Maximizing billing in c/l psychiatry

[masterofmonkeys]

So I'm probably going to start a position with a sizeable C/L component. I'm aware of the horrors of trying to make ends meet as a C/L psychiatrist. The unfortunate nature of this position is that clinical incentives are based on RVU collections and not RVUs Billed, which means I'm especially vulnerable to being screwed. This is made even more awesome by the fact that we are a safety net hospital and therefore a lot of my consults will be on unisured patients.

Was wondering if anyone had any tips on maximizing biling/collections beyond the basics (i.e. bill for initial inpatient encounter as much as possible for initial consults).

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[st2205]

Utilize therapy codes when possible, interactive complexity, etc.

 

[chicagochildpsych]

Demand a base salary that meets your needs, and don't expect to meet incentive goals. They are trying to screw you.


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[northernpsy]

CCP is right. The general advice I've always heard is that one should try to do CL on a salary basis whenever possible - especially because a lot of the "liaison" part of the job is stuff you can't really bill for.

 

[masterofmonkeys]

It's a position with an academic group. Essentially Id have the same base salary as any other starting attending, but would be at a giant disadvantage on the productivity incentive. This is one of those gigs where that's a non-trivial amount, but also not half of the paycheck

 

[Lunzio]

Apologies that this is not an answer to your question, but as a psych applicant in the future, I am curious if you could elaborate on the financial difficulties within C/L compared to other focuses like CAP or even general psychiatry practice? Thank you so much!

 

[masterofmonkeys]

Psych is already at a disadvantage because we aren't paid. Consultants do a lot of non face to face work like reviewing records, coordinating with teams, gathering collateral. All of which Medicare decided should be done for free (by all physicians in all environments, generally speaking). Since this is a greater proportion of the workload it means that a greater proportion of our day is unpaid. Then on top of that Medicare decided to make it much harder to bill for consults in the first place. And to make it worse, in a lot of general hospital settings consults are 30-70% uninsured.

Basically, government doesn't value the work of physicians who do anything other than stick things into people and the consequences of this are magnified in the consult field due to the nature of it.

 

[nexus73]

So is there a base salary already?

 

[Information Underload]

Agree with the above. The argument that could be made to the hospital is that C/L service ultimately reimburses in moving patients out of the hospital or avoiding other pitfalls as opposed to through direct reimbursement, so a direct salary is more appropriate.

You could certainly use codes like psychotherapy codes and prolonged service codes, which I think our C/L service often under-utilized. The problem with prolonged service codes is that it requires that you be face-to-face with the patient. Is it appropriate to obtain collateral in front of the patient? Probably not in many cases, although it does lead to transparency in care.

As far as Medicare making it harder to bill for consults, aren't most just using the same inpatient codes now? 99221-99223? I would imagine most consults would merit a 99222 unless you have a suicidal patient or a patient incapable of caring for self at the imminent risk of life.

 

[Candidate2017]

Psych is already at a disadvantage because we aren't paid. Consultants do a lot of non face to face work like reviewing records, coordinating with teams, gathering collateral. All of which Medicare decided should be done for free (by all physicians in all environments, generally speaking). Since this is a greater proportion of the workload it means that a greater proportion of our day is unpaid. Then on top of that Medicare decided to make it much harder to bill for consults in the first place. And to make it worse, in a lot of general hospital settings consults are 30-70% uninsured.

Basically, government doesn't value the work of physicians who do anything other than stick things into people and the consequences of this are magnified in the consult field due to the nature of it.

Isn't it also a function of volume? Nonprocedural radiologists average $15 per patient but their volume is at least 10 times more than psych. The busiest academic consult service I've seen didn't exceed 10-12 patients a day. The community psychiatrists I saw more than doubled the income of academics because they covered the entire hospital in the AM (inpatient, consults and ER), and then outpatient in the afternoons.

 

[Candidate2017]

Agree with the above. The argument that could be made to the hospital is that C/L service ultimately reimburses in moving patients out of the hospital or avoiding other pitfalls as opposed to through direct reimbursement, so a direct salary is more appropriate.

I got the impression academic psychiatrists did more IM on consults but weren't as respected. The IM chiefs would be like, "Thanks for the recs, but whatevs, d/c in AM."

 

[splik]

The busiest academic consult service I've seen didn't exceed 10-12 patients a day.

