Private Practice position

[wolfvgang22]

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I'm considering a private practice position in Texas. They have emailed me the following verbal offer. I worry the amount of money they are offering me per RVU is very low. I've worked in government thus far in my career and no private practice experience, so I'd appreciate any insight or opinions on this:

Compensation: : $300 annually ( $25k draw/month) + RVU compensation bonuses (quarterly reconciliation) + $10k /year per Midlevel provider supervision (paid quarterly).

Breakdown: $150,000 annual salary for telepsych + RVU Model for in person Spravato and Med Management clinic, reconciliated quarterly for bonus breakout.
RVU-based compensation tied to Spravato services, paid quarterly.

Production Base Bonus:
The Production Base Bonus will be evaluated biweekly and will follow the following wRVU rates:
Spravato RVU (includes 99215, 99417 X 5, 90833 possibly, S0013, etc.) = 2.4 RVUs
New Patient RVU (99203-99205 + 90833) = 3.0 RVUs
New Patient RVU (90792) = 2.4 RVUs
99205 = 2.0 RVUs
99214=1.5 RVUs
99213 = 1.0 RVUs
90833 = 1.0 RVUs
99306 = 3.0 RVUs (Nursing Home codes)
99309 = 1.5 RVUs
99308 = 1.0 RVUs
An RVU is worth $30.
**Note**: Current wRVU rates are subject to change with market rates.

Schedule & Expectations
Full-time schedule,
Patient Volume: Avg. 18–20 patients/day
1-hour new evaluations, 20-minute follow-ups
Involvement in Spravato-related care coordination and supervision

Benefits:
Medical, dental, and vision insurance
401(k) with 3% employer match
Malpractice coverage included
DEA and state license reimbursement
3 CME days + up to $1,000 CME course reimbursement
PTO accrual starts at 90 days, 128hrs/year and 8 observed holidays

I don't actually want to see 18 to 20 outpatients a day, that's a non-starter for me. I'm wiped out after 15 patients in government. I also only want to work 4 days a week and take a month of vacation a year. One of the docs with this private practice group told me I should be able to do that and gross $300k, but then their business manager nurse sent me this offer and it looks terrible. Am I wrong?

I'd like to negotiate better terms. An internet search shows a 99214 in Texas should be about $125 in Medicaid reimbursement. I know insurance sometimes reimburses more. So my math says they'd be paying me about $45 per 99214. So they would be keeping 36% of the actual billing, right?

 

[AD04]

I'm considering a private practice position in Texas. They have emailed me the following verbal offer. I worry the amount of money they are offering me per RVU is very low. I've worked in government thus far in my career and no private practice experience, so I'd appreciate any insight or opinions on this:

Compensation: : $300 annually ( $25k draw/month) + RVU compensation bonuses (quarterly reconciliation) + $10k /year per Midlevel provider supervision (paid quarterly).

Breakdown: $150,000 annual salary for telepsych + RVU Model for in person Spravato and Med Management clinic, reconciliated quarterly for bonus breakout.
RVU-based compensation tied to Spravato services, paid quarterly.

Production Base Bonus:
The Production Base Bonus will be evaluated biweekly and will follow the following wRVU rates:
Spravato RVU (includes 99215, 99417 X 5, 90833 possibly, S0013, etc.) = 2.4 RVUs
New Patient RVU (99203-99205 + 90833) = 3.0 RVUs
New Patient RVU (90792) = 2.4 RVUs
99205 = 2.0 RVUs
99214=1.5 RVUs
99213 = 1.0 RVUs
90833 = 1.0 RVUs
99306 = 3.0 RVUs (Nursing Home codes)
99309 = 1.5 RVUs
99308 = 1.0 RVUs
An RVU is worth $30.
**Note**: Current wRVU rates are subject to change with market rates.

Schedule & Expectations
Full-time schedule,
Patient Volume: Avg. 18–20 patients/day
1-hour new evaluations, 20-minute follow-ups
Involvement in Spravato-related care coordination and supervision

Benefits:
Medical, dental, and vision insurance
401(k) with 3% employer match
Malpractice coverage included
DEA and state license reimbursement
3 CME days + up to $1,000 CME course reimbursement
PTO accrual starts at 90 days, 128hrs/year and 8 observed holidays

I don't actually want to see 18 to 20 outpatients a day, that's a non-starter for me. I'm wiped out after 15 patients in government. I also only want to work 4 days a week and take a month of vacation a year. One of the docs with this private practice group told me I should be able to do that and gross $300k, but then their business manager nurse sent me this offer and it looks terrible. Am I wrong?

