Private practice attending ready to answer questions

[doctor4ever]

I've been on this forum since I was a med student. I see a lot of questions about money and private practice and I'm finally ready to start answering questions and yes you can make over 400K in psychiatry doing what you love without selling yourself to drug companies. I've been in practice for five years and I can confidently say I know how the field works. I decided to start this discussion because I have residents that ask me questions that I wish my advisors could have answered. I work in academia (with great benefits) and have a part time private practice.

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[PistolPete]

Do you believe that Child and Adolescent fellowship is the best way to establish a cash-pay private practice? What have you seen done?

Is it possible to do CL in the AM and private practice in the afternoons, without call?

 

[Suspencer83]

Is it true that it's actually that easy to match into psychiatry?

Also, this is a bit of a dumb question, but how does internship work? Do you match into an internal medicine internship, or a psychiatric internship and move onto residency?

 

[JourneyAgent]

Is it true that it's actually that easy to match into psychiatry?

Also, this is a bit of a dumb question, but how does internship work? Do you match into an internal medicine internship, or a psychiatric internship and move onto residency?

http://www.nrmp.org/data/resultsanddata2013.pdf

That's the match data to tell you odds and so forth. Psychiatry programs are 4 years and include the intern year in a single match.

Psych is an easier match along with family.

I think the OP was intending to field questions about private practice and things that s/he would've liked to know before entering professional independent practice.

 

[Armadillos]

I've been on this forum since I was a med student. I see a lot of questions about money and private practice and I'm finally ready to start answering questions and yes you can make over 400K in psychiatry doing what you love without selling yourself to drug companies. I've been in practice for five years and I can confidently say I know how the field works. I decided to start this discussion because I have residents that ask me questions that I wish my advisors could have answered. I work in academia (with great benefits) and have a part time private practice.

Do you feel like private practice psychiatry can easily become overly routine from an intellectual standpoint? I know this happens in all jobs eventually, but curious how you think it compares to other types of psych practice and other specialties in general?

 

[GreenGeek]

Do you believe that Child and Adolescent fellowship is the best way to establish a cash-pay private practice? What have you seen done?

Is it possible to do CL in the AM and private practice in the afternoons, without call?

Is there a location/region (Midwest, TX, NE) that is preferable to pull off cash-pay?
Is cash pay that easy to set up? Where do you even start a patient base from?
Do you absolutely need a fellowship to get into Child or CL?

 

[Psychobabbling]

1) Would you incorporate yourself or try to LLC your name?
2) Suboxone - would it be worth it to do a day or two a week (or 1/2 days)? Seems to be a big, easy $$$ maker
3) I'm not sure what the technical name for this is, but would you do cash for services, and have the patients set up reimbursement on their own?
4) any experience helping famous/wealthy people who want house calls?
5) "weekend warrior" or Psyc ER shifts - how much, if any, do you do in your routine?
6) Do you work for a group or solo? Either way, do you have a social worker and/or psychologist you refer patients to or who might happen to work at your site?
7) how much, if any, does any of this (advice) change for future child psychiatrists?
8) how do you recommend finding a good lawyer, for any reason?
9) any experience with Tele Psyc?
Might think of some more, wrote a few up before I go sleep

 

[tobi44]

Do you think its worth it to do a fellowship in geriatric psychiatry? Also, what have you heard about the field regarding shortages, pay, opportunities or anything else you've heard. Thanks!

 

[michaelrack]

Great questions! Interested in hearing doctor4ever's responses.

 

[doctor4ever]

Great questions thus far. Before I start answering specific questions let me tell you how I started my practice. I didn't do a fellowship because it didn't want to spend more time in training and in my opinion it's far better to go and get a job doing geri psych/CL/substance abuse and earning an attending salary for a year. A doc that's worked as a CL attending for a year has way more overall knowledge about the field than a person just graduating from a fellowship. Child is a different story. I don't know much about forensics though. If you really know you want to make a career out of practicing in a subspecialty, a fellowship may be a good option or if you need an additional year to build confidence.

After graduating I took a job at an academic center with benefits and I started moonlighting at a couple of places. I did quite a bit of moonlighting during residency too. This taught me to be able to think on my own and make difficult decisions, but keeping in mind I could call a colleague to talk over a tough case (something I still do on a regular basis). I did this for 2.5 years and was earning around 275K.
I then opened a part-time private practice (evenings and Sat, 12-15 hours per week) while still keeping my full-time job. It's almost impossible to find a board certified psychiatrist that has evening and weekend hours. I made the decision to not accept any insurance and it took about 1-1.5 years to be consistently full. The good thing was that if I didn't have many patients on a given evening I would just go home. A lot of psychiatrists in my area do not take any insurance. The one's that do have multiple NPs and see many patients per day (i.e. "I never saw the psychiatrist for more than 5 min.") I reserve one hour for a new eval and 30 min for follow-ups. I am the only person in my office (it's a suite located in an office building). Low overhead is the key and when you're self-employed many more expenses can be deducted than if just a salaried employee (e.g. books, computers, mileage, DEA, medical license). You can also start a SEP-IRA (great way to save for retirement and reduce tax burden). This year I raised my fees and there hasn't been much change in demand. Patients will pay to get better care. Most of my private practice patients are middle to upper-middle class. I also have a fair number of patients eligible to receive meds through patient assistance programs. If they are saving $100-500 per month in medications they are more than happy to pay the office visit fees. Some docs don't want to fill out the paperwork or simply don't know about the programs. At this point I work 55 hours per week.