Presumably you mean for an individual doc, a busy c-l service might have 40-80 patients on their census depending on the size of the hospital, but there will usually be a good number of psychiatrists assuming they aren't letting posts go vacant and expecting the existing docs to pick up the slack, which is a probably a foolish assumption

 

[FlowRate]

Isn't it also a function of volume? Nonprocedural radiologists average $15 per patient but their volume is at least 10 times more than psych. The busiest academic consult service I've seen didn't exceed 10-12 patients a day. The community psychiatrists I saw more than doubled the income of academics because they covered the entire hospital in the AM (inpatient, consults and ER), and then outpatient in the afternoons.

Maybe you just haven't seen very busy academic consult services. We've had PGY2's get 15 consults just in the ED in an overnight shift.

Our psych CL service is the busiest consult service in the hospital. Given I was just on neuro where we'd regularly get >15 floor consults in a day, that's gotta be >15. (I'm speaking all news, not olds.)

 

[nexus73]

Agree with the above. The argument that could be made to the hospital is that C/L service ultimately reimburses in moving patients out of the hospital or avoiding other pitfalls as opposed to through direct reimbursement, so a direct salary is more appropriate.

You could certainly use codes like psychotherapy codes and prolonged service codes, which I think our C/L service often under-utilized. The problem with prolonged service codes is that it requires that you be face-to-face with the patient. Is it appropriate to obtain collateral in front of the patient? Probably not in many cases, although it does lead to transparency in care.

As far as Medicare making it harder to bill for consults, aren't most just using the same inpatient codes now? 99221-99223? I would imagine most consults would merit a 99222 unless you have a suicidal patient or a patient incapable of caring for self at the imminent risk of life.

I thought 99358 was prolonged service without face to face with patient. Maybe it just doesn't get reimbursed.

 

[Candidate2017]

Maybe you just haven't seen very busy academic consult services. We've had PGY2's get 15 consults just in the ED in an overnight shift.

Our psych CL service is the busiest consult service in the hospital. Given I was just on neuro where we'd regularly get >15 floor consults in a day, that's gotta be >15. (I'm speaking all news, not olds.)

I can only speak about one C/L attending's list that had a max of 10-12/day. I don't know what their ED is like because they have separate coverage. The place is a tertiary, nearly 1,000 bed hospital so the ED is probably a s***storm like the rest of the hospital (great pathology, diversity and teaching on the service but I was more tired at the end of the day than on my surgery rotation, so a nope for me).

My original point is that an academic C/L attending seems to get a fraction of the billing volume of a community attending who covers the entire hospital (inpatient, consults, ER) in the AM and then does outpatient in the PM.

 

[st2205]

Presumably you mean for an individual doc, a busy c-l service might have 40-80 patients on their census depending on the size of the hospital, but there will usually be a good number of psychiatrists assuming they aren't letting posts go vacant and expecting the existing docs to pick up the slack, which is a probably a foolish assumption

How big of a hospital are you talking? We have 600+ beds and I couldn't fathom anything remotely near that volume... even at a 1k bed facility, unless those consulting really are that bad.

 

[masterofmonkeys]

to put it into maybe cleaner perspective, I'll be making the same base salary as any other junior attending. The difference is they'll collect far more RVUs per patient contact than I will (while our med floors act as a safety net, there is a CMHC that takes all uninsured inpatient and outpatient psychiatry as well as most of the medicaid so our inpatient psychiatry sees relatively little medicaid and our outpatient psychiatry does'nt see a whole lot either. i.e. mostly private.)

I'm not sure how to deal with that other than ask for a higher base salary which I'm sure will be denied based on 'unfairness', even though doing work that I don't get credited for would also probably count as 'unfair'.

 

[nexus73]

to put it into maybe cleaner perspective, I'll be making the same base salary as any other junior attending. The difference is they'll collect far more RVUs per patient contact than I will (while our med floors act as a safety net, there is a CMHC that takes all uninsured inpatient and outpatient psychiatry as well as most of the medicaid so our inpatient psychiatry sees relatively little medicaid and our outpatient psychiatry does'nt see a whole lot either. i.e. mostly private.)

I'm not sure how to deal with that other than ask for a higher base salary which I'm sure will be denied based on 'unfairness', even though doing work that I don't get credited for would also probably count as 'unfair'.

Or take a different job. I imagine they've had a difficult time filling this position because the pay is not equitable. Unless you need them more than they need you.

 

[chicagochildpsych]

This is why academics was never the right fit for me. Taking a pay cut for the privilege of an assistant professor spot doesn't pay back naivient or my mortgage.


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[splik]

This is why academics was never the right fit for me. Taking a pay cut for the privilege of an assistant professor spot doesn't pay back naivient or my mortgage.


