Private Practice after residency

[outptpsych]

I am currently a psychiatry resident and have just over a year left in residency. I'm trying to plan my post-residency career and am highly considering outpt general psychiatry in both med management and psychotherapy. I'm interested to hear perspectives (good and bad) on going into private or group practice after residency. I'm particularly interested in going to a larger city, strongly considering NYC. I may do some part-time with inpt work or consult work; however, would like to focus the bulk of my time on outpt setting. Also wondering if folks have particularly resources they have found useful with my situation. thanks!

---

Members don't see this ad.

 

[vistaril]

I may do some part-time with inpt work or consult work

consult work, except within academic depts, is really becoming just something you do when necessary as part of your regular job. for example the psychiatrists employed or having a contract with a hospital system also agree to cover consults within that system as part of the contract.

 

[dl2dp2]

For bigger markets, being in one of them, my suggestion from the faculty grapevine is consider wealthy suburbs. Those practices fill up really fast, and the cost of living is relatively lower. You may even live in the city center and practice in the suburbs though perhaps not as convenient for after hour private appointments.

The unfortunate reality with desirable locations is that there are more psychiatrists. This means competition for cash pay is a bit stiffer, so your credential matters more in my opinion if you want to fill quickly, though I looked into insurance reimbursements, and if you fill with Medicare patients you can still make ~ $220 an hour in revenue, but you'll need to hire a medical coder, at least part time. You might have to start with signing up for panels if you want to fill 75% full time within a few months. This means start looking into this paperwork NOW if you are a PGY4!!! The flip side is there are also more wealthy people and people with good private insurance with out of network benefits, so you can often get a bigger load of therapy patients. You might want to consider networking a bit and get into the community you are interested in.

A couple of other tips: you can pay for supervision--so one easy way to get into the community is paying well known people--you can find them on psychologytoday or some other yellow page. Sublease an office on psychooffice.net. Get an LLC or at least a business account, start scouting for malpractice. Potentially call recruiters for locum jobs.

I actually think if you can get all the ducks in a row, starting a full time office solo practice taking SOME insurance in a wealthy NYC or DC or Chicago suburb as a new grad from a reputable program is EASY. A lot of people are scared of all the business aspects, but I think it's not as scary as it seems, just need an initial investment of time and money. Look into the APA online manual also if you are a member. PM me if interested.

 

[outptpsych]

For bigger markets, being in one of them, my suggestion from the faculty grapevine is consider wealthy suburbs. Those practices fill up really fast, and the cost of living is relatively lower. You may even live in the city center and practice in the suburbs though perhaps not as convenient for after hour private appointments.

The unfortunate reality with desirable locations is that there are more psychiatrists. This means competition for cash pay is a bit stiffer, so your credential matters more in my opinion if you want to fill quickly, though I looked into insurance reimbursements, and if you fill with Medicare patients you can still make ~ $220 an hour in revenue, but you'll need to hire a medical coder, at least part time. You might have to start with signing up for panels if you want to fill 75% full time within a few months. This means start looking into this paperwork NOW if you are a PGY4!!! The flip side is there are also more wealthy people and people with good private insurance with out of network benefits, so you can often get a bigger load of therapy patients. You might want to consider networking a bit and get into the community you are interested in.

A couple of other tips: you can pay for supervision--so one easy way to get into the community is paying well known people--you can find them on psychologytoday or some other yellow page. Sublease an office on psychooffice.net. Get an LLC or at least a business account, start scouting for malpractice. Potentially call recruiters for locum jobs.

I actually think if you can get all the ducks in a row, starting a full time office solo practice taking SOME insurance in a wealthy NYC or DC or Chicago suburb as a new grad from a reputable program is EASY. A lot of people are scared of all the business aspects, but I think it's not as scary as it seems, just need an initial investment of time and money. Look into the APA online manual also if you are a member. PM me if interested.

Thanks guys for posting. sluox, i have 15 months left of residency fyi. I'm not in my last year quite yet so i have some time to plan fortunately. I've noticed in NYC for instance (with my google searches) there appears to be a lot of out-of-network private practices which seems to make things easier. I'm wondering, if in a place like NYC, if those practices pick up quickly or if they are slow. I would ideally want to of course fill the practice quickly. What do you mean when you say "signing up for panels ". I'm also interested in med management and psychotherapy (particularly psychodynamic and CBT) and I prob will enroll in some evening training at a psychoanalytic institute. I need to network more; unfortunately I don't live close to NYC right now so not sure the best way to do that.

