Pure- Forensic/Addictions Practice

[vistaril]

I do not understand how Suboxone visits in your area are mostly self-pay. Regardless of where you are in the country, most PCPs will accept a wide variety of insurances. Providers cannot simply cherry-pick Suboxone patients and demand cash as it would violate their insurance contracts. An exception to this is if the patient is on an insurance plan that is not offered by the practice or if the patient does not have insurance. These exceptions, however, do not mean the practice is self-pay. It just means the the patient is paying out-of-pocket because of lack of insurance. The alternative scenario I can think of is your area has mostly niche Psych/addiction cash practices that are self-pay because they operate on an out-of-network basis. Either way, your claim does not appear to be representative of the rest of the United States. If you believe it is, I would like to hear of any evidence you have supporting the claim.

a lot of insurance plans(I dont know what percentage...I thought most?) pay for suboxone as a medication but will not pay for suboxone visits since many insurance plans do not pay for outpt addiction medicine services. Or they do and they come with large copays that wont be met based just on office visits within addiction medicine.

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[vistaril]

Out of curiosity, and who can blame me for asking the question given your tone on this forum, but do you think you're genuinely helping your patients at all with psychiatry? Or are you doing it simply because you find the material easy to intellectually consume, it provides a nice lifestyle, and medicine in general sucks?

I'm not judging either way, because I understand both motives. I'm just interested in your perspective.

yeah, I think if done right(and I do it right) it can help some patients in some ways.

 

[digitlnoize]

Right, and then you realize the only buyers are folks who went to medical school and gave up their dreams of being rock stars! Full circle

And I think this contributes somewhat to the banjo and mandolin market being so different from the guitar market (most of your buyers are middle-aged guys with reasonable jobs, not heroin addicts deciding between a paul reed smith and a dime bag). Though I'm guessing I've used a lot more banjo and mandolin than you have, seeing as my redneck past is still nipping at my heels. You seem more of a carpetbagger than a scalawag.

Yeah, I never did much banjo or mandolin. Sold a few, but never spent much time with them. I've actually gotten VERY into country music while I was in med school...I think something about the simple things in life aspect of it appealed to me when I was that busy. Plus, a lot of my music friends have defected from the rock world to Nashville and are now playing in some very well known country acts, so I like to keep in touch. Brad Paisley could be the greatest guitar player alive.

yeah, I think if done right(and I do it right) it can help some patients in some ways.

To me, this still doesn't answer the question of why you chose psychiatry over another medical field. Was it the lesser of many evils? Lifestyle? Your say that you think psychiatry "CAN" help "SOME" patients in "SOME" ways. That's a lot of maybes.

Why did you not choose something with more concrete results, like surgery, anesthesia, or ER. Where you ARE helping MOST patients in MANY ways (to compare to your previous comment).

Just curious, as I think we're all curious about why you went into a field that you don't seem to think very highly of, although some of your points about lack of efficacy are valid.

 

[F0nzie]

a lot of insurance plans(I dont know what percentage...I thought most?) pay for suboxone as a medication but will not pay for suboxone visits since many insurance plans do not pay for outpt addiction medicine services. Or they do and they come with large copays that wont be met based just on office visits within addiction medicine.

Appreciate your response Vistaril. Your claim is based upon anecdotal evidence which may be more consistent to your specific area. I think it may be possible that what you're saying is true because we all know insurance companies can flat out deny our claims and leave us hanging out to dry.

However, here's a section on buppractice.com, a site supported by ASAM:

Commonly Used CPT Codes - Primary Care
Although there are few specific codes for billing for buprenorphine treatment (nor for all of addiction medicine), most private health insurance companies are now covering the cost of treatment. PCPs have been successfully using standard evaluation and management outpatient billing codes for both the induction and maintenance stages of treatment.

Coding is either based on complexity of service or time, with four contributing components:

history
physical exam
complexity of decision-making
contributing factors (eg: time)
In the event of an audit, the documentation for a single visit must stand alone, unless another record is specifically referenced.

