows, and when this happens and if they want to reschedule I'll just ask them to pay in advance. Never had people come in and refuse to pay. Presumably because my fee is high enough that people who are cheap don't come through.

After intake, presumably, you have a better sense of what's going on, whether it's appropriate for your practice, that sort of thing, and you can explain your no show policy.

 

[roastedcapers]

I also have a solo private practice, and I don't take insurance. I'm a computer guy, but everything in my practice is extremely low-tech by design.

Since I don't take insurance, don't use an EMR, and don't do e-prescribing, (and a few other things), I'm not a covered entity under HIPAA which is nice. I don't have any sort of portal, messaging system, email for patients, etc.

My process is basically like this:
1. Potential patient calls and leaves a voicemail
2. I call them back and get an idea of what they're wanting treatment for. I also give them a quick rundown of my practice, some of the policies (no controlled subs, etc), my hours, fees, and how the first visit is an evaluation/consultation and that I don't take everyone on as a patient. This takes like 5 minutes usually. If I can instantly tell I don't want this person as a patient, I tell them about community resources and don't even bother with the whole speech.
3. If they want to schedule an evaluation, I only take credit cards, and they have to pay part of the fee up front over the phone as a deposit. While I'm on the phone with them I log into the merchant account on my computer or you can even do it on the browser on your phone. I let them know I keep cards on file for billing (you need verbal permission to keep cards on file, per policies from most card issuers).
4. I write down their appointment in my physical schedule book.

99% of people who have actually become ongoing patients have said on that first phone call 'Ok that sounds great' and given their credit card info.

Most people say "Ok well let me think about it" or "Let me ask my spouse" or "Ok that sounds great but let me call you back tomorrow because I'm [insert weird excuse here]". These people NEVER call back. I think maybe one person actually called back after a week and I did not take him as a patient after the evaluation.

Having the credit card on file for billing is key. I didn't want to waste my time tracking down balances because someone forgot their checkbook again.

(Also: I'm not a lawyer and this isn't legal advice, but what I've learned and was told from my lawyer from day 1, is that you need to be extremely careful how you word things both on your website and over the phone to any potential patient. Offering what could be construed as medical advice, making any sort of verbal promise to accept them as a patient, etc, you need to avoid all of that if you have a 'consultative' model like me. Otherwise you can prematurely create a patient-physician treatment relationship.)

I try to have everything set up so that I would be comfortable if I was the patient. I honestly would not want to see a psychiatrist or any kind of doctor where I'd have all my stuff in an EMR or some portal system, but that's the unfortunate reality of most modern practices and it's not avoidable usually. It's annoying enough they want your social security #, now they want your email and everything else.

When they show up for the evaluation, I actually do have a few simple pieces of paperwork for them to fill out and sign. But it's mostly like demographics info, treatment/consultation agreement, policies, etc. All worded correctly from the lawyer.

Basis, would you be willing to offer some wording you use to tell a client after an initial evaluation that it is not a good fit? And language you use on the phone to turn a client away, or to temper their expectations that an initial evaluation will lead to ongoing treatment? I struggle with setting these boundaries. Any advice on educational resources around language to use for boundaries would be helpful.

 

[Candidate2017]

Basis, would you be willing to offer some wording you use to tell a client after an initial evaluation that it is not a good fit? And language you use on the phone to turn a client away, or to temper their expectations that an initial evaluation will lead to ongoing treatment? I struggle with setting these boundaries. Any advice on educational resources around language to use for boundaries would be helpful.

Most of my attendings allow me leeway to reject new patients if I don't feel they are willing to work with me. I tell new evals up front this is merely a consultation to understand what they seek, I may not be able help with anything, and as a consultation we don't have a Dr patient relationship unless we both agree on an A&P, no hard feelings if they disagree with me because they should find someone else they can work with. Honest, direct and plain language with empathy works best just like when we discuss topics like SI, HI, childhood sexual abuse, rape, PTSD.

 

[Basis]

Just out of curiosity, as someone who is still starting his career: why not charge at the time of service? I feel there isn't much to gain, but a lot to lose, by asking for a deposit up front (unless you have an extremely high rate of no-shows for first appointments).