I def appreciate the rec for supervision, i think that will be really important in the beginning. I also plan on taking a look at psychoffice.net (i wasn't aware of that site). I'm also open to considering suburbs - only issue is if I live in NYC then it would be ideal to be close to the practice. I like the hustle/bustle of the city and would prefer that (though I'm open minded about things). My other question is how much money i would be making? I'm an extremely hard worker who likes to prepare for things and get my ducks in a row early so i have that. I just don't know what a realistic income would be and how quickly my practice would fill in a big city like NYC. Any insight would be appreciated. thanks so much.

 

[nitemagi]

Think about getting a side job with some flexibility in hours/schedule while you fill your practice.

Anywhere saturated will be slower to fill at first. I'm in West LA and I had only 1 patient for my first few months.

Do good work, network and communicate well, be helpful to others, and word will spread.

Reach out to other providers (psychologists, therapists, primary care doctors, other specialists if you work in a related area).

Add a website. Develop a niche. Consider further PT training in a psychotherapy or two. Do what you need to to distinguish yourself.

Sub-lease to start, with the option to add hours.

Take credit cards. It offers flexibility for everyone.

Get digital. EMR, efax, email, Skype.

 

[outptpsych]

Think about getting a side job with some flexibility in hours/schedule while you fill your practice.

Anywhere saturated will be slower to fill at first. I'm in West LA and I had only 1 patient for my first few months.

Do good work, network and communicate well, be helpful to others, and word will spread.

Reach out to other providers (psychologists, therapists, primary care doctors, other specialists if you work in a related area).

Add a website. Develop a niche. Consider further PT training in a psychotherapy or two. Do what you need to to distinguish yourself.

Sub-lease to start, with the option to add hours.

Take credit cards. It offers flexibility for everyone.

Get digital. EMR, efax, email, Skype.

thanks nitemagi. did you take a job right after residency? only one patient for your first few months?! do you do mainly outpt now and what is your practice like now?

 

[dl2dp2]

What do you mean when you say "signing up for panels ". I'm also interested in med management and psychotherapy.

Cash practices ALWAYS fill slowly, no matter where you are, especially if you don't have a referral network. What you need to do is to sign up to become an in-network provider for insurance panels.

other question is how much money i would be making? I'm an extremely hard worker...

Medicare fees for physicians doing psychotherapy increased dramatically for FY2014
99213 is $68
90833 is $65
90836 is $83

i.e. 30 min med check = $133
45 min combined therapy med check = $151
You should be able to fill 36 hours with medicare rates within 6 months. Say you have half therapy half meds = $200*18 + $260*18 (I'm rounding) = $8280 * 48 weeks a year = ~400k revenue

Office will cost 20k a year, part time medicare coder/secretary will cost at least another 50k, malpractice 5k, misc office expense 5k Medicare has a pretty high no-show rate and failure to collect, so say optimistically you collect 80%, this gets you to ~250k/year net. Obviously you will also take insurance that pays more than Medicare, so that adds some here and there.

Sounds about right! If you work for a hospital in a similar scenario (mostly Medicare) they take another cut of 50k, but saves you the trouble of having to find your own coder/secretary/chasing after bills, etc., which gives you the average psychiatrist salary of 200k. But keep in mind this is 36 patient care hours a week with 4 weeks of vacation. Seems like a pretty good lifestyle.

Private pay psychiatrists charge between $400-$600 an hour. Overhead stays constant--maybe even lower because you don't need a medicare coder/chasing after bills/much lower no-show rate. You can do the math and see how much they make if they fill 36 hours--of course that can be difficult, so the income spans a spectrum. Some people also like to work less for lifestyle reasons, etc. Nevertheless, senior people in fancy markets tend to do VERY well financially regardless. I know almost no one over 55 who doesn't have two homes in some of the most expensive parts of the country. You won't make billions and live in a compound, but you'll be doing very well. And the degree of autonomy is breathtaking. It really is a nice life--just be a bit patient.

 

[outptpsych]

Cash practices ALWAYS fill slowly, no matter where you are, especially if you don't have a referral network. What you need to do is to sign up to become an in-network provider for insurance panels.



Medicare fees for physicians doing psychotherapy increased dramatically for FY2014
99213 is $68
90833 is $65
90836 is $83

i.e. 30 min med check = $133
45 min combined therapy med check = $151
You should be able to fill 36 hours with medicare rates within 6 months. Say you have half therapy half meds = $200*18 + $260*18 (I'm rounding) = $8280 * 48 weeks a year = ~400k revenue

Office will cost 20k a year, part time medicare coder/secretary will cost at least another 50k, malpractice 5k, misc office expense 5k Medicare has a pretty high no-show rate and failure to collect, so say optimistically you collect 80%, this gets you to ~250k/year net. Obviously you will also take insurance that pays more than Medicare, so that adds some here and there.