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well depending on the position they may actually pay off much or even all of your student loan, and give you a reduced rate mortgage

 

[chicagochildpsych]

I was offered between 99-150k salary with some mild production bonuses from academic employers. I started at around 250k base a few years ago and now with productivity I make over 500k (an outlier while working very hard). I just don't see the mortgage and student loan help making up the difference. Also, I'm living in a desirable area, at least relative to the academic jobs with reasonable perks. Academic powerhouses often offer under 120k base and little else for the "honor" of the title.


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[northernpsy]

I know what you mean, CCP. When I was considering accepting an academic job, even though it was appealing in a lot of non-material ways, there was just no way I could justify the opportunity cost of missing out on the money that private employers were offering.

 

[SmallBird]

Academic powerhouses often offer under 120k base and little else for the "honor" of the title.

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Your argument still applies, but under 120k base is lower than any of the academic jobs I explored. Columbia, Emory, Brown, Yale, Penn were all significantly more than that for starting clinician-educators. On the other hand if you are looking for 50% protected time and have no grants that might be an accurate number.

 

[dl2dp2]

You don't have leverage. This is true for CL everywhere as far as I know. CL is a money losing program, and the fewer people they hire the better, as the value of preventing readmission, etc. is difficult to assess.

These issues are sort of piecemeal symptoms of a larger problem: extreme level shortage of outpatient psychiatrists nationwide.

It appears that CL psychiatry tends to be done nationwide as 1) part of "service" that a private psych group provides to the hospital in exchange for a steady referral source. This is more common in the Midwest/low density areas, since referral for outpatient psychiatry for insurance based patients in any major metro is a complete joke (i.e. don't need it.) 2) academic "mommy track" jobs given to women and other underprivileged groups who don't negotiate and want a fixed hour job.

^^ 50% protected time and no grants, your salary will be $0, not $120. LOL.

Clinician educators are getting a pay raise into the high 100s, because universities realized that people never stay longer than 1-2 years and they have very high turnovers. Meanwhile, chill outpatient group jobs are starting to pay in the 250k+ range (as the poster noted above in Chicago), so the exodus continues. Clinician educator jobs (some are CL based) are being filled with women and other underprivileged groups who have no geographical flexibility and don't "need" to make more money. EVEN THEN, I'd say a lot of women I know are leaving, since part time private group gigs, especially at integrated systems (i.e. Kaiser) are often better for this kind of purpose (mommytracking). Academic departments are starting to have problems growing because of the massive shortage. It's becoming more common that the only real reason that you'd stay in academia is to do research, which cannot be done as part of a private group. And given NIH funding drying up, that's definitely not growing either. So more recently "creative" strategies have emerged on the academic scene, where departments are opening up clinics that charge cash only for full time junior faculty (but charge them a heavy "dean"/overhead tax), once upon a time an extremely rare phenomenon, as academic staffing was conventionally salaried, not performance based. Medicaid clinics that used to be academically affiliated are sold to private mill-runners. State and local systems are losing academic affiliation. In essence, academic departments are trying to cross-subsidize money losing research/insurance based practice with private $$ from relatively "wealthy" individuals. Cornell pioneered this and it's starting to disseminate across the country. Frankly I'm not really sure how ethical this is, given that the whole point of a faculty practice in my mind is to discourage tiering of healthcare. But I suppose given the world as it is, we have to die or adapt (#America!!)...

Academic hospital executives and psychiatry department heads have very different priorities. Hospital-driven psychiatry is a cost center (i.e. CL). Psych patients are high maintenance and have bad insurance, damage QA metrics (frequent re-admit, complain, bad patient satisfaction, high complication rates from surgeries, poor compliance, etc.) so hospital CEOs want to keep them out. What better way to keep them out than not have any outpatient psych service or artificially clamp down the amount of services you provide? It's very often that hospital discharges from academic centers having very difficult psychiatry placement, which angers rank-and-file, which then goes back up to the chair, to whom the Dean/CEO gives the middle finger... Hospitals don't want to subsidize psychiatry departments because procedural departments are vastly more lucrative and are always paid by 3rd party payer. Psychiatry is like a little sideshow line on their balance sheet that they just prefer to not think about.

That said, the style of a typical "old school" clinician educator job is very different compared to a private group job. These jobs are very similar to state/VA jobs, sans "teaching". People avoid seeing patients. Clinics are half empty. Consults are routinely rejected or 'curbside/over the phone'. You have the leisure of having a cup of coffee when you want, and universities will always float you regardless of how "unproductive" you are. It may be a very good fit for a lot of people.