Even then, I just feel that asking for payment ahead of time, or allowing you to keep their cc on file if they agree, would work just as well without alienating patients who don't like giving cc over the phone.

I think if you didn't get the credit card ahead of time, you'd have a lot of logistical issues if someone no-shows to the initial appointment. What if they call a few hours later wanting to reschedule, or you just never hear from them again? I'm honestly amazed at how shameless some people are. If they don't have to pay a little bit ahead of time, some people will value your time so little they just blow it off and never call you or show up. This method kind of avoids those people.

Initially I was charging the whole amount, up front, over the phone, but I'd be a little hesitant at dropping hundreds of dollars on someone I hadn't met before, so I can understand that. Also I was having an issue where people would pay the $400 or whatever (I've changed the fee around a lot for the first appointment), and then no-show. Then they call up angry wanting a refund, or say they forgot. So I was eating credit card fees on $400 for nothing. It's way more palatable to only eat fees on $100 or $150, if you do a refund (or whatever your deposit is).

Basis, would you be willing to offer some wording you use to tell a client after an initial evaluation that it is not a good fit? And language you use on the phone to turn a client away, or to temper their expectations that an initial evaluation will lead to ongoing treatment? I struggle with setting these boundaries. Any advice on educational resources around language to use for boundaries would be helpful.

I'm naturally a pretty reserved guy, so I kind of turn up the charm when I'm on the phone with these people. After I get off the phone, I usually write them down in my 'no go' list that I keep, so that in case they call back I'm forewarned (perhaps they have spun a better story this time, not raising as many red flags). From what I can recall, and from looking at my no go list, these are the typical red flags:
- Got fired by their last psychiatrist
- Cursing (ok I'm not a prude but honestly what kind of person would call up a physician they've never met and use swear words?)
- Calling for a family member ("I told my husband if he doesn't see a shrink I'm leaving him!")
- Wanting disability or a support peacock
- Some kind of imminent crisis ("I got fired from my job and my doctor won't give me my oxy anymore, I don't know how I can cope!")
- On tons of controlled substances (they usually sound drugged and can't hold a conversation)

Anyway, in terms of what I say on the phone, I usually hem and haw about my schedule being pretty full for the next few months (yeah, it's not), and how I might not be the best fit for them since I'm just one person and it sounds like they might need a higher level of care. I try to devalue myself in their eyes, before they have the chance to do it. None of these people are really that invested or really demand to be seen. I usually say "I'd be happy to tell you about some community resources and some ways you can find a psychiatrist". I spent a few minutes on this, keep them happy, then get off the phone and put them on that list to warn myself. Only a few of them have ever called back, and they were too zonked out on xanax to remember having talked to me 2 weeks ago.

Also I tell everyone as part of my little phone speech, even people I think will be good patients, that I am extremely selective about who I take as an ongoing patient.

I've only had like less than 5 people actually come to a scheduled evaluation and then I did not take them as a patient. Most of those cases were people trying to hustle for drugs and thinking my 'no controlled substances' policy I told them about over the phone was somehow not going to apply to them.

I've usually told them, or the non-drug seeking ones, that they've pretty much tried everything I would have to offer, and I don't really think I can help them. A good angle for this is if they're ambivalent about medications, you can work this to your advantage and then they can walk away happy thinking "yeah I didn't want to be on meds anyway."

As I said in another thread, I refund 100% of the visit cost for these people I don't take. I don't want any bad reviews on google or anywhere else, and so far so good. I also want a nice clean break and I never want to hear from these people again. Do I wanna get paid for my time and effort? Of course, but this rarely happens now, and it keeps the antisocial guy from holding a grudge.

I think I have a good innate sense for boundaries, but I've found that some of the phrases and training I got from learning psychodynamic psychotherapy in residency is useful for this kind of stuff.

 

[roastedcapers]

That is so helpful, thank you!