Sounds about right! If you work for a hospital in a similar scenario (mostly Medicare) they take another cut of 50k, but saves you the trouble of having to find your own coder/secretary/chasing after bills, etc., which gives you the average psychiatrist salary of 200k. But keep in mind this is 36 patient care hours a week with 4 weeks of vacation. Seems like a pretty good lifestyle.

Private pay psychiatrists charge between $400-$600 an hour. Overhead stays constant--maybe even lower because you don't need a medicare coder/chasing after bills/much lower no-show rate. You can do the math and see how much they make if they fill 36 hours--of course that can be difficult, so the income spans a spectrum. Some people also like to work less for lifestyle reasons, etc. Nevertheless, senior people in fancy markets tend to do VERY well financially regardless. I know almost no one over 55 who doesn't have two homes in some of the most expensive parts of the country. You won't make billions and live in a compound, but you'll be doing very well. And the degree of autonomy is breathtaking. It really is a nice life--just be a bit patient.

how slow do you think cash practices fill? Only reason i ask is it seems so expensive to be in network with 50K in office costs, etc. And sorry for my slowness (how did you get the 200 and 260 figures)? i get the other figures.

any thoughts on group practices? i imagine it is tough to join any of those unless you have a connection.

 

[nitemagi]

This depends on how interested you are in getting involved with insurance panels. In my limited experience they are a headache and you end up eating a lot time as unbillable trying to get paid for past billed services.

I know very few psychiatrists, even here in LA, that charge more than $400 an hour if doing therapy. In fact some of the most elite are only in the 3-400 range. Maybe NYC is different. More commonly is if you're doing med only visits then people charge $200 for a visit and then do 15-20 minute visits. I prefer to not do that, and have no appointments less than 30 minutes. I therefore make less per hour, but I do good therapy and frankly a lot of my patients get better (and even "graduate" out of treatment).

The referral network is absolutely key. If you do good work, the goal is that your patients refer to you (that becomes your referral network).

Right out of residency I took a job with the county 4 days a week, and started my PP one day a week. I had bills to pay and had to support my family. I built from there. Later I switched to contract work that paid a better hourly, was only 1/2 time, and allowed me the flexibility to grow my practice. My PP has slowly grown, even though I'm not super-aggressive about networking/advertising. I believe in doing high quality work, if at all possible. And that means (to me) [trying to ] be a great therapist AND a great psychopharmacologist. Being great at both is a work in progress, and I continue to read and even do workshop trainings to improve my skill set/knowledge base, years after finishing at a top-notch residency where I got A LOT of therapy training. You're never "done." That's my practice model.

Even then there are limitations (not everyone can afford to come in, not everyone is ready for treatment, etc).

 

[vistaril]

Private pay psychiatrists charge between $400-$600 an hour. .

now we're up to 600 dollars an hour at the high end.....I swear give it another year or two and this forum will be agreeing that charging 4 figures per hour for psychotherapy as a cash pay psychiatrist is very doable.

 

[outptpsych]

This depends on how interested you are in getting involved with insurance panels. In my limited experience they are a headache and you end up eating a lot time as unbillable trying to get paid for past billed services.

I know very few psychiatrists, even here in LA, that charge more than $400 an hour if doing therapy. In fact some of the most elite are only in the 3-400 range. Maybe NYC is different. More commonly is if you're doing med only visits then people charge $200 for a visit and then do 15-20 minute visits. I prefer to not do that, and have no appointments less than 30 minutes. I therefore make less per hour, but I do good therapy and frankly a lot of my patients get better (and even "graduate" out of treatment).

The referral network is absolutely key. If you do good work, the goal is that your patients refer to you (that becomes your referral network).

Right out of residency I took a job with the county 4 days a week, and started my PP one day a week. I had bills to pay and had to support my family. I built from there. Later I switched to contract work that paid a better hourly, was only 1/2 time, and allowed me the flexibility to grow my practice. My PP has slowly grown, even though I'm not super-aggressive about networking/advertising. I believe in doing high quality work, if at all possible. And that means (to me) [trying to ] be a great therapist AND a great psychopharmacologist. Being great at both is a work in progress, and I continue to read and even do workshop trainings to improve my skill set/knowledge base, years after finishing at a top-notch residency where I got A LOT of therapy training. You're never "done." That's my practice model.

Even then there are limitations (not everyone can afford to come in, not everyone is ready for treatment, etc).

