Moonlighting in PCP office?

[hamstergang]

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Hi, wondering if anyone has any idea about the legality, allowability, and mechanics of this.

I know a pediatrician who owns her own private practice. She has many patients she is referring to psychiatrists, but without as much luck as she'd want. I'm about to start my second year of C/A fellowship. Could I moonlight seeing these patients in her office as an independent contractor or something?

 

[F0nzie]

I admire the attitude and enthusiasm. At this point it might be more headache than it's worth. You will have plenty of time once you're out of residency to test out that roller coaster. It sounds like a sure fire way to transition into private practice with minimal risk. 🙂

 

[VMSmith]

You'd have to figure out how you'd be getting paid, if she is not going to pay you some kind of salary. You can't bill for physical health and behavioral health appointments for patients seen the same day in the same location - so either the patient would have to come on a different day to see you, or you'd have to have her patients see you somewhere else that day.

 

[serimeri]

As an aside, can you moonlight on these patients in the capacity of a General practitioner? I think I've heard of some psychiatry residents doing shifts in urgent cares.

 

[clausewitz2]

You'd have to figure out how you'd be getting paid, if she is not going to pay you some kind of salary. You can't bill for physical health and behavioral health appointments for patients seen the same day in the same location - so either the patient would have to come on a different day to see you, or you'd have to have her patients see you somewhere else that day.

As a slight tangent, do you think there is going to be any movement in the near future to change this asinine restriction against billing for different visit types? Seems like really integrated care is a dead letter outside of grant--heavy settings in the community while it remains in effect.

 

[milesed]

We have 2 therapists who see patients in a PCP's office, enter notes into our EMR online and we bill for it. It is more of a convenience for the patients and some are less resistant to seeing someone this way. I don't know anyone doing this as a psychiatrist, but see no reason why it wouldn't work the same way. We pay no rent or fees to the pcp as it helps them out.

 

[heyjack70]

What hours/availability will you be able to moonlight? The tricky thing is you'll be on call for your patients 24/7. You shouldn't have the pediatrician taking your call for psychiatric issues because they are not a specialist in the field, just like you wouldn't take her pediatric call.

There is going to be a lot of paperwork to do to get onto insurance panels, and this could take several months. If you are planning on staying in the area and building up a practice out of this office it might make sense to start now. If you are planning on leaving it is going to be a lot of startup work for just 1 year of moonlighting, and you would probably be better off finding alternate moonlighting options.

 

[VMSmith]

We have 2 therapists who see patients in a PCP's office, enter notes into our EMR online and we bill for it. It is more of a convenience for the patients and some are less resistant to seeing someone this way. I don't know anyone doing this as a psychiatrist, but see no reason why it wouldn't work the same way. We pay no rent or fees to the pcp as it helps them out.

They see the patients the same day as their medical appointment?

 

[VMSmith]

As a slight tangent, do you think there is going to be any movement in the near future to change this asinine restriction against billing for different visit types? Seems like really integrated care is a dead letter outside of grant--heavy settings in the community while it remains in effect.

The hope is that this will change, and/or that the way payment is handled will just change drastically with ACOs. Otherwise integrated care can only really happen with grants or in organizations like the VA or Kaiser.

 

[VMSmith]

There is going to be a lot of paperwork to do to get onto insurance panels, and this could take several months.

This by itself would have dissuaded me from doing it during training.

 

[clausewitz2]

Please report back on how well it works out if you end up doing it; sub out adults for kiddos, and this is a type of practice setting I have a great deal of interest in.

 

[hamstergang]

What hours/availability will you be able to moonlight? The tricky thing is you'll be on call for your patients 24/7. You shouldn't have the pediatrician taking your call for psychiatric issues because they are not a specialist in the field, just like you wouldn't take her pediatric call.

Hmm, I imagined that I would moonlight around 1 evening night per week and then every other Saturday (that's when the office is already open), or something like that. I haven't looked at the numbers yet to see what would be needed in order to cover the cost of malpractice insurance and then justify the work that I'd be doing, especially as there are other simpler moonlighting gigs available to me.

I wasn't planning on being on call 24/7. This pediatrician isn't always available -- sometime patients have to go to the ER or leave a voicemail. I was thinking I could officially dedicate 1 hour a night (or something like that) to returning calls that the office staff has collected for me throughout the day. I'd have to make sure to not be doing moonlighting stuff while on an actual rotation, but still provide adequate care to the patients, so I feel this could accomplish that.

I know this sounds totally half-baked right now, but that's because I hadn't thought much about this until I made this thread. I wasn't even sure if it would be possible so I figured I'd come here to find out. I'm not even clear yet if their EMR can handle psych notes.