I'd like to negotiate better terms. An internet search shows a 99214 in Texas should be about $125 in Medicaid reimbursement. I know insurance sometimes reimburses more. So my math says they'd be paying me about $45 per 99214. So they would be keeping 36% of the actual billing, right?

Waiting for flight so I have a few minutes to answer.

wRVU amount is lowered than standard.

Dollar per wRVU is way lower than median.

$45 per 99214? Can you do better having your own practice even if you take insurance?

 

[Merovinge]

I don't understand the impetus to take this terrible job? Trying to negotiate up from a awful start does not typically bode well. Also WTF with supervising a midlevel for $10k per YEAR. This job sounds like they are trying to provide mediocre psychiatry care and funnel as many people into Spravato as possible to push the money machine while it still prints...

 

[calvnandhobbs68]

They're lowballing you on the wRVUs to begin with (another reason why I hate RVUs like in the other thread).

Ex. 99204 (2.6wrvu) + 90833 (1.5wrvu) = 4.1 wRVU-> they're saying it's 3.0wrvu (27% difference)

Also yeah the $/RVU is awful BUT is that on top of the 150K base? So like I could see this possibly marginally making sense (but you'd have to run the numbers) if you're getting paid for EVERY RVU you bill. It does not make sense if you have some "base" RVU amount and then that's all you're getting for additional salary over that RVU target or if they're doing something goofy like paying you RVUs for in person clinic vs base salary telepsych (I honestly can't tell from that description).

For example:
Scenario 1: You see 0 patients. You still make 150K/year base. You see 1 99214. You make $150,045....etc etc.
With scenario 1, you could feasibly still make it to high 200s (not 300K) seeing 15 patients/day 4 days a week.
Call it 15 20min 99214s a day with a full panel.
15 * $45/patient= 675
675 * 4 days = 2700
2700 * 47 weeks= 126900
150,000 + 126900 = $276,900 -> throw a few 90833s in there for good measure (we can debate the ethics of the 20 minute 99214 + 90833 visit another time lol) and you might get closer

Scenario 2: You make 150K/year base UP TO an RVU threshold and only start getting extra RVUs after that threshold.
I'm not even doing this scenario because this would be terrible.

Their phrasing is weird because at first theyre saying 300K + RVU bonus + Midlevel supervision but then in the next line they're saying 150K + RVU? So what is it actually?

Edit: I actually realized they give you PTO but you'd have to figure out how that PTO is calculated, so I didn't change my numbers above (assuming 5 weeks off a year with holidays). Do you only get paid whatever the base salary is for the PTO or do they reimburse you for the theoretical "lost" RVUs? Cause it's not really PTO if you're actually getting paid less than you would otherwise for taking time off lol.

 

[wolfvgang22]

I don't understand the impetus to take this terrible job? Trying to negotiate up from a awful start does not typically bode well. Also WTF with supervising a midlevel for $10k per YEAR. This job sounds like they are trying to provide mediocre psychiatry care and funnel as many people into Spravato as possible to push the money machine while it still prints...

It's located in my smallish home town with a relatively low cost of living and family ties. There are a couple of worse jobs in town (possibly including the one I'm doing now), and private practice as options. I can't afford to not have an income in the time it takes to start a private practice, and I may be too burned out to try at the moment.

How much do you think would be reasonable to supervise an NP who is mostly administering Spravato?

 

[Merovinge]

It's located in my smallish home town with a relatively low cost of living and family ties. There are a couple of worse jobs in town (possibly including the one I'm doing now), and private practice as options. I can't afford to not have an income in the time it takes to start a private practice, and I may be too burned out to try at the moment.

How much do you think would be reasonable to supervise an NP who is mostly administering Spravato?

From what I recall about your posts you are good a psychiatrist. Why not take a part-time tele psych job that can suck equally to this one while you build out a practice? Then you can practice good medicine and not just cram a bunch of people into shoving esketamine up their nose.

 

[wolfvgang22]

They're lowballing you on the wRVUs to begin with (another reason why I hate RVUs like in the other thread).

Ex. 99204 (2.6wrvu) + 90833 (1.5wrvu) = 4.1 wRVU-> they're saying it's 3.0wrvu (27% difference)

Also yeah the $/RVU is awful BUT is that on top of the 150K base? So like I could see this possibly marginally making sense (but you'd have to run the numbers) if you're getting paid for EVERY RVU you bill. It does not make sense if you have some "base" RVU amount and then that's all you're getting for additional salary over that RVU target or if they're doing something goofy like paying you RVUs for in person clinic vs base salary telepsych (I honestly can't tell from that description).