The most commonly used CPT codes by Primary Care Physicians are as follows:

Type of Visit Code
Assessment Visit:
Comprehensive evaluation of new patient or established patient for suitableness for buprenorphine treatment New Patient: 99205
Established Patient: 99215

Induction Visits:
Any of the new patient evaluation and management (E/M) codes might be used for maintenance visits. Codes listed are in order of increasing length of time with patient and/or severity of the problems.
Prolonged visit codes (99354, 99355) may also be added onto E/M codes for services that extend beyond the typical service time, with or without face-to-face patient contact. Time spent need not be continuous.

New Patient E/M: 99201-05

Established Patient E/M: 92211-15

Patient Consult: 99241-45

Add-on Codes:
30-60 minutes: 99354; 60+ minutes: 99355

Maintenance Visits:
Any of these established patient E/M codes might be used for maintenance visits.
Counseling codes are commonly used to bill for maintenance visits, since since counseling and coordinating service with addiction specialists comprise the majority of these follow-up visits.

See the following page on counseling for more detailed information on how to bill for these visits.

Established Patient: 92211-15

The ICD-9 Code for opioid dependence is 304.0x. For the (x) use these classifications: 0=unspecified, 1=continuous, 2=episodic, 3=in remission.

Some private health insurers are developing standard billing codes for buprenorphine treatment services. For instance, Cigna tells clinicians to use the HCPCS code for "unspecified mental health care" for buprenorphine-related visits. The code is H0033 - Oral Medication Administration, Direct Observation. Cigna allows for approximately $300 reimbursement for the induction visit.

If you noticed, the CPT codes quoted above are for PCPs. Psychiatrist use their standard 90801 (initial eval), 90805 (20-30 min med check), and 90807 (45-50 min med check). FYI 90862 (15 minute med check) is soon to be abolished. As I mentioned in one of my previous posts, our CPT codes may be changing next year. I believe the proposals are still kept under wraps (I have not checked again) until they are announced in January 2013. We should definitely keep an eye on it because any changes to our CPT codes can have an effect on clinical practice (especially private) and salaries across the board.

 

[vistaril]

If you noticed, the CPT codes quoted above are for PCPs. Psychiatrist use their standard 90801 (initial eval), 90805 (20-30 min med check), and 90807 (45-50 min med check). FYI 90862 (15 minute med check) is soon to be abolished. As I mentioned in one of my previous posts, our CPT codes may be changing next year. I believe the proposals are still kept under wraps (I have not checked again) until they are announced in January 2013. We should definitely keep an eye on it because any changes to our CPT codes can have an effect on clinical practice (especially private) and salaries across the board.

is it certain that the 90862 will be abolished?

my big question is this: if the 90862 is abolished and the lowest level of care we can do for a med check is 90805(with the next being 90807):

1) are insurers likely to drop their rates for this code, as it now represents the lowest level of care?

2) are insurers going to make us space pts out more for the lowest level visits/lower the cap on total visits?

3) for outpt providers who have a set number of pts, mostly now 90862's, are they going to be able to keep all these pts? Or are insurers going to be real strict about how they are coded?

I could see this turning out bad potentially for psych. I certainly don't need anywhere near 30 minutes to see most follow up patients for med mgt.

 

[BS81]

http://www.psych.org/practice/news-and-alerts/cpt-coding-changes-for-psychiatry
http://www.psych.org/practice/manag...reimbursement/changes-to-psychiatry-cpt-codes

90862 is gone for sure. Most 908xx codes are also deleted. Looks like they want psych to move to E/M codes if not doing any psychotherapy.

 

[BS81]

90862 was/is 1.72 total RVUs for outpatient for a $58.54 national average for medicare

99213 a repeat patient E/M code which typically has 15 mins face to face time reimburses $70.46 for 2.07 RVUs... so it should be an INCREASE in pay. That sounds pretty good to me especially since psych has minimal overhead.