I should have mentioned this earlier but you really have to love what you do and the environment you work in. You also have to have a genuine interest in helping patients with psychiatric illness and keeping up with current data. Patients and their families can tell right away when a doc appears disinterested or hurried.

 

[Still Kickin]

I second the question about incorporating, becoming an LLC, etc. I'm sure something along these lines is a good idea. Is it also a legal requirement?

Any hints about selecting malpractice insurance? (Any companies you'd recommend?)

I assume you have to purchase your own (individual policy) health insurance? Any hints or pitfalls to be aware of there?

Since you mention being the only person in your office, I'm wondering whether you have any thoughts on:
-Security Issues. (Esp with new patients who are a complete "unknown" - or does this tend to be less of an issue with people who can afford to pay out of pocket?)
(Also *especially* wondering about your thoughts on this during the time you were moonlighting evenings & weekends - it seems like those are times when security issues might potentially be an even greater concern...)
-What do you do about cross-coverage (when you're on vacation, etc.)

Do you have any kind of screening / referral process before you take on a new patient? Or do you take all comers?

Do you provide you patients with a "superbill" that they can then submit to their insurance? If so - do insurance co's ever come back & demand to see your note or some other evidence that you coded for the appropriate level of service? I assume payment is due from them at the time of service? How did you initially go about deciding how much you'd charge for visits? Have you had any "price increases" over time, and if so, how did you communicate that to patients?

What about things like devising "CYA" policies - ie, do you have new patients sign any sort of "consent to treatment," description of your practice's policies, etc. - ?? (Do you have any sort of explicit understanding / agreement about things like missed appointments, what to do in case of emergency, how quickly calls will be returned, etc.). If a patient needs you to fill out special forms for them, or something like that, do you bill by the hour for that extra time spent? What about if their insurance requires pre-authorization for a certain medication - do you go to bat for them on that since it's hopefully just a 1 time [or once per year] thing? Or is that more involvement with insurance co's / bureaucracy than you care to deal with? Do patients ever request their records from you, and if so, do you release them? (I know there's a sort of mental-health "exclusion" regarding records - like if you think it would be too damaging for them emotionally to see the stuff.)

If you do 30min appts that clearly gives you a bit of time to actually talk to your patients. Do you conceptualize this time you spend with them as "psychotherapy" and/or adhere to any sort of formal psychotherapeutic approach? Do you have certain patients that you see more often because they are doing psychotherapy with you?

What about records & HIPPAA? (and any other regulations you may need to comply with) I wouldn't even know what constitutes HIPPAA compliant storage of records - where can one go about finding out about these regulations / minimum requirements so that we know we've got standards in place that are adequate so we don't get in trouble with some regulatory agency at some point.

You say you work about 55 hours per week. Is that 55 hours spent with patients (ie - 110 patients / week?) or does that include time outside of patient contact for paperwork, etc. About how many patients do you have in your practice & is there a "typical" frequency with which you see them. (ie - just telling us the number of patients in your practice doesn't necessarily mean so much to me as both a patient who was seen q 6 months and a patient who was seen weekly would each still just count as "1 patient".)

Basically, I have these types of logistical questions because I've been giving a lot of thought to doing something similar to what you described having done initially - ie, hang out my shingle to "moonlight," not take insurance, not have additional staff, etc. I have no idea how to go about that in terms of practical matters and making sure I'm doing everything in compliance with any applicable regulations. You don't necessarily have to provide specific answers if you know of a website you could direct me to.

Any hints about finding office space while one is still at the ~15 hours per week "moonlighting" phase of this plan?

Also, I echo the question about wondering if things start to feel "routine" and not so intellectually stimulating with this patient population after awhile - ???

 

[vistaril]

What about if their insurance requires pre-authorization for a certain medication - do you go to bat for them on that since it's hopefully just a 1 time [or once per year] thing? Or is that more involvement with insurance co's / bureaucracy than you care to deal with?

think about this question.....if a patient is paying out of pocket straight cash to see you and you write them a medication that requires a PA, how in the heck are you going to avoid doing the PA yourself(or having someone from your office do it which means more overhead)....you can't tell the patient "oh, a PA? Well I don't do those. I know I wrote the prescription for you and your paying me cash but it's not my responsibility to help you get it filled as well".......I mean I guess you could say that, but I think it would be disastrous from a business perspective. And the pt can't do the PA themselves....they need you to do it. As for how frequently PA's are...they may be only once a year, but for many every dose change within the year requires a PA as well.