Just telling like how it is...

 

[SmallBird]

^^ 50% protected time and no grants, your salary will be $0, not $120. LOL.

I try and constrain my perspective to my own experience or that of close colleagues - you may have a large sample size of places where that is the case, but again, at multiple institutions their exists the opportunity to be an 'instructor' aiming for a clinician-scholar track where the pay is around $100 - $120k with typically less than a 50% clinical load. I encountered these positions at multiple programs in the Northeast, at Mayo, UCLA, UCSD and Penn.

 

[dl2dp2]

I try and constrain my perspective to my own experience or that of close colleagues - you may have a large sample size of places where that is the case, but again, at multiple institutions their exists the opportunity to be an 'instructor' aiming for a clinician-scholar track where the pay is around $100 - $120k with typically less than a 50% clinical load. I encountered these positions at multiple programs in the Northeast, at Mayo, UCLA, UCSD and Penn.

OH i see, I misunderstood. You want to work another 50% at the same facility for a grand total of 100% FTE.

Here is how the math works: a full time clinical job/clinician educator job at said facility will be ~190k (as I said before). Comparable job in private would be ? 250-300k
No grant support: 50% research = $0, 50% clinical = 190*0.5 = ~ 100k

I thought you meant like $100k for the 50% protected research time without a grant. It seems like the instructors are basically doing research for free without a grant, right?

Also, this is weird math in that if NIH audits you you'll be toast, since K salary is 75%. So technically, the 100k K salary would only bring your salary up to 150k, since otherwise you'd be working 125%. In reality, departments are routinely telling people to write 100% FTE on NIH K budgets so that they can pay you whatever they feel like paying you regardless of what NIH wants them to pay you. Another symptom of the said macroscopic problem as mentioned above.

 

[hamstergang]

Hospitals make money by people using their services and paying for that. Yet people seem to say that hospitals prefer patients to have shorter stays and not have readmissions. But staying in the hospital fewer days or not coming back means using fewer hospital services and therefore paying the hospital less money. To resolve this contradiction, I had 3 thoughts:

1) Patients that have longer lengths of stay or readmissions have worse insurance so hospitals don't actually make money on them (or hospitals possible lose the opportunity to make more money from someone else with better insurance).

2) Insurance pays a lump sum for a hospitalization, so shorter stays means more money for fewer services used. Insurances don't pay the same for readmissions as initial admissions.

3) I have some other or more major misunderstanding.

All 3 would make sense, but does anyone actually know which is true?

 

[dl2dp2]

Hospitals make money by people using their services and paying for that. Yet people seem to say that hospitals prefer patients to have shorter stays and not have readmissions. But staying in the hospital fewer days or not coming back means using fewer hospital services and therefore paying the hospital less money. To resolve this contradiction, I had 3 thoughts:

1) Patients that have longer lengths of stay or readmissions have worse insurance so hospitals don't actually make money on them (or hospitals possible lose the opportunity to make more money from someone else with better insurance).

2) Insurance pays a lump sum for a hospitalization, so shorter stays means more money for fewer services used. Insurances don't pay the same for readmissions as initial admissions.

3) I have some other or more major misunderstanding.

All 3 would make sense, but does anyone actually know which is true?

Both are true. Inpatient reimbursement has been bundled for a long time. Also, there are now specific insurance side QA utilization eview where readmits are no longer reimbursed if certain criteria are met (i.e. too short of a time in between, etc.)

 

[clausewitz2]

Both are true. Inpatient reimbursement has been bundled for a long time. Also, there are now specific insurance side QA utilization eview where readmits are no longer reimbursed if certain criteria are met (i.e. too short of a time in between, etc.)

Yeah, the fiscally optimal patient at this point is admitted for exactly two midnights with exactly 31 days in between admissions and who also needs some manner of surgery on every admission.

 

[nexus73]

Have you already taken the job?

 

[masterofmonkeys]

Not yet, they're rejiggering the schedule to provide me better collection rates through time in other settings (clinic, etc)

 

[SeniorWrangler]

My impression is that academic psychiatric programs hire lots of people with a tacit understanding that they're not going to be around forever; there's a funnel effect where lots of attendings work for a while and then leave to go to another institution or to the VA or private practice, and a smaller core group stays, gathering titles and tiny bits of influence. The ones who leave are replaced fairly easily with new graduates who are starry eyed about academic medicine, so the wheel keeps turning.