For example:
Scenario 1: You see 0 patients. You still make 150K/year base. You see 1 99214. You make $150,045....etc etc.
With scenario 1, you could feasibly still make it to high 200s (not 300K) seeing 15 patients/day 4 days a week.
Call it 15 20min 99214s a day with a full panel.
15 * $45/patient= 675
675 * 4 days = 2700
2700 * 47 weeks= 126900
150,000 + 126900 = $276,900 -> throw a few 90833s in there for good measure (we can debate the ethics of the 20 minute 99214 + 90833 visit another time lol) and you might get closer

Scenario 2: You make 150K/year base UP TO an RVU threshold and only start getting extra RVUs after that threshold.
I'm not even doing this scenario because this would be terrible.

Their phrasing is weird because at first theyre saying 300K + RVU bonus + Midlevel supervision but then in the next line they're saying 150K + RVU? So what is it actually?

Edit: I actually realized they give you PTO but you'd have to figure out how that PTO is calculated, so I didn't change my numbers above (assuming 5 weeks off a year with holidays). Do you only get paid whatever the base salary is for the PTO or do they reimburse you for the theoretical "lost" RVUs? Cause it's not really PTO if you're actually getting paid less than you would otherwise for taking time off lol.

I really appreciate your insights. Scenario #1 is what they are proposing. I think the practice administrator nurse who sent me this offer didn't communicate very well. I wonder what a reasonable counter proposal from me should look like in regard to RVUs? That's what I'm trying to figure out.

The whole point of going private practice would be to get away from government bureaucracy and have more flexibility in time off while maintaining the $300k I earn now while seeing 10 to 15 patients a day. The government likes to add to and change my job responsibilities on a whim which causes me a ton of burnout and uncertainty. I have very little autonomy and it's exhausting answering to 16 bosses including receptionists .

From what I recall about your posts you are good a psychiatrist. Why not take a part-time tele psych job that can suck equally to this one while you build out a practice? Then you can practice good medicine and not just cram a bunch of people into shoving esketamine up their nose.

Thank you for your kind words! I will think on what you've said. I'm not sure I'm able to build a practice while working another job, or I would already be doing that. Working only part time would force me to use savings and I'm not sure I am that desperate yet.

 

[Merovinge]

Thank you for your kind words! I will think on what you've said. I'm not sure I'm able to build a practice while working another job, or I would already be doing that. Working only part time would force me to use savings and I'm not sure I am that desperate yet.

I'm no expert on opening a PP, but plenty of people here are, and have often been able to get up and running in a relatively short amount of time. I know several doctors who work say 3 days remotely, could easily take home 200k from that, while spending the other 2 seeing anyone in-person and just spending the time on it. The upfront cost would be clearly present financially and emotionally, but the upside is also much higher both financially and emotionally. This is an example where (due to small town setup) the best available alternative is so poor that it makes the calculus favor PP much more, even if you fully account of the upfront work.

 

[splik]

RUN! This is not a place you want to work for. multiple red flags

 

[wolfvgang22]

RUN! This is not a place you want to work for. multiple red flags

Can you elaborate?

 

[splik]

These are fake RVUs which are much lower than the actual wRVUs associated with the codes.
Then, to add insult to injury, the conversion factor of $30 is less than half the median.
Then, they seem to encourage overbilling (99205+90833 is not a combo that can easily be used)
20 min f/us and 20 pts per day is pill mill vibes
Fake PTO (if you are on a RVU model then you are not being paid if you don't work)

I am sure there are better jobs. You do not negotiate with this kind of predatory offer. I am guessing this clinic mostly hires NPs. Most NPs wouldn't accept this BS either!

 

[wolfvgang22]

These are fake RVUs which are much lower than the actual wRVUs associated with the codes.
Then, to add insult to injury, the conversion factor of $30 is less than half the median.
Then, they seem to encourage overbilling (99205+90833 is not a combo that can easily be used)
20 min f/us and 20 pts per day is pill mill vibes
Fake PTO (if you are on a RVU model then you are not being paid if you don't work)

I am sure there are better jobs. You do not negotiate with this kind of predatory offer. I am guessing this clinic mostly hires NPs. Most NPs wouldn't accept this BS either!

They hire other psychiatrists. I would be joining one of them here who says he is pleased, but he is doing 1099 only. He is well known in the community for being financially savvy. I'm going to talk to him some more and see what he recommends. Perhaps my desire for a safety net salary is to my detriment here and has made me a target for a bad deal. I appreciate you because you have no incentives to stwer me wrong, so I will be extra cautious .

