Question about billing extra in private practice

[HarryMTieboutMD]

So I'm in my 4th year of residency and have some long term patients from PGY3 that I am seeing this year as well (this is the norm in most residencies I think).

Though I picked my most interesting patients that I enjoy given that I am on PGY4 clinical rotations and doing research, sometimes I get really annoyed by the time that gets chipped away with this: making the trek over to the outpatient clinic (mega academic hospital complex), having to check in when patients call the clinic, calling in controlled Rx's, prior auths, patients no showing when I build my daily schedule around them, etc.

Hypothetical question: Now, these are obviously small annoyances in the scheme of things, but I'm wondering in a (cash only setting, insurance would be more complicated), how much can one bill for these ancillary things that effectively eat at time? I know most outpatient doctors will charge a fine (usually the same cost the appointment) for no shows or cancellations sooner than expected, but could you bill for time spent calling in a controlled rx (rather than the patient just taking a paper script from your office), calling because they are in "crisis mode" or whatever, etc etc.

Lawyers seem to charge for every second of client contact- could private practice CASH ONLY MDs do the same?

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[splik]

you can technically charge for anything but people will get really annoyed (rightly so) if you nickle and dime them for everything. doing prior auths and calling in necessary prescriptions (i.e. not early refills or things related to patient's own disorganization or failure to turn up) are part of your job and should be worked into the rate you are charging to see the patient. but yes you should absolutely bill for calls greater than 5 minutes if frivolous (if it seems like a genuine thing then you can opt to waive the fee) and for calling in refills or stuff because the pt did not show up or failed to plan ahead. But no, it is in my view, inappropriate to charge for things that should be reasonably expected as part of your job. and it invites complaints (frivolous as they may be) if you charge people for things and patients react with righteous indignation or narcissistic injury etc.

tl;dr your hourly rate should factor in these annoyances; you can charge for anything but really should only charge for >5min calls and refill requests that result as a result of failure of the patient to turn up/plan ahead.

 

[clausewitz2]

Lawyers seem to charge for every second of client contact- could private practice CASH ONLY MDs do the same?

You do know that many people hate lawyers for this very reason, right? Thing is, you can hate your attorney and he can still help you achieve your objectives/you may feel compelled to keep using his services. Hate your psychiatrist...you will probably just find a cheaper psychiatrist who you don't hate eventually.

 

[HarryMTieboutMD]

You do know that many people hate lawyers for this very reason, right? Thing is, you can hate your attorney and he can still help you achieve your objectives/you may feel compelled to keep using his services. Hate your psychiatrist...you will probably just find a cheaper psychiatrist who you don't hate eventually.

There's such a dearth of good quality psychiatrists that if you get to the point where you are cash only, I doubt this would be an issue as long as you make your billing policies clear up front. But it location is key, as well. In places where the market is saturated (NYC, SF) you would have to be REALLY established and senior to get away with this, I presume. However in St Louis, the area west of the city is one of the wealthiest areas in the country (hence the protests there are deliberate), and patients from this area are willing to pay cash for high level care. Also, there are basically two strains of psychiatrists (in terms of quality) in STL- the ones who trained at Wash U (or similar, but Wash U trained psychiatrists naturally have bigger #s) and the ones who trained at lower tier programs, who, for the most part are incompetent. A good number of the Wash U trained guys/women in private practice in the west county area are cash only with waiting lists. Some take insurance to diversify, but they all do VERY well

 

[clausewitz2]

There's such a dearth of good quality psychiatrists that if you get to the point where you are cash only, I doubt this would be an issue as long as you make your billing policies clear up front. But it location is key, as well. In places where the market is saturated (NYC, SF) you would have to be REALLY established and senior to get away with this, I presume. However in St Louis, the area west of the city is one of the wealthiest areas in the country (hence the protests there are deliberate), and patients from this area are willing to pay cash for high level care. Also, there are basically two strains of psychiatrists (in terms of quality) in STL- the ones who trained at Wash U (or similar, but Wash U trained psychiatrists naturally have bigger #s) and the ones who trained at lower tier programs, who, for the most part are incompetent. A good number of the Wash U trained guys/women in private practice in the west county area are cash only with waiting lists. Some take insurance to diversify, but they all do VERY well

Fair enough as it goes, but I am willing to bet they have waiting lists partly because they are not actually itemizing their bills in ten minute increments and asking for money every time they even discuss someone's case with a colleague or read a letter.

 

[slappy]

I guess you can always try it out and see what happens?

 

[medium rare]

I've been doing a cash only practice for 8 years; I'm completely booked with a waiting list. In my opinion, it's better (and simpler) to charge a higher rate to factor in the additional time ancillary practice activities require than to do itemized billing.