 

[vistaril]

90862 was/is 1.72 total RVUs for outpatient for a $58.54 national average for medicare

99213 a repeat patient E/M code which typically has 15 mins face to face time reimburses $70.46 for 2.07 RVUs... so it should be an INCREASE in pay. That sounds pretty good to me especially since psych has minimal overhead.

so im confused(this doesnt apply to me yet so I admit to being not caught up).....what is the difference between an E/M and a med mgt visit now?

so what you're saying is that the lowest level med mgt visit is now going to be a 99213 which is 2.07 rvus??

The quick med mgt visits(where docs do 4-5 or in some cases even more!) in one hr are here to stay.....everyone knows that. insurers know it. So what happens if insurers don't play ball here? Quite frankly, this seems to good to be true.....if the APA can change coding such that lowest level med mgt visits now get 2.07 rvu's and insurers can't do anything about it, why stop there? Why not 4 rvu's and 140 bucks medicare reimbursement for the lowest level med mgt visit?

Maybe I'm too pessimistic, but I'll cross my fingers until I see the money in my bank account.....if the payout system for insured outpt high volume med mgt becomes more favorable(which sort of flys in the face of where medicine is going now), I may have to do some outpt high volume med mgt

 

[BS81]

so im confused(this doesnt apply to me yet so I admit to being not caught up).....what is the difference between an E/M and a med mgt visit now?

so what you're saying is that the lowest level med mgt visit is now going to be a 99213 which is 2.07 rvus??

The quick med mgt visits(where docs do 4-5 or in some cases even more!) in one hr are here to stay.....everyone knows that. insurers know it. So what happens if insurers don't play ball here? Quite frankly, this seems to good to be true.....if the APA can change coding such that lowest level med mgt visits now get 2.07 rvu's and insurers can't do anything about it, why stop there? Why not 4 rvu's and 140 bucks medicare reimbursement for the lowest level med mgt visit?

Maybe I'm too pessimistic, but I'll cross my fingers until I see the money in my bank account.....if the payout system for insured outpt high volume med mgt becomes more favorable(which sort of flys in the face of where medicine is going now), I may have to do some outpt high volume med mgt

As long as you satisfy the requirements for 99213 then you can bill for it. A good portion of insurance plans already allow you to bill for it as a psychiatrist. There are still some hold outs, but that will be completely eliminated by Jan 1st.

This is a nice little website that quickly lets you see how you can bill for 99213 vs 99214 vs 99215...

http://www.soapnote.org/general/visit-coding/

For example, what do I need for a 99214 EM Code?
1.History Present Illness: 4 or more elements HPI
a.Psychiatric Review of Systems
b.Past Medical History, Past Surgery History
c.Past Psychiatric History
d.Family Psychiatric History
e.Social History
3.Review of System: 2-9 elements
4.Mental Status Examination: 9 or more elements including Vital Signs (At least three Ht., Weight, BP, RR, Temp)
5.Medical Decision Making: Moderate Level
6.No Time Requirement

BTW 99214s are about 3 RVUs, so about $100. I've seen outpatient psychiatrists take a blood pressure, weight, RR, pulse etc. and I sometimes wondered why... I guess it's partly for the billing.

 

[vistaril]

As long as you satisfy the requirements for 99213 then you can bill for it. A good portion of insurance plans already allow you to bill for it as a psychiatrist. There are still some hold outs, but that will be completely eliminated by Jan 1st.

This is a nice little website that quickly lets you see how you can bill for 99213 vs 99214 vs 99215...

http://www.soapnote.org/general/visit-coding/

For example, what do I need for a 99214 EM Code?
1.History Present Illness: 4 or more elements HPI
a.Psychiatric Review of Systems
b.Past Medical History, Past Surgery History
c.Past Psychiatric History
d.Family Psychiatric History
e.Social History
3.Review of System: 2-9 elements
4.Mental Status Examination: 9 or more elements including Vital Signs (At least three Ht., Weight, BP, RR, Temp)
5.Medical Decision Making: Moderate Level
6.No Time Requirement

BTW 99214s are about 3 RVUs, so about $100. I've seen outpatient psychiatrists take a blood pressure, weight, RR, pulse etc. and I sometimes wondered why... I guess it's partly for the billing.

so like with the 99214.....how would you justify things like the social history and past surgical hx and stuff every visit? or would that just be for intakes?