Thanks for reply. I too believe in high quality work and can't imagine doing 15-20 min apps. I absolutely love psychotherapy thus far (although I admit that i'm just a resident and obviously have a lot to learn). you said you weren't super aggressive about advertising. why is that? were you concerned about the image that might create? How much do you charge (obviously you don't have to answer that if not comfortable). you also mentioned doing contract work....I see that term a lot and it has raised some confusion. could you explain that a little more as you said you did contract 1/2 time for a period.

 

[dl2dp2]

how slow do you think cash practices fill? Only reason i ask is it seems so expensive to be in network with 50K in office costs, etc. And sorry for my slowness (how did you get the 200 and 260 figures)? i get the other figures.

any thoughts on group practices? i imagine it is tough to join any of those unless you have a connection.

I have one group practice hiring contact that quotes me a $125 per hour all inclusive excepting malpractice. This again roughly translates to 200k. Not sure what their partnership track is like, but I explored it and believe that I can make a lot more in solo practice per hour if i only have a part time practice.

400k*0.8-80k overhead = 240k

The timing for filling cash practice depends on a LOT of things, and I do think credentialism is alive and well in expensive markets, though the exact size of that effect is difficult to quantify. Some people may never fill 100% cash. Some people may fill under 6 months. It's just very hard to say. I'd say if you take insurance you should fill within 6 months.

I go to a "top" program but don't live in NYC. I'm familiar with NYC, DC, Boston, SF and LA, and the quotes are roughly similar with prime Manhattan being slightly higher than everywhere else, but not much higher (at most 3-5%, maybe 10%?) than say Georgetown or Pacific Heights. Chicago is lower, but still doable. Nitemagi, you are right it's hard to charge $400 for 45min therapy, but I don't think it's rare for people in wealthier parts of LA to charge $200 for 99213+90833. I've heard it and seen it. Two of those you get $400 right there. Houston is also a great market for this kind of setup.

A different way to think about it is if you have decent out-of-network coverage, say BCBS, deductible is ~$2000 a year, unlimited visits, 80% coverage for "usual-and-customary" can get you $250. For once weekly therapy, you MAX out at 2k a year as a patient. A LOT of angsty young professionals are willing to do this kind of thing. A lot of them also need meds.

Vistaril, you should move. You are right it's hard to charge $600, but senior people do it routinely. It's really a different world out there. On the other hand, you can probably get two beautiful houses around where you live with a 200k salary. The other thing is to consider certain "under-exposed" wealthy areas which I think have huge potentials. Texas, as I said being one. San Diego I think is another. I bet you can do really really well working cash in La Jolla.

 

[vistaril]

. I've heard it and seen it. Two of those you get $400 right there. Houston is also a great market for this kind of setup.
A different way to think about it is if you have decent out-of-network coverage, say BCBS, deductible is ~$2000 a year, unlimited visits, 80% coverage for "usual-and-customary" can get you $250. For once weekly therapy, you MAX out at 2k a year as a patient. A LOT of angsty young professionals are willing to do this kind of thing. A lot of them also need meds.

Vistaril, you should move. You are right it's hard to charge $600, but senior people do it routinely. It's really a different world out there. On the other hand, you can probably get two beautiful houses around where you live with a 200k salary.

where are these insurance plans that allow pts to run up 5 figure+ reimbursements for outpt weekly mental health care? I can't get insurances to pay an extra 20 bucks for Adderall xr instead of ir(or whatever the difference is)....and these are patients with 'good' insurance(professionals, many of whom work for the govt and large hospital systems).

And no, you can't get two 'beautiful houses' around where I live on that salary. The nice neighborhoods here aren't super cheap.....you're looking at 350-400 sq/ft in the neighborhoods people want to be. Looking at average housing prices in some areas is very misleading for a number of reasons. So do the math on two 2500 sq ft houses....not happening on that salary.

 

[outptpsych]

I have one group practice hiring contact that quotes me a $125 per hour all inclusive excepting malpractice. This again roughly translates to 200k. Not sure what their partnership track is like, but I explored it and believe that I can make a lot more in solo practice per hour if i only have a part time practice.

400k*0.8-80k overhead = 240k

The timing for filling cash practice depends on a LOT of things, and I do think credentialism is alive and well in expensive markets, though the exact size of that effect is difficult to quantify. Some people may never fill 100% cash. Some people may fill under 6 months. It's just very hard to say. I'd say if you take insurance you should fill within 6 months.