 

[Attending1985]

I think if you didn't get the credit card ahead of time, you'd have a lot of logistical issues if someone no-shows to the initial appointment. What if they call a few hours later wanting to reschedule, or you just never hear from them again? I'm honestly amazed at how shameless some people are. If they don't have to pay a little bit ahead of time, some people will value your time so little they just blow it off and never call you or show up. This method kind of avoids those people.

Initially I was charging the whole amount, up front, over the phone, but I'd be a little hesitant at dropping hundreds of dollars on someone I hadn't met before, so I can understand that. Also I was having an issue where people would pay the $400 or whatever (I've changed the fee around a lot for the first appointment), and then no-show. Then they call up angry wanting a refund, or say they forgot. So I was eating credit card fees on $400 for nothing. It's way more palatable to only eat fees on $100 or $150, if you do a refund (or whatever your deposit is).



I'm naturally a pretty reserved guy, so I kind of turn up the charm when I'm on the phone with these people. After I get off the phone, I usually write them down in my 'no go' list that I keep, so that in case they call back I'm forewarned (perhaps they have spun a better story this time, not raising as many red flags). From what I can recall, and from looking at my no go list, these are the typical red flags:
- Got fired by their last psychiatrist
- Cursing (ok I'm not a prude but honestly what kind of person would call up a physician they've never met and use swear words?)
- Calling for a family member ("I told my husband if he doesn't see a shrink I'm leaving him!")
- Wanting disability or a support peacock
- Some kind of imminent crisis ("I got fired from my job and my doctor won't give me my oxy anymore, I don't know how I can cope!")
- On tons of controlled substances (they usually sound drugged and can't hold a conversation)

Anyway, in terms of what I say on the phone, I usually hem and haw about my schedule being pretty full for the next few months (yeah, it's not), and how I might not be the best fit for them since I'm just one person and it sounds like they might need a higher level of care. I try to devalue myself in their eyes, before they have the chance to do it. None of these people are really that invested or really demand to be seen. I usually say "I'd be happy to tell you about some community resources and some ways you can find a psychiatrist". I spent a few minutes on this, keep them happy, then get off the phone and put them on that list to warn myself. Only a few of them have ever called back, and they were too zonked out on xanax to remember having talked to me 2 weeks ago.

Also I tell everyone as part of my little phone speech, even people I think will be good patients, that I am extremely selective about who I take as an ongoing patient.

I've only had like less than 5 people actually come to a scheduled evaluation and then I did not take them as a patient. Most of those cases were people trying to hustle for drugs and thinking my 'no controlled substances' policy I told them about over the phone was somehow not going to apply to them.

I've usually told them, or the non-drug seeking ones, that they've pretty much tried everything I would have to offer, and I don't really think I can help them. A good angle for this is if they're ambivalent about medications, you can work this to your advantage and then they can walk away happy thinking "yeah I didn't want to be on meds anyway."

As I said in another thread, I refund 100% of the visit cost for these people I don't take. I don't want any bad reviews on google or anywhere else, and so far so good. I also want a nice clean break and I never want to hear from these people again. Do I wanna get paid for my time and effort? Of course, but this rarely happens now, and it keeps the antisocial guy from holding a grudge.

I think I have a good innate sense for boundaries, but I've found that some of the phrases and training I got from learning psychodynamic psychotherapy in residency is useful for this kind of stuff.

Do you have a full time private practice or is this something you do in addition to another job. I’m just wondering if being so selective interferes with building a patient load?

 

[FlowRate]

my 'no controlled substances' policy

I come across this sentiment from PP folks pretty frequently on this forum. Do you actually never prescribed CS (sched 2/3?) to your patients, or just not within the initial visit --> tried several other interventions time frame?

 

[Basis]

Do you have a full time private practice or is this something you do in addition to another job. I’m just wondering if being so selective interferes with building a patient load?

Yeah, my practice has been my only job since I graduated. But the first 6 months I was basically living off my meager savings from residency. I guess that tiny bonus for being a chief resident finally mattered. For most people I'd definitely recommend doing some sort of contractor job to supplement income at first, but I kept my expenses/spending at residency levels so it worked ok for me.