 

[BS81]

so like with the 99214.....how would you justify things like the social history and past surgical hx and stuff every visit? or would that just be for intakes?

Sorry that wasn't very clear, for medical/surgical/family/social history in a follow up you only need one item from any of the histories. So asking about current meds would satisfy that requirement. Here is a list of the one thing you can ask to satisfy the problem focused history requirement for follow-up visits:

Past Medical History (PMHA review of past illnesses, operations or injuries, which may include:
Prior illnesses or injuries
Prior operations
Prior hospitalizations
Current medications
Allergies
Age appropriate immunization status
Age appropriate feeding/dietary status
Family History (FH): A review of medical events in the patient’s family which may include information about:
The health status or cause of death of parents, siblings and children
Specific diseases related to problems identified in the Chief Compliant, HPI, or ROS
Diseases of family members which may be hereditary or place the patient at risk
Social History (SH): An age appropriate review of the patient’s past and current activities which may include significant information about:
Marital status and/or living arrangements
Current employment
Occupational history
Use of drugs, alcohol or tobacco
Level of education
Sexual history
Other relevant social factors

 

[TexasPhysician]

so like with the 99214.....how would you justify things like the social history and past surgical hx and stuff every visit? or would that just be for intakes?

I think it's more difficult than he/she explained, but I haven't seen how the codes work for psych.

In IM, you need a certain number of diagnoses/med changes/difficulty per visit to qualify to bill for a higher code.

 

[BS81]

I think it's more difficult than he/she explained, but I haven't seen how the codes work for psych.

In IM, you need a certain number of diagnoses/med changes/difficulty per visit to qualify to bill for a higher code.

Yes, it's based on the level of "medical decision making", it's surprisingly easy to qualify for a moderate decision making category... here are some examples

And for some reference Level 1s are minimal MDM, Level 2 (99212,99202) is straightforward, Level 3 is low MDM (99213,99203), Level 4 is moderated, etc...

So a psychiatrist would see at minimum the Level 3s who are stable and primarily the Level 4s for med management follow-up

Straightforward MDM

The straightforward level of MDM might apply to a patient with some very mild depressive symptoms, who has no other medical problems and no medical evaluation component. It is probably too low a level to apply to most situations, except, perhaps, when a "watchful waiting" decision for minor depression seems appropriate.

Low MDM

The low MDM level might apply to a patient with some mild depressive symptoms and 1 or 2 medical issues or medications, with low risks involved with the depressive symptoms. Patients presenting with an episode of major depressive disorder would most likely require a higher level of MDM, especially if there are medical comorbidities and/or use of medications.

Moderate MDM

The moderate MDM level seems appropriate for a patient with a DSM-IV Axis I psychiatric diagnosis (such as major depressive disorder, substance induced mood disorder, or adjustment disorders). The presence of medical comorbidities complicating the psychiatric diagnosis (such as comorbid arthritis, cancer, bowel disease, etc.), as well as the use of psychotropic medication and issues involved in the use of multiple medications, would justify this level of MDM.

High MDM

A high level of MDM would be justified with a depressed patient in the presence of hallucinations, drug withdrawal panic attacks, suicidality, or severe depression requiring an urgent visit. It is likely that a patient of this severity would be referred to the mental health care sector.