Now there are certain things that offices do charge for(especially if they are taking insurance and they are things you can't bill to insurance)....PA's may even be one of them under this model, but it's more likely to be stuff like sending out records request, filling out work leave papers, etc.....

 

[michaelrack]

think about this question.....if a patient is paying out of pocket straight cash to see you and you write them a medication that requires a PA, how in the heck are you going to avoid doing the PA yourself(or having someone from your office do it which means more overhead)....you can't tell the patient "oh, a PA? Well I don't do those. I know I wrote the prescription for you and your paying me cash but it's not my responsibility to help you get it filled as well".......I mean I guess you could say that, but I think it would be disastrous from a business perspective. And the pt can't do the PA themselves....they need you to do it. As for how frequently PA's are...they may be only once a year, but for many every dose change within the year requires a PA as well.

Now there are certain things that offices do charge for(especially if they are taking insurance and they are things you can't bill to insurance)....PA's may even be one of them under this model, but it's more likely to be stuff like sending out records request, filling out work leave papers, etc.....

If I was doing psychiatry on a cash basis, I would charge extra for the PA or do it as part of an office visit (which would reduce the time available for other things during that office visit)

 

[vistaril]

If I was doing psychiatry on a cash basis, I would charge extra for the PA or do it as part of an office visit (which would reduce the time available for other things during that office visit)

the problem is though is that the psychiatrist is (presumably) picking the medication. It just seems sorta ridiculous for the psychiatrist to choose a prescription medication for the patient that will come with patient fees being paid to the psychiatrist that cost above and beyond the office visit.

 

[doctor4ever]

I'm sorry I haven't been able to answer questions quickly. My clinic policy is to charge $15 for prior authorizations, $25 for written correspondence to work or schools (except for excuses for illness or clinic appointments), and 50% of the office visit fee for no shows. I give pts a credit card authorization form to put on file and that has been a great way to minimize no shows. I rarely charge for prior auths or letters because I can do them during clinic visits.

I'm still deciding about whether I should be a PLLC or a C/S corp. I'm still a sole proprietor.

 

[doctor4ever]

I don't want this to be an ad hominem attack but is Vistaril an attending?

I think Still Kickin has asked some very thoughtful questions. There is no reason to mock or ridicule a fellow psychiatrist just for asking a question. This post is intended to answer questions not make fun of others. When I was in training I asked many questions that my attendings could have laughed at but they didn't. They instead encouraged me to look for answers.

 

[vistaril]

I don't want this to be an ad hominem attack but is Vistaril an attending?

I think Still Kickin has asked some very thoughtful questions. There is no reason to mock or ridicule a fellow psychiatrist just for asking a question. QUOTE]

dude, if you think my response was mocking or ridiculing, you've got to gain a real appreciate for that term. Maybe watch an episode of tosh.0 or whatever that show is called. He's annoying and gets old after about 5 minutes, but then you will at least know what real mocking/ridiculing is.

I just think the concept of the prescriber charging extra for a PA(especially in cases where the pt doesn't request that specific drug) is problematic in terms of therapeutic alliance. It would be very easy for a pt to think that is a reason the psych chose that drug. It's not like PA's just come up completely unexpectedly and out of the blue. Anyone paying attention knows the drugs that typically require a PA and which don't.

All the other stuff(forms and such) I completely agree with.

 

[digitlnoize]

I don't want this to be an ad hominem attack but is Vistaril an attending?

I think Still Kickin has asked some very thoughtful questions. There is no reason to mock or ridicule a fellow psychiatrist just for asking a question. QUOTE]

dude, if you think my response was mocking or ridiculing, you've got to gain a real appreciate for that term. Maybe watch an episode of tosh.0 or whatever that show is called. He's annoying and gets old after about 5 minutes, but then you will at least know what real mocking/ridiculing is.

I just think the concept of the prescriber charging extra for a PA(especially in cases where the pt doesn't request that specific drug) is problematic in terms of therapeutic alliance. It would be very easy for a pt to think that is a reason the psych chose that drug. It's not like PA's just come up completely unexpectedly and out of the blue. Anyone paying attention knows the drugs that typically require a PA and which don't.

All the other stuff(forms and such) I completely agree with.

We can't be expected to know what drugs require PA on every insurance formulary. Especially if you don't take insurance. If its explained ahead of time that this can sometimes happen, and that the psychiatrist, since they don't take insurance, is not aware of every insurance panels formulary, I don't see why it'd be a problem for most patients.