I go to a "top" program but don't live in NYC. I'm familiar with NYC, DC, Boston, SF and LA, and the quotes are roughly similar with prime Manhattan being slightly higher than everywhere else, but not much higher (at most 3-5%, maybe 10%?) than say Georgetown or Pacific Heights. Chicago is lower, but still doable. Nitemagi, you are right it's hard to charge $400 for 45min therapy, but I don't think it's rare for people in wealthier parts of LA to charge $200 for 99213+90833. I've heard it and seen it. Two of those you get $400 right there. Houston is also a great market for this kind of setup.

A different way to think about it is if you have decent out-of-network coverage, say BCBS, deductible is ~$2000 a year, unlimited visits, 80% coverage for "usual-and-customary" can get you $250. For once weekly therapy, you MAX out at 2k a year as a patient. A LOT of angsty young professionals are willing to do this kind of thing. A lot of them also need meds.

Vistaril, you should move. You are right it's hard to charge $600, but senior people do it routinely. It's really a different world out there. On the other hand, you can probably get two beautiful houses around where you live with a 200k salary. The other thing is to consider certain "under-exposed" wealthy areas which I think have huge potentials. Texas, as I said being one. San Diego I think is another. I bet you can do really really well working cash in La Jolla.

so for folks with many BCBS plans they only have a deductable of 2000 a year with an out of network psychiatrist? that sounds like a pretty good deal if you are getting weekly therapy.

 

[vistaril]

so for folks with many BCBS plans they only have a deductable of 2000 a year with an out of network psychiatrist? that sounds like a pretty good deal if you are getting weekly therapy.

why stop at weekly therapy at several hundred an hour though? If the insurance company is going to reimburse 17k or whatever for the worried well to get therapy from a psych weekly, why not 20k? 22k? 25k? Heck, why not therapy twice a day?? I'm sure blue cross wouldn't have a problem with that...

 

[whopper]

I've worked in private practice and had extremely wealthy patients. Just to give you an idea of a few: a hedge fund manager that brought in dozens of millions a year, a corporate officer of a name-brand corporation, someone that owned a medical equipment manufacturing company....

Wealthy patients can bring in a conundrum of headaches. Often times they want more than what you're allowed or can realistically give without violating boundaries. I've seen some psychiatrists service wealthy patients and lived in fear that if there was a bad outcome, the family would use every dollar they had to destroy that psychiatrist.

Just to give an example, a patient with an eating disorder saw a colleague of mine. The father, that demanded to sit in the interview and was showing some rather over-controlling tendencies was enraged when my colleague told him there really aren't any good meds for anorexia, and he blew up in anger, making statements like,"what is this about? How much money do I have to give you to get you to fix my daughter!?!?!, Do you know who I am!?!?!?"

My friend thought to himself that this was exactly the type of behavior he'd expect from a father whose daughter had anorexia.

Another colleague of mine had a patient who's father is a corporate officer of the highest caliber and did major work in globalization. The patient almost killed himself. He talked to me for over an hour fearing that his father would use all of his money and power to possibly destroy his career, and that he spent a lot more time than he would vs with other patient's families to make sure they felt that he did everything he could have (that I thought was questionable on an ethical level).

 

[nitemagi]

A general rule of thumb is give yourself 5 years to fill a cash-only practice.

 

[dl2dp2]

so for folks with many BCBS plans they only have a deductable of 2000 a year with an out of network psychiatrist? that sounds like a pretty good deal if you are getting weekly therapy.

I've worked in private practice and had extremely wealthy patients. Just to give you an idea of a few: a hedge fund manager that brought in dozens of millions a year, a corporate officer of a name-brand corporation, someone that owned a medical equipment manufacturing company....

Whopper, I agree with you that the extremely wealthy and celebrities can be quite a handful. However, they are NOT the mainstay of a cash practice. Most clients of a cash practice are working professionals who have good insurance. Let's say they make between 80-100k a year. Suppose you see them once a month for med management for $200. That's $2400 a year. They are willing/able to pay that to ensure that their mental health stays on track, even out of pocket. Sometimes they pay less because there's some amount of insurance coverage. A course of CBT without insurance would cost around $5000. It's expensive, but you don't need to be a hedge fund manager to be able to afford that.

This hopefully also answers vis' question as to why insurance is willing to pay that much for therapy. Let's say someone doing weekly therapy at a lowish rate of $250 per hour. The insurance pays 80%, about 9k. The patient pays 2k, which hits his deductible limit. The patient is very willing to do this, but the insurance is willing too because (1) out of that 9k, another ?2k is covered by increased premium from switching to a PPO plan. (2) if this prevents a hospitalization then it's very much worth it because 1 day of hospital stay is at least 2k. There's no obvious reason out-of-network benefits would cost more for insurance companies. It simply creates a mechanism for balance billing. Suppose Medicare provides a mechanism for this, and reimburses the patient $150 per 45 min, whereas you charge $250. A lot of people are willing to pay $100 per session out of pocket. It doesn't cost Medicare one cent more.