 

[HarryMTieboutMD]

I guess you can always try it out and see what happens?

I plan on staying in academia, starting out in research and hopefully tenure track and for my clinical duties seeing medicaid/uninsured because they are much more grateful for their care (including the personality disorders, comparatively) and are more gratifying to treat.

If I'm at an institution that allows private practice (meaning, the NYC model) I would just do it for the money (cash only if possible) and have no issues charging very high rates for upper SES patients, in a similar manner as lawyers. Their entitlement is painful enough- once in child clinic (where the patients are officially are our attendings, so we see them and staff) I had an upper SES white male parent tell me (regarding his child's care) "you know, sometimes you go to a great college and you expect a famous professor, but you end up getting a TA". I would have told him to go f himself were my attending (famous) not in the room

Wouldn't you love to have managed Susannah Calahan's antipsychotics while she drank heavily after discharge, had an inappropriate relationship with her neurologist, and derided psychiatry? (Brain on fire/anti nmda encephalitis woman- the paragon of white privilege who is basically a combination of libby zion and jenny mccarthy)

 

[slappy]

I plan on staying in academia, starting out in research and hopefully tenure track and for my clinical duties seeing medicaid/uninsured because they are much more grateful for their care (including the personality disorders, comparatively) and are more gratifying to treat.

If I'm at an institution that allows private practice (meaning, the NYC model) I would just do it for the money (cash only if possible) and have no issues charging very high rates for upper SES patients, in a similar manner as lawyers. Their entitlement is painful enough- once in child clinic (where the patients are officially are our attendings, so we see them and staff) I had an upper SES white male parent tell me (regarding his child's care) "you know, sometimes you go to a great college and you expect a famous professor, but you end up getting a TA". I would have told him to go f himself were my attending (famous) not in the room

Wouldn't you love to have managed Susannah Calahan's antipsychotics while she drank heavily after discharge, had an inappropriate relationship with her neurologist, and derided psychiatry? (Brain on fire/anti nmda encephalitis woman- the paragon of white privilege who is basically a combination of libby zion and jenny mccarthy)

I don't know if you meant to quote my post, but it sounds like you're trying to justify (to yourself mostly) your decision to charge a certain population a lot of money. Do whatever will make you happy. Sometimes it is a good idea to plunge in without thinking too much.

About Cahalan, I honestly wouldn't have felt any way about her if I was her psychiatrist. I distance myself from patients a lot (my own limitation; also why I enjoy consultative type of work in addition to research), so if someone doesn't want to take my advice (or tries to devalue), I shrug and move on. Despite my self-proclaimed narcissism, I don't seem to suffer narcissistic injuries.

 

[justfolks]

In places where the market is saturated (NYC, SF) you would have to be REALLY established and senior to get away with this, I presume.

Just a patient, in NYC (Manhattan), see a cash-only psychiatrist, $350/45 mins. I would be pretty surprised if anyone charged for calls and texts, have never heard of that happening. As others said, I think the general expectation is that when you are paying that much in cash, the occasional phone call and text is basically included.

 

[splik]

If you have such negative countertransference to rich white people, you have no business treating them. Physicians who nickle and dime their patients are basically telling their patients they are a narcissistic douche and tend to encourage complaints from their patients, defaults on billings, frivolous lawsuits, and complaints to the medical boards. Not all wealthy people are insufferable, and there are plenty of poor people who are entitled demanders too. wealthy people are cheap, which is how they accumulate their wealth in the first place, and will be quite happy to not pay anything that provokes their righteous indignation or tells them they are being had. and you won't win. also there are plenty of people who aren't really wealthy who are willing to pay out of pocket to see a psychiatrist (hell ive had medicaid patients pay cash to see a shrink) and there are more of those people than there are the wealthy entitled demanders.

Hell, even lawyers don't like the be nickle and dimed for everything even though they do it themselves. medicine is not law. one of the (many) nice things about doing expert witness work is that you can bill for all the collateral, record review, report writing, telephone calls, prep with attorney etc. Its not appropriate to this in clinical practice. Some people have a membership model where there is an annual or monthly fee to be part of a clinic, and that fee will get you unlimited access in terms of calls, speedy appointments, coordination of care, family meetings etc etc. which is another way of doing it.

you cant treat patients you don't like.

 

[HarryMTieboutMD]

you cant treat patients you don't like.

Of course you can...

"The mode of production of material life conditions the social, political and intellectual life process in general. It is not the consciousness of men that determines their being, but, on the contrary, their social being that determines their consciousness." -Marx

 

[Crayola227]

I don't know if you meant to quote my post, but it sounds like you're trying to justify (to yourself mostly) your decision to charge a certain population a lot of money. Do whatever will make you happy. Sometimes it is a good idea to plunge in without thinking too much.