There is going to be a lot of paperwork to do to get onto insurance panels, and this could take several months. If you are planning on staying in the area and building up a practice out of this office it might make sense to start now. If you are planning on leaving it is going to be a lot of startup work for just 1 year of moonlighting, and you would probably be better off finding alternate moonlighting options.

I was planning on starting a private practice in the area eventually, but I thought I would have to take more time as I don't have much in the way of an initial investment or enough money saved up to wait for the practice to build up and start making money. This plan might actually solve those problems.

I did also think about eventually starting a private practice in this very office, if possible. It would reduce my initial investment needs and provide an excellent referral source so that I'd fill up much more quickly than otherwise. Plus, it would help the pediatrician as I'd be an on-site consultant who could easily accept her referrals (though I know I'd have to be careful to be set up such that I wouldn't be an unethical, illegal? self-referral). So the moonlighting plan would just be starting this up sooner than planned, more or less.

If anything actually happens, I'll update this thread. Until then, I'm open to hearing more things I should be considering.

 

[heyjack70]

Hmm, I imagined that I would moonlight around 1 evening night per week and then every other Saturday (that's when the office is already open), or something like that. I haven't looked at the numbers yet to see what would be needed in order to cover the cost of malpractice insurance and then justify the work that I'd be doing, especially as there are other simpler moonlighting gigs available to me.

I wasn't planning on being on call 24/7. This pediatrician isn't always available -- sometime patients have to go to the ER or leave a voicemail. I was thinking I could officially dedicate 1 hour a night (or something like that) to returning calls that the office staff has collected for me throughout the day. I'd have to make sure to not be doing moonlighting stuff while on an actual rotation, but still provide adequate care to the patients, so I feel this could accomplish that.

I know this sounds totally half-baked right now, but that's because I hadn't thought much about this until I made this thread. I wasn't even sure if it would be possible so I figured I'd come here to find out. I'm not even clear yet if their EMR can handle psych notes.


I was planning on starting a private practice in the area eventually, but I thought I would have to take more time as I don't have much in the way of an initial investment or enough money saved up to wait for the practice to build up and start making money. This plan might actually solve those problems.

I did also think about eventually starting a private practice in this very office, if possible. It would reduce my initial investment needs and provide an excellent referral source so that I'd fill up much more quickly than otherwise. Plus, it would help the pediatrician as I'd be an on-site consultant who could easily accept her referrals (though I know I'd have to be careful to be set up such that I wouldn't be an unethical, illegal? self-referral). So the moonlighting plan would just be starting this up sooner than planned, more or less.

If anything actually happens, I'll update this thread. Until then, I'm open to hearing more things I should be considering.

Another possible issue (not to dissuade you) is if you had to terminate a psychiatry patient for whatever reason (unruly parents, non-adherence, etc) that patient might stay on with the pediatrician and working in the same office might be a difficult situation.

As a child psychiatrist especially, I doubt you will have any problems filling up with your own patients with your own office/practice. A potential downside with sharing peds office space is your office will be incredibly cheap. The pediatric side has a lot more overhead in terms of medical assistants/nurses, schedulers and billers etc, along with the medical supplies required to run a peds office. I would be wary about how much of that you end up paying as a psychiatrist in the same office.

You might be better off just finding a psychiatry group with office space that is willing to have you come on part time in the evenings and Saturdays with the plan to go full time once fellowship is done. The benefit here would be the staff knows psych practice; billing, scheduling, crisis phone calls, etc. In addition, they might have staff, or at least other psychiatrists, to guide you when getting onto insurance panels, including the basic procedure, but also which insurance pays well, which is a hassle to collect from etc. This will probably be different than pediatrics. And your pediatrician colleague can still refer as many patients as she wants to you.

 

[Shikima]

We have 2 therapists who see patients in a PCP's office, enter notes into our EMR online and we bill for it. It is more of a convenience for the patients and some are less resistant to seeing someone this way. I don't know anyone doing this as a psychiatrist, but see no reason why it wouldn't work the same way. We pay no rent or fees to the pcp as it helps them out.

Not sure how billing and collections is arranged. Overhead is covered which is good, but someone much be paying the salary of the SW's.
Many insurance companies forbid same day services and I know of only one ins company which does allow same day visits.

 

[TexasPhysician]

Could you do this? - Yes
Should you do this? - Unlikely

You would need to negotiate very well to make this worth your while.

 

[milesed]

Not sure how billing and collections is arranged. Overhead is covered which is good, but someone much be paying the salary of the SW's.
Many insurance companies forbid same day services and I know of only one ins company which does allow same day visits.