 

[michaelrack]

We can't be expected to know what drugs require PA on every insurance formulary. Especially if you don't take insurance. If its explained ahead of time that this can sometimes happen, and that the psychiatrist, since they don't take insurance, is not aware of every insurance panels formulary, I don't see why it'd be a problem for most patients.

This sounds reasonable, along with the policy of doctor4ever- do it during a clinic visit or otherwise charge a small fee.

 

[LimbicResponse]

What area of the country are you in? Did you move to that area purposely? How does one pick a location to set up shop ?

 

[Armadillos]

Do you feel like private practice psychiatry can easily become overly routine from an intellectual standpoint? I know this happens in all jobs eventually, but curious how you think it compares to other types of psych practice and other specialties in general?

sorry to post twice, but any thoughts about this aspect of your private vs academic practice?

 

[doctor4ever]

I ended coming back to the area I grew up in to he close to family. I'm not sure it's a good idea to move to a place just because you think there may be more potential income. If you have a choice I would pick a state with no income tax.

Does private practice get boring or routine? I haven't found that to be the case thus far. A good thing about psychiatry is that you can work in multiple locations. Being affiliated with an academic center is important to me because I have access to more educational opportunities and teaching.

 

[vistaril]

We can't be expected to know what drugs require PA on every insurance formulary. Especially if you don't take insurance. QUOTE]

the two aren't really connected. Anyways, I bet if you paid a little bit of attention you would catch on very soon as to what requires a PA and what doesn't. It's not like we write for 100 different drugs, and it's also pretty similar across insurance companies.

 

[medicaresucks]

First thanks for taking the time to come and answer questions here so I'll be brief in mine.

1. Once in private practice does having a fellowship give any difference in income potential aside from maybe having done one in pain? If one wanted a variety in oupt private practice seeing Addiction (suboxone/methodone), geriatric, and even seeing kids 15yo+ this can be done with just a regular adult 4 year fellowship?

2. 400k is possible gross salary or after overhead? Seeing 20 pts 4 days a week and 46 out of 52 weeks in the year and billing each one 99213+psychotherapy add on gives 110 a pt at medicare rates. Should give 400k not even accounting for new pt billing codes and some 99214 visits and not to mention any work you do outside your clinic ex: hospital inpt, calls, jails, etc..

 

[strangeglove]

I always do PA's for free as a courtesy, since I include such costs into the setting of my fees. My fee is high enough that the $15 dollars or whatever I would be charging my patients for a PA would not really add significantly to my income and only add to feelings that my patients would have about me that I would rather avoid. For example, such fees could be seen as some form of deterrent to take a medication. Also, they could foster a view of the doctor as someone who is interested in money above patients' wellbeing. I'm not saying this is my view, but that many patients, especially those who are more narcissistically vulnerable, may have these views of you already, and if you charge them such fees, you will only confirm them. Of course, if you are doing psychodynamic psychotherapy, then this would all be "grist for the mill." However, I am doubtful that many psychiatrists who charge such fees are actually exploring their patients' feelings about them for a therapeutic purpose. Paperwork like disability, etc., I usually do in front of the patient, so that they are aware of what I am writing about them (e.g. "patient expected to regain full function). Same thing for leaving messages on their therapists voicemail, especially for issues that tend to foster splitting. I am using their time for these tasks, but with of a therapeutic purpose.

 

[whopper]

PAs are a pain in the ass. When I did private practice the staff simply handled it for me. We didn't charge for them, but we all came to a mutually agreed decision at that office that if PAs ever were to the degree where it became a full-on battle (e.g. more than 30 minutes of work) to get it approved, we'd likely bill the patient, not the first time, but if it became a chronic issue.

Where I do practice now, the university makes me do PAs that I find incredibly frustrating given that some of the companies make me work for 45 minutes doing it. We don't bill for PAs, so, university, doesn't make sense to me to have a doctor do that for free when you could be paying someone $10-15 an hour to do it, and I could've actually been doing billable work that could've gotten the institution $100, but hey, I've already told them this 100X and they don't seem to care.

Some insurance companies, the PA takes just a few mintues . Others, it's several minutes, maybe even 2-3 hours.

The university I'm at is a big, and unfortunately, often-times slow to respond animal. There's plenty of things they're doing that are cost-ineffective, but because the person I need to talk with to fix it doesn't make more money from doing it, they usually don't care. When I was in private practice, if any of us came up with an idea that could make more money, it was often times acted upon immediately or within a few days unless I thought it would lead to worse care, in which case I'd say screw it. My philosophy is about making money but only based on good care--no cutting corners.

Does private practice get boring or routine? I haven't found that to be the case thus far. A good thing about psychiatry is that you can work in multiple locations. Being affiliated with an academic center is important to me because I have access to more educational opportunities and teaching.