Finally, as to why people don't just do 3x per week therapy... First of all, it becomes unaffordable as per session cost ramps up. Secondly there's a huge opportunity cost for a working professional to see a therapist 3x/week. People can do it, but they don't usually enjoy it or get any benefit from it, so that kind of practice stays very small.

 

[outptpsych]

for folks who feel comfortable sharing, what are your average salaries per year for private practice work? Also are you in private or group practices? Are you accepting insurance or out of network? How busy are your clinics? What kind of pts are you seeing?

 

[nitemagi]

Whopper, I agree with you that the extremely wealthy and celebrities can be quite a handful. However, they are NOT the mainstay of a cash practice. Most clients of a cash practice are working professionals who have good insurance. Let's say they make between 80-100k a year. Suppose you see them once a month for med management for $200. That's $2400 a year. They are willing/able to pay that to ensure that their mental health stays on track, even out of pocket. Sometimes they pay less because there's some amount of insurance coverage. A course of CBT without insurance would cost around $5000. It's expensive, but you don't need to be a hedge fund manager to be able to afford that.

This hopefully also answers vis' question as to why insurance is willing to pay that much for therapy. Let's say someone doing weekly therapy at a lowish rate of $250 per hour. The insurance pays 80%, about 9k. The patient pays 2k, which hits his deductible limit. The patient is very willing to do this, but the insurance is willing too because (1) out of that 9k, another ?2k is covered by increased premium from switching to a PPO plan. (2) if this prevents a hospitalization then it's very much worth it because 1 day of hospital stay is at least 2k. There's no obvious reason out-of-network benefits would cost more for insurance companies. It simply creates a mechanism for balance billing. Suppose Medicare provides a mechanism for this, and reimburses the patient $150 per 45 min, whereas you charge $250. A lot of people are willing to pay $100 per session out of pocket. It doesn't cost Medicare one cent more.

Finally, as to why people don't just do 3x per week therapy... First of all, it becomes unaffordable as per session cost ramps up. Secondly there's a huge opportunity cost for a working professional to see a therapist 3x/week. People can do it, but they don't usually enjoy it or get any benefit from it, so that kind of practice stays very small.

I would disagree with some of this. While I agree that that's a practice model that many choose, it is not the only practice model.

The keys (like any business) are understanding the needs out there, and offering something others aren't. That might be availability, high quality med mgmt, meds plus good type of therapy, multiple kinds of therapy, specializing in something others don't. It varies on the market and on you as a provider.

Therapy is a heterogeneous area. What you are exposed to in residency is not the only therapy. Many people enjoy AND benefit from therapy more than once a week for an hour. ISTDP therapists can do 3-hour sessions, for example. Some ppl choose to still get this therapy from a psychiatrist because they want someone GOOD (and are willing to pay for it), they don't want to split up providers, and/or they know they want meds and therapy. Sometimes you'll have patients that really have difficulty trusting anyone, so having one person who does it all is a benefit. Plus even in a saturated market, there are a lot of mediocre therapists and psychiatrists out there, and thus an unmet need. If you give a higher quality product that people want, then you can charge more for it.

Rates do have to be adjusted to what the market can sustain.

 

[whopper]

I don't think there's any real disagreement. Any practice is going to have a variable group of patients. Despite what I've written, I had several wealthy patients that were extremely cooperative and pleasant patients.

I wrote my post to show that some, repeat some, wealthy patients can bring in a specific dynamic of problems not typical with non-wealthy patients. One thing I did not mention is don't specifically see wealthy patients as a means to wealth for yourself. Any field of work in this field will bring you money more or less depending on how you play it.

 

[nitemagi]

I agree with you Whopper. My experience is that wealthy patients generally have the same problems as non-wealthy. It's just that money isn't one of them. Now there can be a level of entitlement or enabling from others that perpetuate a problem. Since they have money, people give them more room to become dysfunctional before intervening. On the other hand in my side work with the homeless I see similar behavior (akin to personality rigidity), but they've burnt through their resources by that point.

People are people, people.

 

[outptpsych]

This depends on how interested you are in getting involved with insurance panels. In my limited experience they are a headache and you end up eating a lot time as unbillable trying to get paid for past billed services.