 

[Bartelby]

This does not seem like a great offer, but if I were going to take it I would require that they shift to letting me do mostly 30-minute follow ups and that I control the intakes / panel size. This might be a tough adjustment for some current patients but would let you shape the job over time. If we look at doing 5 hours of 30-min follow-ups per day, 1 hour of 3 x 20 min follow ups without therapy per day, and two intakes per week (presuming a 100% fill and show rate):

99214 + 90833 = 2.5
Two per hour = 5 RVUs = $150/hour

5 RVU per hour x 5 hours per day x 4 days per week x 46 weeks per year = 4600
4.5 RVU per hour x 1 hour per day x 4 days per week x 46 weeks per year = 828
New patient 3.0 RVU per hour x 1 hour per day x 2 days per week x 46 weeks per year = 276

Total RVUs: 5704. 5704 x $30/RVU = $171,120

Total pay = $321,120. This also leaves 1 hour of admin time on intake days and 2 hours of admin time on non-intake days (4 day weeks, 8 hour days).

BUT of course this assumes 100% fill and show rates, which is silly. If we presume 80% of time is utilized, then you are earning close to $137k on top of the $150k, or $287k. But this setup would allow a four-day week, mostly 30-min follow ups, and an intake rate of two per week. And of course a therapy add-on for every 30-min patient is pretty unrealistic, but you could probably land >$250k still and having those extra time gaps in the schedule (from a 10-min follow up in a 30-min slot) is pretty nice!

Overall I think if you are willing to churn that hard you could do what was already suggested above: take a part-time job while building your own practice. But overall if you negotiate hard and can live on $250k, this job could provide a not too unreasonable work-life balance.

 

[Bartelby]

And I didn't get to the supervising NPs, but I worry that is a liability sponge role. Any chance you can negotiate it out, or negotiate a structure where you are supervising at least at the level you would supervise a good resident?

 

[ObsequiousAplomb]

Paying you $45 out of $125 for a 99214 is them paying you 36%, not them keeping 36%. They're keeping 64%.

 

[wolfvgang22]

Paying you $45 out of $125 for a 99214 is them paying you 36%, not them keeping 36%. They're keeping 64%.

Yeah, you're right, sorry. I'm making a counter offer.

 

[psydocc]

This does not seem like a great offer, but if I were going to take it I would require that they shift to letting me do mostly 30-minute follow ups and that I control the intakes / panel size. This might be a tough adjustment for some current patients but would let you shape the job over time. If we look at doing 5 hours of 30-min follow-ups per day, 1 hour of 3 x 20 min follow ups without therapy per day, and two intakes per week (presuming a 100% fill and show rate):

99214 + 90833 = 2.5
Two per hour = 5 RVUs = $150/hour

5 RVU per hour x 5 hours per day x 4 days per week x 46 weeks per year = 4600
4.5 RVU per hour x 1 hour per day x 4 days per week x 46 weeks per year = 828
New patient 3.0 RVU per hour x 1 hour per day x 2 days per week x 46 weeks per year = 276

Total RVUs: 5704. 5704 x $30/RVU = $171,120

Total pay = $321,120. This also leaves 1 hour of admin time on intake days and 2 hours of admin time on non-intake days (4 day weeks, 8 hour days).

BUT of course this assumes 100% fill and show rates, which is silly. If we presume 80% of time is utilized, then you are earning close to $137k on top of the $150k, or $287k. But this setup would allow a four-day week, mostly 30-min follow ups, and an intake rate of two per week. And of course a therapy add-on for every 30-min patient is pretty unrealistic, but you could probably land >$250k still and having those extra time gaps in the schedule (from a 10-min follow up in a 30-min slot) is pretty nice!

Overall I think if you are willing to churn that hard you could do what was already suggested above: take a part-time job while building your own practice. But overall if you negotiate hard and can live on $250k, this job could provide a not too unreasonable work-life balance.

Why is a therapy add-on for every 30 minute visit unrealistic? I couldn't imagine a 30 minute follow up that doesn't feature at least 16 minutes worth of supportive therapy.

 

[Bartelby]

Why is a therapy add-on for every 30 minute visit unrealistic? I couldn't imagine a 30 minute follow up that doesn't feature at least 16 minutes worth of supportive therapy.

I estimate I hit 70% add-on codes for 30-minute follow ups. Two main scenarios pull it down from 100%:

1- They just don't need therapy in that encounter. They are very stable, all is going well, I verify that, chat for a couple minutes, place any orders and close out the visit. The total time is 5-10 minutes. If you know this is the case in advance you could create shorter time slots for these patients. I just enjoy my extra 20 minutes.