If I did private practice 100% I know I'd lose my passion for it. I enjoy psychiatry the most when I have a variation of things such as outpatient, PES, inpatient, etc. I think some people will differ based on their own preferences. A problem for me is the university I'm at doesn't let you work outside of them when you're with them, and while I am doing well with them, I know I could do better on my own. I know this for a fact because I was making more money before I was with them and if I simply went back to that model, I know it'd be about the same. I also have other ideas that could make me even more than my previous situation. Yet if I leave, I lose the academic connections.

For many of you, you won't have this problem. Several academic institutions let you work outside of them.

 

[Leo Aquarius]

What's a PA?

prior authorization? we're doctors, who's authorization do we need?

 

[loveoforganic2]

What's a PA?

prior authorization? we're doctors, who's authorization do we need?

Justification for the patient's prescription to get it covered under their insurance

 

[michaelrack]

My previous comments regarding PA's were based on the hypothetical context of a cash-based practice- something I have no experience in. In my private insurance-based practice PA's are done free, usually by staff. Of course, my practice is sleep, so it is different from a psychiatry practice. My staff knows how to handle Nuvigil PA, we get the drug rep to help out for xyrem, and I prescribe Flonase for nasal congestion- never had any PA problems with that. I tend to stick to the generic hypnotics (Ambien, Ambien CR, Sonata).
When I do weekend locums inpt psychiatry, although I am not responsible for PA's, I do try to stick to using older 2nd generation neuroleptics so that patients aren't hit for a huge charge after they are discharged.

Any forms (especially regarding driving for truckers ) are typically done as part of an office visit- and this upgrades the complexity and reimbursement for the visit.

Certificates of medical necessity for cpap and cpap supplies are a part of sleep medicine and usually done free outside of visits, as long as the person is an active patient of the practice.

 

[SeniorWrangler]

One additional thought about fellowships: if you think you might be going into academic practice at some point, a fellowship might be necessary for career progression in a particular field -- for example, the chief of the C/L program might need to be fellowship trained. If that's not a consideration, I don't think most fellowships are worth the year out of your life unless they're something that you love, or will let you do something you couldn't do otherwise, like TMS or something.

Exception: if you want to practice in a different town that where you trained and have no connections, a fellowship can help you break in. But that's a lot of money you're giving up.

 

[vistaril]

What's a PA?

prior authorization? we're doctors, who's authorization do we need?

PAs are good for rxs because they end up driving down utilization of certain drugs(and thus driving down costs).....

 

[whopper]

Yep, prior authorization. Often times I actually believe they're justified because it fights the model of docs simply prescribing the med the drug-reps asked them to prescribe, being the more needlessly expensive one.

e.g. Patient has a sleep problem, they'd rather you try Trazodone or Zolpidem first before they approve Lunesta.

But some of these companies make it a darned pain in the ass and that's their game. They hope for you to give up because they re-route your car several times before you get to talk to the wizard who can actually make the authorization happen.

 

[billypilgrim37]

PAs are good for rxs because they end up driving down utilization of certain drugs(and thus driving down costs).....

Agreed, much of the time.

The problem is that the authorization process should only involve a simple exchange of appropriate information, rather than simply wasting time that could be spent doing more valuable things for patients. I think it's great that you can't prescribe Cymbalta until they've failed an SSRI and Effexor. I think it's terrible that when that's the case it still might take 90 minutes on the phone and filling out forms to make it happen.

I work in a subsubspecialty research clinic where there is a high rate of appropriate use of atypicals in kids (if they don't need an atypical, they probably aren't going to stay in this resource intensive clinic). I hate that I now have to get PAs for Abilify when I didn't use to before Seroquel and Zyprexa went off patent (I usually can't get approval now until after they've been on a few other atypicals--and it sucks changing to Abilify AFTER the kid gains 40 pounds when you wanted to switch after they gained 5). I hate that after a 3-4 hour evaluation I still have to argue with someone when I prescribe an atypical to a kid under 12. I'm thrilled that other people can't prescribe these willy nilly, but I have the resources and ability to get information that when I want to put a kid on an atypical, it's the right choice.

If PAs were a simple process where you submitted a few bits of information via a quick webform and could get an answer back within minutes to hours, they would be great all around for both discouraging inappropriate use and for not passing the time-cost on to us.

 

[Mastac741]

I'm a current 3rd year psych resident. I'm hoping to go into private practice. What EMR (if any) did you use?

 

[doctor4ever]

I don't use any EMR. Paper and pen

 

[nitemagi]

I'm a current 3rd year psych resident. I'm hoping to go into private practice. What EMR (if any) did you use?

Practice fusion.

 

[vistaril]

Agreed, much of the time.

The problem is that the authorization process should only involve a simple exchange of appropriate information, rather than simply wasting time that could be spent doing more valuable things for patients. I think it's great that you can't prescribe Cymbalta until they've failed an SSRI and Effexor. I think it's terrible that when that's the case it still might take 90 minutes on the phone and filling out forms to make it happen.