It should be okay as long as not providing the same service. Not sure if any actually see a pcp and therapist on the same day or not. Location of where seen doesn't matter.

 

[hamstergang]

Should you do this? - Unlikely

Why? That's what I actually need/want to know.

 

[trophyhusband]

It should be okay as long as not providing the same service. Not sure if any actually see a pcp and therapist on the same day or not. Location of where seen doesn't matter.

Same location and day of service are actually two of the most common duplicate claim checks in a claims system. Add in that they're likely to be billing the same CPT in 9921X and you've just set yourself up for lots of rejected claims.

The situation you're referring to above is a bit different in that the therapist would be billing a different CPT than a physician (plus their provider type in the claims system will be non-physician) so the system might not consider it a dup.

 

[TexasPhysician]

Why? That's what I actually need/want to know.

There are many factors here, especially with joining a non-psychiatrist as they won't want to assume care should you leave. Who will be custodian of the records? If it is you and you leave that practice, how will patients reach you for records? Where would you store them? Releasing psych records (addiction issues) is different than gen peds if they don't regularly treat addiction. Will you be educating all staff on your rules? What about your office policies? Who will be educated on them? How will you get after-hours emergencies? Forms will be different. Have you developed them? What are lease terms with the peds? Any non-compete? Will you operate under peds business or develop your own and sublease? What insurances will you take? Who will handle billing? Psych coding is different than peds. How long until you can get on panels? Will this peds person bill under their name in the meantime? Who will furnish the office? You won't want an exam table in the room. Are staff there to work after 5pm and weekends for moonlighting? How often will you work there? Who will cover patients if you go on vacation?

As you spend many weeks figuring out the answers to the problems above and more, you could instead quickly sign up for a moonlighting gig paying $100-$120/hour and start sometimes within 2 weeks.

The only way this is worth it is if you develop such a good plan and arrangement with this peds person that you stay there for many years to come. You also need a contract guaranteeing the ability to keep your costs/rent low for the foreseeable future. If the peds person raises rent too high, it will be a lot of work to move elsewhere, hire new staff, etc.

I know 1 psychiatrist who joined an endocrinologist. Eventually the endocrine doc felt like the psychiatrist should share costs 50/50 as they both shared the same staff, many patients, and an office suite. The psychiatrist's argument was that he needs fewer supplies, only 1 office (versus multiple exam rooms), less staff requirements, etc. The result was a splitting-up.

 

[milesed]

Same location and day of service are actually two of the most common duplicate claim checks in a claims system. Add in that they're likely to be billing the same CPT in 9921X and you've just set yourself up for lots of rejected claims.

The situation you're referring to above is a bit different in that the therapist would be billing a different CPT than a physician (plus their provider type in the claims system will be non-physician) so the system might not consider it a dup.

Correct. Therapy is a different service. All the OP needs to do is see them on a different day than PCP or provide a different service.

 

[hamstergang]

There are many factors here, especially with joining a non-psychiatrist

Ah, thanks. Half of these aren't an issue for me given the specifics of the situation, but the other half most certainly are. This seems like too much work. I quit already.

 

[F0nzie]

There are many factors here, especially with joining a non-psychiatrist as they won't want to assume care should you leave. Who will be custodian of the records? If it is you and you leave that practice, how will patients reach you for records? Where would you store them? Releasing psych records (addiction issues) is different than gen peds if they don't regularly treat addiction. Will you be educating all staff on your rules? What about your office policies? Who will be educated on them? How will you get after-hours emergencies? Forms will be different. Have you developed them? What are lease terms with the peds? Any non-compete? Will you operate under peds business or develop your own and sublease? What insurances will you take? Who will handle billing? Psych coding is different than peds. How long until you can get on panels? Will this peds person bill under their name in the meantime? Who will furnish the office? You won't want an exam table in the room. Are staff there to work after 5pm and weekends for moonlighting? How often will you work there? Who will cover patients if you go on vacation?

As you spend many weeks figuring out the answers to the problems above and more, you could instead quickly sign up for a moonlighting gig paying $100-$120/hour and start sometimes within 2 weeks.

The only way this is worth it is if you develop such a good plan and arrangement with this peds person that you stay there for many years to come. You also need a contract guaranteeing the ability to keep your costs/rent low for the foreseeable future. If the peds person raises rent too high, it will be a lot of work to move elsewhere, hire new staff, etc.

I know 1 psychiatrist who joined an endocrinologist. Eventually the endocrine doc felt like the psychiatrist should share costs 50/50 as they both shared the same staff, many patients, and an office suite. The psychiatrist's argument was that he needs fewer supplies, only 1 office (versus multiple exam rooms), less staff requirements, etc. The result was a splitting-up.

Details, details....