About Cahalan, I honestly wouldn't have felt any way about her if I was her psychiatrist. I distance myself from patients a lot (my own limitation; also why I enjoy consultative type of work in addition to research), so if someone doesn't want to take my advice (or tries to devalue), I shrug and move on. Despite my self-proclaimed narcissism, I don't seem to suffer narcissistic injuries.

The irony is that many narcissists, self proclaimed or not, claim this as well. It makes a lot of sense, actually.

 

[Crayola227]

Of course you can...

"The mode of production of material life conditions the social, political and intellectual life process in general. It is not the consciousness of men that determines their being, but, on the contrary, their social being that determines their consciousness." -Marx

I'll commit the sin of not providing citations, but I recall in medical school more than one study that came by my virtual desk supporting the following conclusions, some was part of our formal curriculum

-for the most part, people think they are good at spotting liars
-for the most part, people aren't actually good at it at all, in RCTs
-however, people are *very* good at gauging how much someone likes them, even in professional and formal scenarios
-patients are very good at telling how much their doctor likes them
-how much a patient perceived their physician liking them, was one of the number one predictors of how much the patient in turn liked the physician
-patients that like their physicians and feel they are liked back, are more adherent
-this was actually independently linked to hard outcome measures like lowered Ha1c
-this was actually one of the biggest predictors

Yes, you can treat patients even when you hate them and your job. But assuming competence, your colleague that actually gives a shyte will always be more effective than you, comparatively. I'd really be willing to bet this effect is even more important in psychiatry than in treating DM.

TLDR:
Stop pissing on the therapeutic alliance. What the patient and the physician feel about each other matters a lot. It might be one of the number one factors affecting adherence.

 

[Crayola227]

and I agree with @splik , rich or poor, no one likes someone they perceive as greedy and money-grubbing

I shouldn't have to explain to anyone here the benefits of likeability

 

[slappy]

The irony is that many narcissists, self proclaimed or not, claim this as well. It makes a lot of sense, actually.

Does it? Hopefully this isn't too much of a digression from the thread, but would you mind expounding on this a bit?

Although I don't actually think I'm a narcissist. I just claim that. I do have a ginormous ego.

 

[Crayola227]

Does it? Hopefully this isn't too much of a digression from the thread, but would you mind expounding on this a bit?

Although I don't actually think I'm a narcissist. I just claim that. I do have a ginormous ego.

eh, part of the a typical narcissistic facade, if you were to try to point out how their ego is "fragile" or they are prone to narcissistic injury, they will claim they aren't

at least in my experience with them

classic "don't admit you have a weakness" thing

 

[slappy]

eh, part of the a typical narcissistic facade, if you were to try to point out how their ego is "fragile" or they are prone to narcissistic injury, they will claim they aren't

at least in my experience with them

classic "don't admit you have a weakness" thing

Ah, gotcha.

 

[clausewitz2]

eh, part of the a typical narcissistic facade, if you were to try to point out how their ego is "fragile" or they are prone to narcissistic injury, they will claim they aren't

at least in my experience with them

classic "don't admit you have a weakness" thing

I think it depends on what specific flavor of narcissist we are talking about. Some people have wanted to draw a distinction between overt and covert narcissism, or grandiose v. vulnerable. An overt narcissist, in this telling, is not going to have a problem endorsing that they are a narcissist because they are awesome and want everyone to know about it. The covert narcissist hides behind a facade of modesty. The DSM naturally is framed around the more overt form of narcissism, but some of the personality literature supports the idea of a second subtype.

 

[NickNaylor]

If you have such negative countertransference to rich white people, you have no business treating them. Physicians who nickle and dime their patients are basically telling their patients they are a narcissistic douche and tend to encourage complaints from their patients, defaults on billings, frivolous lawsuits, and complaints to the medical boards. Not all wealthy people are insufferable, and there are plenty of poor people who are entitled demanders too. wealthy people are cheap, which is how they accumulate their wealth in the first place, and will be quite happy to not pay anything that provokes their righteous indignation or tells them they are being had. and you won't win. also there are plenty of people who aren't really wealthy who are willing to pay out of pocket to see a psychiatrist (hell ive had medicaid patients pay cash to see a shrink) and there are more of those people than there are the wealthy entitled demanders.

I completely agree. There are entitled, demanding folks in both populations. People from both populations can be tiresome to work with, often just for different reasons.

I would say that, in general, the wealthier patients tend to be, on the whole, more grateful for the care they receive than the more indigent folks in my experience. That being said, I’ve found it’s often easier to make small changes in a poorer patient’s life - be it fairly straightforward psychosocial stuff or small medication changes - than in a wealthier patient’s life, which can make the work more satisfying.