Being super selective definitely slows down the growth some, but having just one patient giving you a headache can ruin the whole joy of having your own practice. I usually get about 1-3 new patients a week I'd say? Less with all this coronavirus stuff.

I come across this sentiment from PP folks pretty frequently on this forum. Do you actually never prescribed CS (sched 2/3?) to your patients, or just not within the initial visit --> tried several other interventions time frame?

I never ever prescribe any scheduled drugs for any reason. I didn't even bother to get a DEA number until a few months ago (sometimes insurance companies identify you by that instead of your NPI number when paying for non-scheduled meds, even though the DEA discourages that practice). I also don't take people on controlled substances usually, there are a few exceptions. But someone who wants prozac from me for anxiety but is getting adderall from their PCP? Yeah no thanks.

Controlled substances were an absolute nightmare in residency, and our program was very conservative with benzos and basically never did stimulants in adults. But it was still so aggravating. I swore to myself when I graduated I'd never write another controlled (outpatient) Rx as long as I lived.

Even when I'm clear about the policy up front on the phone, some people are like 'that's fine!' and then sneak their way into the evaluation and start talking about how bad their focus is. Then they make it clear they want amphetamines and they clearly thought with a little begging I'd bend the rules. Huge waste of time for both of us.

 

[Candidate2017]

I come across this sentiment from PP folks pretty frequently on this forum. Do you actually never prescribed CS (sched 2/3?) to your patients, or just not within the initial visit --> tried several other interventions time frame?

I've had controlled substance seekers yell, cry, curse and/or become verbally abusive at the initial eval when they don't get their substance of choice. It's the residency's clinic but if I had a private practice, I wouldn't want any of that. No doubt it would also scare away your regular patients in the waiting room to witness that.

 

[Ironspy]

I come across this sentiment from PP folks pretty frequently on this forum. Do you actually never prescribed CS (sched 2/3?) to your patients, or just not within the initial visit --> tried several other interventions time frame?

I say no to everything initially as a screen but reserve the right to start something later if appropriate. I have one patient on one low dose stimulant currently. You have to be working or in school to get stimulants in my practice . No benzos. No z drugs. I am upfront when I schedule that if they are on a controlled substance that I will not continue it. These patients never schedule an intake after they find this out as they will be out $600 and will not get the refill of their choosing.

 

[PikminOC]

I say no to everything initially as a screen but reserve the right to start something later if appropriate. I have one patient on one low dose stimulant currently. You have to be working or in school to get stimulants in my practice . No benzos. No z drugs. I am upfront when I schedule that if they are on a controlled substance that I will not continue it. These patients never schedule an intake after they find this out as they will be out $600 and will not get the refill of their choosing.

How much are the follow ups?

 

[Ironspy]

How much are the follow ups?

300

 

[Attending1985]

300

how many minutes?

 

[liquidshadow22]

300

Youre crushing it. However do patients ever get pissed if the OON benefits do not reimburse at these rates?

 

[Ironspy]

Youre crushing it. However do patients ever get pissed if the OON benefits do not reimburse at these rates?

No. I have patients confirm OON benefits prior to scheduling intake so they know what their share is

 

[Ironspy]

how many minutes?

30 for meds or 45 for therapy.

 

[liquidshadow22]

No. I have patients confirm OON benefits prior to scheduling intake so they know what their share is

Ok can you perhaps explain what the reimbursement might look like for 90792 when you charge $600 for e.g. Blue cross or United health care PPO plans? Are there any plans that would cover even 70 to 80% of the cost of a $600 initial eval?

 

[Ironspy]

Ok can you perhaps explain what the reimbursement might look like for 90792 when you charge $600 for e.g. Blue cross or United health care PPO plans? Are there any plans that would cover even 70 to 80% of the cost of a $600 initial eval?

Yes. They have to cover up to (I think?) 95 percentile in your region and my fee is average for my area. I have colleagues with much higher fees. Most plans have a deductible and cover a percentage after. If my deductible is $1000 I pay the first 1000 and then insurance covers 60-80%. The deductible resets January 1.

