Great stuff, this is the kind of thing I am interested in finding out more about. If you do feel up to another post detailing pay rates as you mentioned, I for one would lap it up.
Heh, careful what you wish for...
Outpatient Billing
Private outpatient psychiatry in Australia is Fee-for-Service, and there are a large range of Item Numbers attached to psychiatric services (291-352). However, in practice there’s only a few that would be used regularly: 296 is an initial assessment for at least 45 minutes, and numbers 300-308 are for time based outpatient reviews. The equivalent for an inpatient is 297 and numbers 320-328. 348-352 are codes for seeing someone other than the patient for collateral/diagnostic clarification.
For outpatient practice, I’ll use a standard half hour review (item “304”) as an example. How I decide to bill for that item number determines my reimbursement.
From
Item 304 | Medicare Benefits Schedule, there’s a lot of different dollar figures which don’t mean too much to the casual observer.
Fee: $133.10 Benefit: 75% = $99.85 85% = $113.15
The “Fee” referred to above what is called the Schedule Fee, or the amount that the Medicare, our national insurer, thinks is a fair price for the service offered. For non-GP specialist services Medicare will pay only 85% of the Scheduled Fee: this is the Bulk Billed rebate. The difference that a patient pays is what is referred to as the “Gap.”
Scenario 1 - Bulk Billing
If I elect to Bulk Bill a patient for a 304, Medicare pays me $113.15. More accurately, the patient assigns their rebate to me. The overall result is that the patient pays nothing (which they generally like).
Scenario 2 - Schedule Fee
If I charge the Schedule Fee, the patient pays me $133.10 and gets back $113.15 from Medicare, leaving them with a $20 out of pocket gap.
Scenario 3 - Private Billing/AMA Rates
Now the Schedule Fee hasn’t kept up with inflation for ages, so most psychiatrists charge a higher amount than the schedule fee. So if decide to charge the AMA rate (which is the doctor’s union fee updated annually to keep pace with inflation), the patient pays me $250, and gets back $113.15 from Medicare leaving them with a $137 gap.
Scenario 4 - Third Party
For third party payers, approved Workers Compensation and Veterans Affairs patients pay a higher rate usually between the Schedule Fee and the private AMA rate, and in some cases more –eg. the WorkCover rate for a 291 assessment is higher than the AMA rate. Not everyone accepts WorkCover patients, as there can be additional paperwork especially if a hospital admission is needed.
There are a couple of other things that can influence the hourly rate.
Item 291 Assessments
An Item 291 is a one-off assessment designed to allow increased access to a psychiatrist. These have to be specifically requested by the referring GP, and are supposed to be for patients that can be managed in primary care setting with minimal specialist involvement, although they are often used to get patients who could not otherwise afford specialist care seen.
The Medicare rebate for this is $384, which I believe is the highest amount paid for any kind of consultation. Aside from the higher rebate (a regular initial assessment 296 is $220), these assessments are any different from one’s standard initial assessment, but there are administrative limitations and requirements. To be eligible for a 291 a patient can’t have seen a psychiatrist in the last 2 years, a report to the referrer must be provided within 2 weeks, and a rating scale must be used among other things. When these were first introduced, there was a bit of rorting and inappropriate claiming going on resulting in Medicare audits.
The AMA fee for a 291 is around $700, which you would think is out of reach for most patients. Most psychiatrists charge well below this figure, say around the $400-500 mark, but there are some patients who will agree to pay the higher rate. Recently I did one of these for a new WorkCover patient, and found that they paid $750 which was a nice surprise.
IME Assessments
The only thing that I can think of that pays higher, is the fee for an Independent Medical Examination. Eg. a patient gets injured/bullied at work, they develop depression and claim Worker’s Compensation. Before the insurer will approve it they send them to an “IME” to determine if the problems are actually work related. The only requirement to being an IME is to do a short course, and pay an annual fee to go on the register. There’s a perception that those who only do this kind of work are “guns for hire,” likely working on the assumption that if one accepts too many claims they may not be favoured in getting work from the insurance companies who are footing the bill. The going rate for this kind of work is something like $880/hr (800 + 10% GST), but the trade off is that they seem to be universally despised by patients.
Outpatient Hourly Rates
In working out an hourly rate, I should also mention that Medicare pays proportionally more for shorter consults, and while most of the psychiatrists at my clinic would see 30 minute reviews, if someone wanted to run a pure therapy practice or churn through 4 med reviews an hour that would also be possible. The ranges given below are BB to the AMA rate, assuming no cancellations.
1 x 60 minute consult: $156 – 370/hr
2 x 30 minute consults: $226 – 500/hr
4 x 15 minute consults: $294 – 720/hr
Therefore, one’s hourly rate in private outpatients can theoretically range from $156 (a bulk billed long consult – Item 306) to $880 (IME). Most privately billing general adult psychiatrists would charge around $350-400 for an initial 60 minute intake, and $150-250 for a review. You could probably get more if you did Child Psychiatry. There was an Australian doctor who was arrested in Canada for doing very unsavoury things in public toilets: the media dug around and found he charged $750-$990 for a 90 minute intake (500-660/hr), and $395-$445 for reviews, but I have no idea if this is the norm for them.
Even after taking into account costs like room rental, empty slots and cancellations, one can still earn well above $1000 per half day session in a mixed billing practice. In contrast, a colleague who works a day a week at the local university clinic and bulk bills all the patients struggles to clear $1000 for that day.
Inpatient Billing
Private inpatient work operates slightly differently from the descriptions I read here, as you generally only look after your own outpatients. Again, it’s Fee-for-Service, and can be done alongside outpatient work or ignored completely if one chooses. If I decide a patients needs to come into hospital, then I arrange the admission either under myself, but if I didn’t want to I could contact another doctor who has admitting rights. Another form of inpatient work is providing second or third opinions for other colleagues - sometimes this is clinically warranted for particularly tricky patients or when considering contentious or potentially risky treatment options like MAOis. It's also something nice about psychiatry compared to other specialities who are more worried about colleagues "stealing" their patients.
Unlike outpatient work, the Medicare rebate paid for consultations is 75% of the Schedule Fee. The patient’s private health insurance (PHI) pays an additional amount that usually takes the total over the schedule fee as an incentive to not charge an additional gap.
For an Item 324 (the inpatient equivalent of a 304), this additional amount can take the total to anywhere from $150-180 depending on the patient’s insurance. While this is less than the private outpatient fee, the advantage is that it’s more consistent work. If want to, I can see my inpatients every day and bill accordingly: if I have a couple of inpatients and round each evening, that’s potentially another $2000-2500 per week which can offset any quiet clinic days. Some psychiatrists will even see their inpatients twice a day, before their clinic and afterwards.
The disadvantage is that you are on call for the duration of their stay in hospital, but the good news is that you don’t get called very often if you have sorted out your patients, and there are no overheads as when we admit the hospital makes good money. The cost of staying in hospital is about $800 a day, which the insurance covers. For those without PHI, the patients has to to pay the hospital fee a week in advance (> $5000) or half that amount if they have partial cover. The disadvantage for admitting doctors is that under those two scenarios, the insurance does not top up their payments, and they only receive the lower 75% rebate (worse than Bulk Billing) - found this out the hard way.
(you've just described the exact set up at the clinic I attend)