I work in a subsubspecialty research clinic where there is a high rate of appropriate use of atypicals in kids (if they don't need an atypical, they probably aren't going to stay in this resource intensive clinic). I hate that I now have to get PAs for Abilify when I didn't use to before Seroquel and Zyprexa went off patent (I usually can't get approval now until after they've been on a few other atypicals--and it sucks changing to Abilify AFTER the kid gains 40 pounds when you wanted to switch after they gained 5). I hate that after a 3-4 hour evaluation I still have to argue with someone when I prescribe an atypical to a kid under 12. I'm thrilled that other people can't prescribe these willy nilly, but I have the resources and ability to get information that when I want to put a kid on an atypical, it's the right choice.

If PAs were a simple process where you submitted a few bits of information via a quick webform and could get an answer back within minutes to hours, they would be great all around for both discouraging inappropriate use and for not passing the time-cost on to us.

But clearly the process(for most people at least) isn't that difficult, or you wouldn't see....

http://www.businessinsider.com/10-best-selling-blockbuster-drugs-2012-6?op=1

5.2 billion spent in one year on one single antipsychotic? Hell that's like 15+ dollars per year per person in the whole country!! Just on freaking abilify. I wonder in how many of those cases abilify was truly helpful/indicated.....10-15%? Maybe?

We as a psychiatrists waste a ton of money prescribing expensive drugs. Occasionally there is a decent reason to pick such drugs. But far too often(just look at the numbers on any drug company list) money is just wasted for little benefit at all.

 

[strangeglove]

I also use paper and pen. I print out a template basically in a SOAP note format, including a checkbox mental status exam (description of normal finding vs. other and then describe). I've made sure to include all elements that are required for Medicare coding, even though I don't bill Medicare, just in case some insurance company requires notes for out of network reimbursement (this hasn't happened yet). I complete the note while talking to the patient. I spend zero time outside of sessions writing progress notes. EMR is largely worthless if you are cash only, since you are hopefully the only one who will ever read your notes. It is only an extra step and may be a good idea if you have really bad handwriting. I type out things like initial assessment/treatment plan/risk assessments and informed consent discussions. BTW I use iPrescribe for eprescribing. Works very well, and obviates another function of Practice Fusion.

 

[jettavr6]

A patient that I'm treating came in the other day with the forms in hand, already filled out and organized alphabetically. I just copied most of what was correct and changed what wasn't accurate. But the fact that this man tried to help ease my work, was truly heartwarming. I followed up personally with the insurance company to make sure the medications were approved. He needs to have yearly approvals. It's a pain in the ass, but the meds have helped him immensely.

I don't charge for prior authorizations. However, I do charge to fill out private insurance long term disability forms.

 

[billypilgrim37]

But clearly the process(for most people at least) isn't that difficult, or you wouldn't see....

http://www.businessinsider.com/10-best-selling-blockbuster-drugs-2012-6?op=1

5.2 billion spent in one year on one single antipsychotic? Hell that's like 15+ dollars per year per person in the whole country!! Just on freaking abilify. I wonder in how many of those cases abilify was truly helpful/indicated.....10-15%? Maybe?

We as a psychiatrists waste a ton of money prescribing expensive drugs. Occasionally there is a decent reason to pick such drugs. But far too often(just look at the numbers on any drug company list) money is just wasted for little benefit at all.

The PA for Abilify is new for most of the companies around here since zyprexa and seroquel went off patent and cost 20 bucks a month. No PA was needed when they all cost 800 bucks a month. Of course, diabetes is pretty expensive too, but that doesn't fit on the same spreadsheet for the pharmacy benefit.

 

[Mastac741]

Thanks for the reply. I'm still deciding what to do. I'm reluctant to use Practice Fusion as being dependent on a company that may or may not be around in 10 years. They'd let you export your records if they were to shut down, but I'd rather stick with something that I can control.

Another question, were you available 24/7 to your patients? If not, did you have coverage or just a "go to the ER" message on your machine?

 

[whopper]

Another question, were you available 24/7 to your patients? If not, did you have coverage or just a "go to the ER" message on your machine?

This was brought up before.

One argument: malpractice is based on a geographic standard. If you are the only provider in the area with outpatient, you could argue you are THE standard. If you aren't the only provider and there are a small amount of providers not providing 24/7 coverage, then you could argue you are still providing the standard geographic care. If there are a large number of providers in the area, the likelihood of all of them not giving 24/7 coverage will significantly drop.

The counter-argument, professional societies such as the APA, AMA, and medical journals could make recommendations that they say should be the national standard. By the way, that already has happened in this regard. There already has been the call forth by national organizations that outpatient psychiatric emergency coverage should be 24/7. An established national standard would nullify a local geographic standard.