 

[PikminOC]

Yes. They have to cover up to (I think?) 95 percentile in your region and my fee is average for my area. I have colleagues with much higher fees. Most plans have a deductible and cover a percentage after. If my deductible is $1000 I pay the first 1000 and then insurance covers 60-80%. The deductible resets January 1.

The insurance covers what they define as reasonable, which means very little.

 

[dl2dp2]

lol u guys with you charge a deposit before meeting.

I have not had a patient who saw me for eval without paying. people like that usually skip scheduled evals. at that point I tell the patient that they need to pay upfront. I don't feel the need to make it seem as if I don't trust the patients even before meeting them.

I wouldn't feel necessarily comfortable giving out my credit card prior to meeting the doctor either. Try and see if you can just recruit patients to come in, and THEN discuss payment. Why don't you accept check/QuickPay/Zelle?

I've had controlled substance seekers yell, cry, curse and/or become verbally abusive at the initial eval when they don't get their substance of choice. It's the residency's clinic but if I had a private practice, I wouldn't want any of that. No doubt it would also scare away your regular patients in the waiting room to witness that.

This doesn't happen very often in private practice. The high screening fees typically eliminates a large fraction of this population. Remember, supposedly 50% of Americans don't have $300 in their bank accounts. Patients who do this are more appropriately managed in a clinic setting where the system can provide wraparound services and set stricter boundaries.

 

[liquidshadow22]

Yes. They have to cover up to (I think?) 95 percentile in your region and my fee is average for my area. I have colleagues with much higher fees. Most plans have a deductible and cover a percentage after. If my deductible is $1000 I pay the first 1000 and then insurance covers 60-80%. The deductible resets January 1.

The insurance covers what they define as reasonable, which means very little.

Had a patient tell me that he would only be reimbursed whatever is the average rate for a cpt code by bluecross. I'm new to PP so I'm curious to see how it shakes out for most of my pts

 

[PikminOC]

lol u guys with you charge a deposit before meeting.

I have not had a patient who saw me for eval without paying. people like that usually skip scheduled evals. at that point I tell the patient that they need to pay upfront. I don't feel the need to make it seem as if I don't trust the patients even before meeting them.

I wouldn't feel necessarily comfortable giving out my credit card prior to meeting the doctor either. Try and see if you can just recruit patients to come in, and THEN discuss payment. Why don't you accept check/QuickPay/Zelle?



This doesn't happen very often in private practice. The high screening fees typically eliminates a large fraction of this population. Remember, supposedly 50% of Americans don't have $300 in their bank accounts. Patients who do this are more appropriately managed in a clinic setting where the system can provide wraparound services and set stricter boundaries.

Oh it happens in private practice. People are even more entitled because "I paid for this appt"!

 

[Candidate2017]

Can you guys describe what your cash patient population is like? I don't have any cash patients in my residency clinic, so that population is a mystery to me. I fear it would be entitled narcissists expecting me to be available on demand at all times and prescribing whatever stimulant they want.

I find it quite enjoyable to work with my established insurance patients in the residency clinic. Hence I am leaning toward taking good insurance. But paneling takes some time -- it seems I'm not allowed to apply for paneling prior to graduation ("must be board eligible"), followed by a wait of 3-6 months, in addition to paying for a physical location while waiting.

 

[TexasPhysician]

Can you guys describe what your cash patient population is like? I don't have any cash patients in my residency clinic, so that population is a mystery to me. I fear it would be entitled narcissists expecting me to be available on demand at all times and prescribing whatever stimulant they want.

I find it quite enjoyable to work with my established insurance patients in the residency clinic. Hence I am leaning toward taking good insurance. But paneling takes some time -- it seems I'm not allowed to apply for paneling prior to graduation ("must be board eligible"), followed by a wait of 3-6 months, in addition to paying for a physical location while waiting.

Generally middle class America that wants a thorough eval and ample education. They expect your time and knowledge. They want customer service, minimal wait times,
etc. You provide a premium product.

I generally see more drug seeking in insurance practices. If I can get my Adderall for a $15 copay to sell for $400, why pay $300 for it?