I know very few psychiatrists, even here in LA, that charge more than $400 an hour if doing therapy. In fact some of the most elite are only in the 3-400 range. Maybe NYC is different. More commonly is if you're doing med only visits then people charge $200 for a visit and then do 15-20 minute visits. I prefer to not do that, and have no appointments less than 30 minutes. I therefore make less per hour, but I do good therapy and frankly a lot of my patients get better (and even "graduate" out of treatment).

The referral network is absolutely key. If you do good work, the goal is that your patients refer to you (that becomes your referral network).

Right out of residency I took a job with the county 4 days a week, and started my PP one day a week. I had bills to pay and had to support my family. I built from there. Later I switched to contract work that paid a better hourly, was only 1/2 time, and allowed me the flexibility to grow my practice. My PP has slowly grown, even though I'm not super-aggressive about networking/advertising. I believe in doing high quality work, if at all possible. And that means (to me) [trying to ] be a great therapist AND a great psychopharmacologist. Being great at both is a work in progress, and I continue to read and even do workshop trainings to improve my skill set/knowledge base, years after finishing at a top-notch residency where I got A LOT of therapy training. You're never "done." That's my practice model.

Even then there are limitations (not everyone can afford to come in, not everyone is ready for treatment, etc).

What kind of work did you do for 4 days a week? I think doing something part-time while letting a practice fill is a good idea. I'm trying to think of ideas what to do part-time until my practice would be more full. what kind of part-time psych jobs do you know of in psychiatry?

 

[@JackShephard]

.

 

[nitemagi]

What kind of work did you do for 4 days a week? I think doing something part-time while letting a practice fill is a good idea. I'm trying to think of ideas what to do part-time until my practice would be more full. what kind of part-time psych jobs do you know of in psychiatry?

I worked for the county in a mental health urgent care clinic.

Contract work refers to any work where you are an independent contractor, rather than an employee.

 

[outptpsych]

hey everybody, thanks for all the help! was wondering if anybody else had ideas on part-time work that could be done while setting up private practice and waiting for it to fill. let me know your thoughts. thanks.

 

[clusterF]

Hi,

So I took a job out of residency at a county part time while trying to build a cash practice. This isn't going so well. Mostly because everyone wants to use insurance. I have now tried to get on insurance plans and almost everyone wants me to be on staff at a hospital. Although I am staff at the county hospital, that doesn't count because they don't take private insurance.
I have medicare but there really isn't a lot of medicare. There is tons of tricare but that is also difficult because they are being managed by united.

Any ideas? Or do i just call a local hospital and try to get privileges?

Thanks for your help.
Wish I had just taken that job with Kaiser.

 

[nitemagi]

Without knowing your particular location and the availability of other providers, make sure to emphasize that you give superbills, and have them check with their insurance to find out how much they can get reimbursed for out-of-network providers.

 

[outptpsych]

Hi,

So I took a job out of residency at a county part time while trying to build a cash practice. This isn't going so well. Mostly because everyone wants to use insurance. I have now tried to get on insurance plans and almost everyone wants me to be on staff at a hospital. Although I am staff at the county hospital, that doesn't count because they don't take private insurance.
I have medicare but there really isn't a lot of medicare. There is tons of tricare but that is also difficult because they are being managed by united.

Any ideas? Or do i just call a local hospital and try to get privileges?

Thanks for your help.
Wish I had just taken that job with Kaiser.

so was nobody willing to be out of network with you for your practice?

 

[nitemagi]

hey everybody, thanks for all the help! was wondering if anybody else had ideas on part-time work that could be done while setting up private practice and waiting for it to fill. let me know your thoughts. thanks.

The more you're in an area and network, the more you will hear about PT work.
Some low hanging fruit include: Locum tenens work locally, PT work with county, hospitals looking to hire PT such as to cover C/L, local non-profits that need some psychiatric coverage, Kaiser (depending on your area), local ER/psych ER shifts.

 

[outptpsych]

The more you're in an area and network, the more you will hear about PT work.
Some low hanging fruit include: Locum tenens work locally, PT work with county, hospitals looking to hire PT such as to cover C/L, local non-profits that need some psychiatric coverage, Kaiser (depending on your area), local ER/psych ER shifts.

thanks nitemagi, that was helpful!

 

[HealthHare]

Hi,

So I took a job out of residency at a county part time while trying to build a cash practice. This isn't going so well. Mostly because everyone wants to use insurance. I have now tried to get on insurance plans and almost everyone wants me to be on staff at a hospital. Although I am staff at the county hospital, that doesn't count because they don't take private insurance.
I have medicare but there really isn't a lot of medicare. There is tons of tricare but that is also difficult because they are being managed by united.