2 - I need to do more than ~5 minutes of E&M. For example, a detailed review of medication trials, reviewing a recent hospital stay, a prolonged informed consent discussion for a particularly wary patient (or for starting something like an MAOI or lithium augmentation). If all of that takes 20 minutes, it technically is not therapy and I'm not going to try to shoehorn in 16 minutes of therapy to add that code. Morally I think getting paid for a longer interaction is appropriate, but by the current rules that is not an 90833 add-on situation.

Bigger picture my approach to outpatient is different from what I often hear about from others. Many psychiatrists seem to book frequent one hour intakes, fill every time slot, carry panel sizes too large to offer adequate follow up, overbook any "admin time," and then complain that outpatient is a grind. To which I say... of course it is! If I did eight continuous hours of clinical care using every available minute and then followed that up with wrapping up notes, orders, etc. in the evening every day I would burn out fast. I also think having no holes in the schedule means you are going to have a very stressful time managing higher-risk, more demanding patients (having the time to actually dedicate to these cases makes them much lower-stress). The way I structure my schedule I have meaningful downtime which makes the day pretty pleasant, which works better for me long term despite yielding fewer total RVUs.

 

[kelminak]

I'm not sure I'm able to build a practice while working another job, or I would already be doing that. Working only part time would force me to use savings and I'm not sure I am that desperate yet.

Could you find some sort of shift-work role like working in the ED for 3 days a week 10-12 hour shifts so you have a fairly stable income, and then on the days you have off schedule patients for your growing practice?

 

[wolfvgang22]

I estimate I hit 70% add-on codes for 30-minute follow ups. Two main scenarios pull it down from 100%:

1- They just don't need therapy in that encounter. They are very stable, all is going well, I verify that, chat for a couple minutes, place any orders and close out the visit. The total time is 5-10 minutes. If you know this is the case in advance you could create shorter time slots for these patients. I just enjoy my extra 20 minutes.

2 - I need to do more than ~5 minutes of E&M. For example, a detailed review of medication trials, reviewing a recent hospital stay, a prolonged informed consent discussion for a particularly wary patient (or for starting something like an MAOI or lithium augmentation). If all of that takes 20 minutes, it technically is not therapy and I'm not going to try to shoehorn in 16 minutes of therapy to add that code. Morally I think getting paid for a longer interaction is appropriate, but by the current rules that is not an 90833 add-on situation.

Bigger picture my approach to outpatient is different from what I often hear about from others. Many psychiatrists seem to book frequent one hour intakes, fill every time slot, carry panel sizes too large to offer adequate follow up, overbook any "admin time," and then complain that outpatient is a grind. To which I say... of course it is! If I did eight continuous hours of clinical care using every available minute and then followed that up with wrapping up notes, orders, etc. in the evening every day I would burn out fast. I also think having no holes in the schedule means you are going to have a very stressful time managing higher-risk, more demanding patients (having the time to actually dedicate to these cases makes them much lower-stress). The way I structure my schedule I have meaningful downtime which makes the day pretty pleasant, which works better for me long term despite yielding fewer total RVUs.

Yeah, the burn out grind you succinctly described is exactly why I'm looking for another job, because they burned me out, bad, doing that.

 

[wolfvgang22]

Could you find some sort of shift-work role like working in the ED for 3 days a week 10-12 hour shifts so you have a fairly stable income, and then on the days you have off schedule patients for your growing practice?

I hate ED work. I'm good at it, but I hate it. Thanks for the suggestion, though! I'd do it in a worst case scenario.

 

[Merovinge]

I hate ED work. I'm good at it, but I hate it. Thanks for the suggestion, though! I'd do it in a worst case scenario.

But again, if you get paid well for it (like substantially better than this rubbish job) AND it's a known short-term thing for a few years while you build a practice AND you are good at it, I would certainly keep that higher than a worst case scenario.

 

[wolfvgang22]

I ended up countering that I only want to see 10 to 12 patients per day, not counting supervising 2 spravato NPs. I also asked to work 4 days a week, at $50 per RVU in addition to the base $150,000 salary. I told them to delete a 2 year, 20 mile radius noncompete, and that I want 4 weeks of paid time off, and $4k and 4 days of paid CME time. I said I want 228 paid time off hours, not 128. They also wanted me to purchase my own tail insurance if/when I leave. I'm asking them to pay for that.

So I'll wait and see if they will work with me.