So which is it for you and your locality? I can't answer that because it will depend on your area. I could see this possibly already having gone to court in a case that I haven't yet reviewed. If one of you have Lexus-Nexus, you could do a search.

I can tell you this. If there is a case where this happened, the verdict in that case would only set a significant precedent in the jurisdiction where the case happened, however, other jurisdictions could use that existing case as a framework giving them ammo and arguing it should be a precedent elsewhere. If such a case hit the federal level, well viola, it's now a national standard.

My own opinion if it were my practice? Do 24/7. Aside that it's a higher standard of care and you should always err on that side, Applebaum and Gutheil, two of the biggest names in forensic psychiatry, in their textbook Clinical Handbook of Psychiatry & the Law wrote that the national standard usually trumps a geographic standard when the geographic standard is argued as a defense in court.

I'm quoting them...

the homogenization of practice made psosibly by widely disseminated professional journals, continuing education programs, national professional meetings, and uniform standards for peer review has led many-but not all- jurisdictions to abandon the locality rule. Clinicians are generally judged by the standards of their confreres of similar training and orientation throughout the country.

And further, given that a forensic psychiatrist and/or psychologist willing to testify on a malpractice case against you, even outside your area, is most definite so long as the plaintiff's lawyer is willing to pay enough, I'd recommend against ever thinking the geographic/local standard will be your get out of jail card unless you know with solid ground that it is the accepted standard in that jurisdiction, and even if it is, guess what? They could try to sue you through federal court, virtually eliminating that local standard because federal standards hold for the entire country. How tough is that? If your practice is close to a border, and you got a patient driving over state lines to see you.....do the math.

 

[strangeglove]

Edit.

 

[strangeglove]

With respect to 24/7 coverage, aside from important issues of what is the best care for your patients and what is the standard that will be invoked in a medicolegal context, there is also the business angle: if you are cash-only, your patients might expect 24/7 for urgent matters, especially if they are paying high fees. You can't charge people a lot of money and not provide them with good "service." Some would bristle at characterizing patient care as a service, but this is the Faustian bargain of successful cash-only private practice. There is no free lunch. In practice, my patients rarely call me after hours and when they do I'm glad that I spoke to them because it usually pre-empts situations that are much more work later on. I also make it clear at the start of treatment that I do not do unscheduled psychotherapy over the phone, except in urgent situations.

 

[michaelrack]

They could try to sue you through federal court, virtually eliminating that local standard because federal standards hold for the entire country. How tough is that? If your practice is close to a border, and you got a patient driving over state lines to see you.....do the math.

Thanks for the warning regarding practicing on the border. Are there any steps you could take to counteract this? For example, I practice in MS, just south of the TN border. I am licensed in Mississippi and Alabama. Could I get patients (especially my TN/Arkansas patients) to sign a statement acknowledging that I am licensed to practice medicine in MS, that I am seeing them in MS, and that I will be (attempting to) practice according to MS standards??

 

[Salpingo]

This was brought up before.
The counter-argument, professional societies such as the APA, AMA, and medical journals could make recommendations that they say should be the national standard. By the way, that already has happened in this regard. There already has been the call forth by national organizations that outpatient psychiatric emergency coverage should be 24/7. An established national standard would nullify a local geographic standard.

Do you have a link to some of these recommendations? I'd be curious to see what is considered outpatient psychiatric emergency coverage. From my standpoint, the most crucial component of 24/7 coverage would be if a patient ended up in an ED overnight or over the weekend. Then, there's an urgent need for collateral (get meds, past psych history, etc.) But if all I'm going to get is some covering service that barely knows the patient, has no access to records, what's the point?

I'd also be curious to see the evidence used to make these recommendation, and experience some attendings on the board have. Is 24/7 coverage providing meaningful care? Are you essentially taking on the role of a DBT skills coach? Talking someone off a ledge? Diagnosing medication side effects? Are these things that a covering physician, who doesn't have a meaningful relationship with the patient, can do?

 

[strangeglove]

Do you have a link to some of these recommendations? I'd be curious to see what is considered outpatient psychiatric emergency coverage. From my standpoint, the most crucial component of 24/7 coverage would be if a patient ended up in an ED overnight or over the weekend. Then, there's an urgent need for collateral (get meds, past psych history, etc.) But if all I'm going to get is some covering service that barely knows the patient, has no access to records, what's the point?

I'd also be curious to see the evidence used to make these recommendation, and experience some attendings on the board have. Is 24/7 coverage providing meaningful care? Are you essentially taking on the role of a DBT skills coach? Talking someone off a ledge? Diagnosing medication side effects? Are these things that a covering physician, who doesn't have a meaningful relationship with the patient, can do?

You only become a DBT skills coach if you want to. If your patients are so suicidal or self-injurious that they are going to be calling you every day to keep from harming themselves, then they should probably be getting DBT (from you or whomever), or be in an IOP or some such thing.