I do sporadically get patients that are demanding, but I’m pretty sure everyone does. Set limits. They will get the idea or leave.

Cash practices are becoming common in many fields due to high deductible plans and people wanting a better experience.

My last PCP would have me in the waiting room waiting, then I’d get roomed and wait 2x as long there. He moved quickly, and he couldn’t pick me out of a group of 2 people. I joined a DPC for $50/month. My wait time is about 5 minutes, staff are more friendly, and the doctor at least pretends to care. I spend 3x as long with the MD. She could spot me across a cro

I then switched to a cash dermatologist. More time and attention.

Maybe insurance doctors are just more efficient and equally as good in 1/3rd the time, but I feel better getting additional education about my illness and feeling as though no one is missing anything.

 

[dl2dp2]

Can you guys describe what your cash patient population is like? I don't have any cash patients in my residency clinic, so that population is a mystery to me. I fear it would be entitled narcissists expecting me to be available on demand at all times and prescribing whatever stimulant they want.

Cash patients span a spectrum, but in general they are more pleasant than your typical Medicaid patient. In general psych patients often have personality disorders, right? It's just that clinic patients have personality disorders AND can't afford to pay for high-quality treatment.

 

[Ironspy]

Can you guys describe what your cash patient population is like? I don't have any cash patients in my residency clinic, so that population is a mystery to me. I fear it would be entitled narcissists expecting me to be available on demand at all times and prescribing whatever stimulant they want.

I find it quite enjoyable to work with my established insurance patients in the residency clinic. Hence I am leaning toward taking good insurance. But paneling takes some time -- it seems I'm not allowed to apply for paneling prior to graduation ("must be board eligible"), followed by a wait of 3-6 months, in addition to paying for a physical location while waiting.

I see a lot of young professionals. Mostly depression/anxiety. Some bipolar disorder and psychosis but higher functioning. Mostly upper middle class but not super wealthy. People who value expertise, discretion and don’t want to sit in a waiting room or interact with a bunch of clinic staff. I educate patients about OON benefits, how they work and how to maximize reimbursement so treatment can be cost effective.

It’s really interesting for me to get an inner look at the finance/art/journalism/entertainment worlds to me. I have had a minority of entitled patients and they either respond to boundaries or vote with their feet

 

[liquidshadow22]

educate patients about OON benefits, how they work and how to maximize reimbursement so treatment can be cost effective.

How do you advise them to maximize reimbursement?

 

[Candidate2017]

Generally middle class America that wants a thorough eval and ample education. They expect your time and knowledge. They want customer service, minimal wait times,

Cash patients span a spectrum, but in general they are more pleasant than your typical Medicaid patient.

I see a lot of young professionals. Mostly depression/anxiety. Some bipolar disorder and psychosis but higher functioning. Mostly upper middle class but not super wealthy.

These sound like my residency clinic patients with insurance, except they are remarkably tolerant of what I would consider terrible service from clinic staff. I have a small percentage of Medicaid patients. The ones who remain with me are pleasant, whereas during my ramp up period, new Medicaid evals were mostly one and done substance seekers who stormed out.

Insurance seems to have a high penetrance in my area, but I'm not sure. I guess I might as well get a cheap office and experiment with a cash practice during the wait to get paneled with insurance.

 

[Ironspy]

How do you advise them to maximize reimbursement?

Many people with commercial insurance (esp young people) don't know about OON benefits because their insurance often does not advertise since they don't want people to actually use them. Patients often come to me expecting to pay 100% and are pleasantly surprised to hear that their insurance will reimburse a significant amount. Also, in cases where people have no OON benefits but psych networks are particularly small and/or have long waits they can sometimes convince their insurance to reimburse bc of parity. This may be less true now that everyone's done tele psych and you don't actually need to see someone nearby just in-state.

 

[hebel]

Medicolegally, what do you do if you see a pt for an initial eval, but end up not wanting to admit them to your clinic?

Is there any obligation to refer them someone else? Do you have a legal blurb for your notes?