Any ideas? Or do i just call a local hospital and try to get privileges?

Thanks for your help.
Wish I had just taken that job with Kaiser.

Are you in a rural area?

 

[vistaril]

Hi,

So I took a job out of residency at a county part time while trying to build a cash practice. This isn't going so well. Mostly because everyone wants to use insurance.

what? are you serious?!

 

[vistaril]

The more you're in an area and network, the more you will hear about PT work.
Some low hanging fruit include: Locum tenens work locally, PT work with county, hospitals looking to hire PT such as to cover C/L, local non-profits that need some psychiatric coverage, Kaiser (depending on your area), local ER/psych ER shifts.

the problem is that a lot of this work tends to be garbage work. It's low hanging fruit for a reason after all......

 

[clusterF]

Without knowing your particular location and the availability of other providers, make sure to emphasize that you give superbills, and have them check with their insurance to find out how much they can get reimbursed for out-of-network providers.

I have had a few patients push back and say they want me to find out and I have NO IDEA how to do that. What is the difficulty range on this? Maybe I need to be more aggressive. Are you not on insurance plans at all?

I am in california. Not at all rural. I don't mind the county work, it's pretty easy and I like the other psychiatrists. I don't like the pay, the fixed hours, pure med management etc. I want to do psychiatry the way we are taught in residency before it is beaten out of me by THEM.

 

[clusterF]

so was nobody willing to be out of network with you for your practice?

Well all my cash patients are out of network but most want to me to take insurance.

 

[Shikima]

I have had a few patients push back and say they want me to find out and I have NO IDEA how to do that. What is the difficulty range on this? Maybe I need to be more aggressive. Are you not on insurance plans at all?

I am in california. Not at all rural. I don't mind the county work, it's pretty easy and I like the other psychiatrists. I don't like the pay, the fixed hours, pure med management etc. I want to do psychiatry the way we are taught in residency before it is beaten out of me by THEM.

Is it clearly printed and given to them the expectations of the clinic - fee schedule, payment at the time of service, commitment to therapy, etc and have them sign the agreement? If they are pushing, it could be they're not wanting to file the paperwork with their ins company and wanting you to do the leg work for them.

I was just thinking too, could your current fee schedule be scaring off potential clients for your practice?

 

[dl2dp2]

Hi,

So I took a job out of residency at a county part time while trying to build a cash practice. This isn't going so well. Mostly because everyone wants to use insurance. I have now tried to get on insurance plans and almost everyone wants me to be on staff at a hospital. Although I am staff at the county hospital, that doesn't count because they don't take private insurance.
I have medicare but there really isn't a lot of medicare. There is tons of tricare but that is also difficult because they are being managed by united.

Any ideas? Or do i just call a local hospital and try to get privileges?

Thanks for your help.
Wish I had just taken that job with Kaiser.

ClusterF, it sounds like you are located in an area with a lot of US Uniformed Service Members. Private out-of-network is very unusual for this population. This is why you are having difficulties. I would suggest that you call Tricare to see if they have out-of-network benefits at all, which I suspect they don't.

In this case, depending on your geographical flexibility, I would start by signing up for insurance panels. Generally speaking, the pay rate for insurance is ~50%-70% of private rates, but they fill much faster. See my previous calculator for reference.

Pure cash practice takes a long time to build in most parts of the country. Like I said, your best bet is the wealthy suburbs with >100k median household salary. Generally speaking what you do with with insurance panels is (1) join a group so they can help with the administrative details. (2) limit a proportion of low paying insurance patients.

It sounds like you are having administrative difficulties to sign up for a panel without hospital privileges. This seems unusual and likely is a tactic used by large organizations to try to absorb you. While in principle it's not necessarily a bad thing to be an affiliated practice, in practice your milage varies and you likely will need to negotiate and work out details with whoever is in charge on an individual basis.

This seems complicated and it is, but I would not give up so quickly because IMHO it's not at all pie in the sky. Once everything is set up you will enjoy it. I'm working on this myself as well. I think it might be really helpful to talk it out with a senior colleague if you can find one. It was very helpful in my case. Again, the average solo practice should generate around 200k right now in pure take home salary across the country, with a reasonable low number of working hours.

 

[clusterF]

Even with medicare, I get reimbursed fairly well. It is close to 250 per hour and much more if I combine a 99214 with a 90833. You are right I do live near a base. However Tricare is now with UBH and they want hospital affiliation. I would never actually go to the hospital and round on my patients but it makes it a lot harder to get credentialed.