Appendix C of the 2003 CPT manual4 provides some pertinent examples. The application of these criteria to psychotherapy or counseling visits is not intuitively obvious. Even though examples listed in the CPT manual have particular specialties identified, applicability is not limited to any particular specialty. Example 1 is for code 99204, an initial office visit for a 17-year-old adolescent girl with depression. Example 2 is for code 99214, an office visit for a 52-year-old, established male patient, with a 12-year history of bipolar disorder responding to lithium carbonate and brief psychotherapy. Both psychotherapy and a prescription are provided. The third example given is for code 99215, an office visit for a 27-year-old, established female patient with bipolar disorder who was stable on treatment with lithium carbonate and monthly supportive psychotherapy but who has developed symptoms of hypomania. (Other examples of 99215 indicate that high complexity MDM would be justified by the presence of hallucinations, severe depressive symptoms requiring an urgent visit, or comorbid panic attacks related to drug abstinence). No examples are provided for psychiatry services for codes 99212–13.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC427609/

 

[TexasPhysician]

Yes, it's based on the level of "medical decision making", it's surprisingly easy to qualify for a moderate decision making category... here are some examples

And for some reference Level 1s are minimal MDM, Level 2 (99212,99202) is straightforward, Level 3 is low MDM (99213,99203), Level 4 is moderated, etc...

So a psychiatrist would see at minimum the Level 3s who are stable and primarily the Level 4s for med management follow-up



http://www.ncbi.nlm.nih.gov/pmc/articles/PMC427609/

My program made me sit through an E&M preparation talk that was non-psych specific. Useless.

Under IM rules for psych to qualify as level 3, we must have 3+ diagnoses/patient and adjust meds at every visit. That's how I understood it. I could be wrong and I hope they better explain it to me soon.

 

[BS81]

Everything should be a lot more clear when the new guidelines come out this fall when psychiatrists will be forced to use E/M codes.

 

[SomeDoc]

My impression has been that being fellowship-trained is not necessarily an absolute requirement in order to practice in some of these fields (ex consult psych/addictions/geriatrics)

That being said, I've thusfar heard from two attendings that it would be a benefit to employees seeking someone who would be willing to fill an administration role at a facility (or in academics- which I have little interest in). The issue is, is the pay in administrative positions really that much different, to forego a year of earning an attendings salary- that is, does it really make financial sense to work a year losing 100K that could be wisely-invested or used to pay off loans, not to mention there is the issue of accrued capitalized interest on existing student loan principal. Typically the additional salary from fellowships in our field generally lead to a 10-year return on investment assuming a conservative 10% increase in annual net income. One attending mentioned that the amount he makes from his side subspecialty is small in comparison (but the amount stated was significant, objectively speaking) to his salary as an administrator. I did not ask for details, but I did get a gestalt of the message he was trying to convey.

Do administrative roles make financial sense, or is this n=1 an anomaly?

 

[michaelrack]

Seems like a bad deal for them. I would think that illicit drugs would be much cheaper than suboxone (and why get clean if getting clean means you're still stealing and turning tricks?). I certainly believe you though.

this was 2nd hand info (from other providers in the area). I think illicit drugs cost more, but I could be wrong. I think persons with addiction d/o's are willing to do much more to get illicit drugs than suboxone.

 

[michaelrack]

My program made me sit through an E&M preparation talk that was non-psych specific. Useless.

Under IM rules for psych to qualify as level 3, we must have 3+ diagnoses/patient and adjust meds at every visit. That's how I understood it. I could be wrong and I hope they better explain it to me soon.

When I see pts, I bill E/M codes. That is inaccurate for a 99213: http://emuniversity.com/Level3EstablishedOfficePatient.html

 

[michaelrack]

etc...

So a psychiatrist would see at minimum the level 3s who are stable and primarily the level 4s for med management follow-up



http://www.ncbi.nlm.nih.gov/pmc/articles/pmc427609/

agree

 

[michaelrack]

How much increased risk is there with Suboxone? I don't see how you could get into more trouble with this than say Ambien. What am I missing?

I believe the risk is similar to opioids.

 

[F0nzie]

How much increased risk is there with Suboxone? I don't see how you could get into more trouble with this than say Ambien. What am I missing?

 

[F0nzie]

Go Tramadol!

 

[michaelrack]

The rate of abuse of a drug is not the same as the rate of DEA/state oversight

 

[whopper]

How much increased risk is there with Suboxone? I don't see how you could get into more trouble with this than say Ambien.