 

[Mastac741]

Thanks again for the discussion. Regarding the 24/7 coverage issue, I understand the theory and the potential concerns for litigation. However, in practice, I find that A LOT of psychiatrist are not doing this and nothing comes of it. For example, we recently had a bad outcome at our institution. An elderly gentlemen who completed suicide. We completed an ECT course on him, and he was doing maintenance ECT thereafter but completed in the beginning of maintenance. The private psychiatrist was notified and didn't call us back for 2 weeks with the excuse "Oh, I was on vacation." No litigation came of this, and I suppose this goes on a lot. Now, I really don't think that if the private psychiatrist was on 24/7 and got back to us immediately that would have changed anything, but again, the theory of 24/7 coverage.

I will probably do 24/7 availability but in a limited way for emergencies only and if it isn't an emergency, charge a high fee.

Couple other questions:

1 - Do you do any screenings before you accept patients? Do you check for any history of violence before accepting a patient? Maybe checking for felonies online or something ...

2 - How do you fire a patient? Do you do this a lot?

 

[whopper]

Oh forgot to mention this. Your malpractice insurance carrier and your local APA branch may be able to answer what the standard is in your area.

I find that A LOT of psychiatrist are not doing this and nothing comes of it.

I have found plenty of doctors not following the rules and getting away with it. If a doc doesn't follow the rules, the only way to stop him for things to happen that rarely do. E.g. the state board revoking their license.

But if you choose not the follow the rules, you do so at your own risk.

E.g. I knew a doctor that folded his practice and refused to give his patients their records even when they requested it. Is this illegal? Yes, but if the patient called the police, the police blew them off saying it was between them and their doctor. You call a lawyer, the lawyer will only pursue getting your records at a financial cost to most people not worth it.

1 - Do you do any screenings before you accept patients? Do you check for any history of violence before accepting a patient? Maybe checking for felonies online or something ...

2 - How do you fire a patient? Do you do this a lot?

You could screen a patient though in doing so, you could technically become their doctor. Just talking to someone about anything medical could tie them to you in a doctor-patient relationship.

Firing a patient? Depends on the local state laws. In Ohio, if you terminate a patient, you have to send them two letters, one through certified mail, the other through regular, you have to keep a copy of the certified mail receipt, and you have to offer them one month's worth of medication. If you fold a practice, this in effect terminates all patients, but you have to put a sign in the office saying your'e stopping the practice at a future date, you have to mail every single patient a letter via certified mail, and you have to put an ad in the local paper with the highest circulation stating you are folding your practice. In other states it varies. E.g. in some states you are required to refer the patient to three other doctors.

Or as Phil Resnick puts it.....
"If you terminate a patient, you likely find this patient very difficult to deal with. Therefore, when you terminate them, you refer them to three psychiatrists you don't like because the last thing you want to do is drop a bad patient on someone you do like."

Yes he was being sarcastic, though it's funny because this is what most doctors do and don't admit to it.

My advice in this area is if you do a practice, get together with psychotherapists and have them refer their patients to you. Psychotherapy-only patients tend to be less severe in pathology. E.g. psychotic patients usually don't see psychotherapy only services. When I did private practice, I had one of the psychotherapists do the 24/7 emergency coverage for me, and he was supposed to call me if he couldn't handle it. This limited the calls I got to maybe only 1-2 per month instead of 4-5 a night. We were able to pay him at a wage that was relatively cheap considering he was taking the work off a doctor's shoulders. We all won. The psychotherapist made extra money, I didn't have to deal with it, and it didn't cost much.

I will probably do 24/7 availability but in a limited way for emergencies only

It's perfectly acceptable to tell a patient to not call you unless it is an emergency. Also, IMHO, don't be too strict with good patients. Sometimes patients won't call you in an emergency if you get too hard on them for doing so. They'll not know if it's an emergency or not. E,g. a patient with a bad rash from Lamictal IMHO is an emergency but if you create a culture that they can never call you unless the world end, they might not do so when it really is one. By the time you've had a patient for a few months, you'll know who the problem ones are vs the responsible ones. I'd rather charge someone for repeat offenses. I have plenty of great patients that for years were low maintenance, then something terrible happens to them and they'll need a little more support than usual and phone calls can help them a great deal.

As for charge them a high fee, I better double check on this. I think you can do this, but I'd rather check before I tell you it's okay.

 

[medicaresucks]

300-400 k in psychiatry private practice as the OP states in the first post without selling your soul or working crazy hours??? Lol if anyone thinks this can be done working 9a-5p M-F..

That must be a gross income number. No way can anyone generate this amount as net income that isn't working 8a-8pm daily in their private practice outpatient office and maybe even then having to round on inpts during the weekday for an hour or two. Plus weekened call coverage and maybe even needing saturday office hours to get anywhere close to 400k net income..


am i right?