Suboxone has a street value. Some people have intentionally exaggerated their need for it so they could get more of it than needed and sell the rest. There is Internet chatter that crushing the tablets and snorting them could cause euphoria though it's not as good as traditional opioids.

Overall the abuse potential with Suboxone is less vs. other opioids but it's still there. I had a patient that tapered down his dosage to 8 mg a day, and sold his other 8 mg. I only found out about because he was arrested. An anonymous tipster even told my office he was doing this before the arrest but I felt I could not hold it against him because for all I knew it was some idiot trying to screw with this guy. I did bring it up to the patient and he refused he was selling any.

 

[F0nzie]

I agree that gathering data to provide an accurate measurement of drug abuse or diversion is problematic as deception is a key pathology in addiction. The extra safeguards (ie. formulation with naloxone, routine monitoring, sublingual film) limit it's potential for abuse, but there are always ways to hack the system. I personally, do not have a Suboxone clinic to provide any anecdotal evidence, but I can imagine that **** hits the fan all the time with routine drug testing. We should never underestimate how far addicts will go to abuse meds. We even need to be careful with prescribing them seemingly inconspicuous meds such as Seroquel or Wellbutrin. In my despair, I'm waiting for the nation to start crushing up and snorting Flintstones vitamins. 10 million strong and growing.

 

[michaelrack]

. In my despair, I'm waiting for the nation to start crushing up and snorting Flintstones vitamins. .

http://www.thesmokinggun.com/buster/overdose-using-flintstones-vitamins-654912

http://www.carbonpoker.ag/blog/80-of-poker-players-abuse-substances-0626-27/

 

[toothless rufus]

is it certain that the 90862 will be abolished?

my big question is this: if the 90862 is abolished and the lowest level of care we can do for a med check is 90805(with the next being 90807):

1) are insurers likely to drop their rates for this code, as it now represents the lowest level of care?

2) are insurers going to make us space pts out more for the lowest level visits/lower the cap on total visits?

3) for outpt providers who have a set number of pts, mostly now 90862's, are they going to be able to keep all these pts? Or are insurers going to be real strict about how they are coded?

I could see this turning out bad potentially for psych. I certainly don't need anywhere near 30 minutes to see most follow up patients for med mgt.

I don't understand why/how these strange outside forces dictate physician billing. What gives them the right/ability to do this?

If you want to do 15 min med checks as a physician that is your prerogative, no? So whomever this is is deciding our SALARIES?! Was ther enot a time when you billed for what you did and were paid for what you billed? We really need a union.

So if I want to do, or rather all that is necessary for a pt load for a particular day is 15 min med check and I see 4 pt/hr x 10 hr I cannot bill for 40 pts but rather only for the time for 3/hr x 10 hr=30. Then multiply that by a year. Thats a huge daily decrease in billable earnings. Beyond NOT COOL. This is an enormous bummer. I don't understand why we cannot prevent this. By the time I finish residency sounds like I'll be taking a pay cut.

 

[digitlnoize]

I don't understand why/how these strange outside forces dictate physician billing. What gives them the right/ability to do this?

If you want to do 15 min med checks as a physician that is your prerogative, no? So whomever this is is deciding our SALARIES?! Was ther enot a time when you billed for what you did and were paid for what you billed? We really need a union.

So if I want to do, or rather all that is necessary for a pt load for a particular day is 15 min med check and I see 4 pt/hr x 10 hr I cannot bill for 40 pts but rather only for the time for 3/hr x 10 hr=30. Then multiply that by a year. Thats a huge daily decrease in billable earnings. Beyond NOT COOL. This is an enormous bummer. I don't understand why we cannot prevent this. By the time I finish residency sounds like I'll be taking a pay cut.

Amen. Plus, they've duped us into doing their paper pushing for them, on our dime. No thank you.

Yet another reason to do cash only.

 

[vistaril]

Amen. Plus, they've duped us into doing their paper pushing for them, on our dime. No thank you.

Yet another reason to do cash only.

well the problem with cash only if you are doing outpt is you are going to miss out on a lot of easy hanging fruit.....meaning stable med mgt patients with insurance who require little time and even less thought that for some illogical reason want to see a psychiatrist.

if I had a large outpt practice, I wouldnt want to miss that group

 

[F0nzie]

I wonder what % of outpatient psychiatrists work full-time and cash only.

 

[vistaril]

I wonder what % of outpatient psychiatrists work full-time and cash only.

a very low %....less than 10% for sure

 

[whopper]

eaning stable med mgt patients with insurance who require little time and even less thought that for some illogical reason want to see a psychiatrist.

Agree. As for cash-only wealthy patients, they can be entitled, time consuming, and more frustrating than borderline PD patients. I'd go as far as to say they have a type of personality similar to borderline PD where there is poor frustration tolerance and delayed gratification, especially if the person came from money and didn't earn it on their own. This is not everyone with money, but as a demographic, it's a lot of them. I've noticed that some people are wealthy enough to keep their Axis II traits going on. For most practical people, they must force themselves out of it because they have to function at work, or it's so severe that they can't. That group are usually people that fall to the bottom of the SES scale.

I had one wealthy patient whose husband would have the lawyer call me up almost weekly for the first few weeks, talk to me as if she were probing me for a lawsuit. I mentioned this in another thread where I told the lawyer point blank that I did nothing wrong and that there was no malpractice case (the lawyer threatened to have me sued). I told her there wasn't even enough criteria for it to meet an arguable definition of malpractice and we both knew it would be thrown out of court.

Turned out they went to several doctors and almost every doctor they saw they sued. Wealthy patients that are litigious are a pain in the neck because if the lawyer tells an unwealthy plaintiff there's no case, fine-it's almost always dropped because there's no money to be had and now the plaintiff will have to pay big money for something with no chance of succeeding. Wealthy people can have their lawyer keep it up even if the defendant did nothing wrong in an attempt to simply screw that defendant with wasted time and legal fees.

Of the uber-wealthy people I've treated, it ranged from problematic like above, to seeing someone who tended to be quite the opposite-friendly, polite, humble, and working with me in a beneficial and realistic manner. The latter tended to be people who didn't start out wealthy and built themselves up. As I mentioned there are exceptions.

 

[digitlnoize]

a very low %....less than 10% for sure

It's way more than this, at least in child. Most child psychs will give the patient a super bill which they can file themselves. Many patients can get in-network reimbursement rates even if the psychiatrist isn't in the network, if they can show that there's not an in-network guy nearby, which in child is often the case...at least around these parts...

In this way, you still get to see the insured people, but don't have to deal with the headaches. At the same time, psych billing isn't the most difficult thing in the world either. Much more straight forward (historically) than our medical counterparts.

Not sure about adult...

 

[aphenomenon]

Couple of responses:

-There are two main "abuse" potentials with buprenorphine. One is with injecting it...and most of the good literature on that is from malaysia and georgia. The other is diversion where people on the street are using it primarily to self-medicate withdrawal, to pop when they can't get opiates for a day, etc. There are others, yes, like snorting, but that is relatively infrequent.

-There is so much more nuance to addiction psychiatry pharmacology and even proper prescribing of these meds than "just suboxone/methadone." E.g. using naltrexone for alcohol in Caucasians and Asians, but not African Americans e.g. only prescribing acamprosate about a week after detox e.g. using naltrexone for opiates in pilots and doctors etc. etc. etc.

 

[vistaril]

It's way more than this, at least in child. Most child psychs will give the patient a super bill which they can file themselves. Many patients can get in-network reimbursement rates even if the psychiatrist isn't in the network, if they can show that there's not an in-network guy nearby, which in child is often the case...at least around these parts...

In this way, you still get to see the insured people, but don't have to deal with the headaches. At the same time, psych billing isn't the most difficult thing in the world either. Much more straight forward (historically) than our medical counterparts.

Not sure about adult...

yeah I'll agree that in child it is more than 10%. Still they are a distinct minority compared to people who do accept insurance.