Whatever floats your boat, I guess. There are going to be downsides no matter what.

 

[Salpingo]

So I'm in my 4th year of residency and have some long term patients from PGY3 that I am seeing this year as well (this is the norm in most residencies I think).

Though I picked my most interesting patients that I enjoy given that I am on PGY4 clinical rotations and doing research, sometimes I get really annoyed by the time that gets chipped away with this: making the trek over to the outpatient clinic (mega academic hospital complex), having to check in when patients call the clinic, calling in controlled Rx's, prior auths, patients no showing when I build my daily schedule around them, etc.

Hypothetical question: Now, these are obviously small annoyances in the scheme of things, but I'm wondering in a (cash only setting, insurance would be more complicated), how much can one bill for these ancillary things that effectively eat at time? I know most outpatient doctors will charge a fine (usually the same cost the appointment) for no shows or cancellations sooner than expected, but could you bill for time spent calling in a controlled rx (rather than the patient just taking a paper script from your office), calling because they are in "crisis mode" or whatever, etc etc.

Lawyers seem to charge for every second of client contact- could private practice CASH ONLY MDs do the same?

In law, the relationship is with the work at hand, while in private practice psychiatry, the relationship is with the patient.

You can certainly treat patients you don't like, but that doesn't mean they'll want to be treated by you. If there's a scarcity of shrinks, they may put up with it. If you're charging them as part of a sadistic enactment, then you might even find a niche treating masochists. But I'll echo what's already been said: there are many ways to stay/become poor, and many ways to stay/become wealthy. Some of the most entitled patients I have are the poorest, and some of the most appreciative are exorbitantly wealthy.

I also don't understand what the slight was behind the father's TA comment. It seems to be accurate and an appropriate rationalization to defend against the anxiety of putting the care of their loved one in a complete strangers hand. Many patients (including poor one) would refuse to see a trainee offhand.

 

[Salpingo]

I completely agree. There are entitled, demanding folks in both populations. People from both populations can be tiresome to work with, often just for different reasons.

I would say that, in general, the wealthier patients tend to be, on the whole, more grateful for the care they receive than the more indigent folks in my experience. That being said, I’ve found it’s often easier to make small changes in a poorer patient’s life - be it fairly straightforward psychosocial stuff or small medication changes - than in a wealthier patient’s life, which can make the work more satisfying.

Whatever floats your boat, I guess. There are going to be downsides no matter what.

I would argue that the ideal private practice patient is wealthy enough to afford the luxury of 45 minutes spent on self-reflection, but not so wealthy that paying the fee for a missed appointment is inconsequential.

 

[futuredo32]

So I'm in my 4th year of residency and have some long term patients from PGY3 that I am seeing this year as well (this is the norm in most residencies I think).

Though I picked my most interesting patients that I enjoy given that I am on PGY4 clinical rotations and doing research, sometimes I get really annoyed by the time that gets chipped away with this: making the trek over to the outpatient clinic (mega academic hospital complex), having to check in when patients call the clinic, calling in controlled Rx's, prior auths, patients no showing when I build my daily schedule around them, etc.

Hypothetical question: Now, these are obviously small annoyances in the scheme of things, but I'm wondering in a (cash only setting, insurance would be more complicated), how much can one bill for these ancillary things that effectively eat at time? I know most outpatient doctors will charge a fine (usually the same cost the appointment) for no shows or cancellations sooner than expected, but could you bill for time spent calling in a controlled rx (rather than the patient just taking a paper script from your office), calling because they are in "crisis mode" or whatever, etc etc.

Lawyers seem to charge for every second of client contact- could private practice CASH ONLY MDs do the same?

Based on your U-M avatar, Ann Arbor is the most saturated city in MI with psychiatrists and the going rate for cash is $275 for child psychiatrists. I started in A2 with a former attending and moved to Ypsi. I take insurance and don't bill for phone consults or calling in meds but do charge full fee for missed apppointments after the first one unless they are ill. Most of my patients are therapy/med patients although I do see some patients for just therapy and some patients for just meds. Ann Arbor is a very diverse area to practice in as you get some very wealthy patients from Ann Arbor and Saline and some very poor patients from Ypsi, Belleville. And I have quite a few that drive over an hour.

 

[HarryMTieboutMD]

Based on your U-M avatar, Ann Arbor is the most saturated city in MI with psychiatrists and the going rate for cash is $275 for child psychiatrists. I started in A2 with a former attending and moved to Ypsi. I take insurance and don't bill for phone consults or calling in meds but do charge full fee for missed apppointments after the first one unless they are ill. Most of my patients are therapy/med patients although I do see some patients for just therapy and some patients for just meds. Ann Arbor is a very diverse area to practice in as you get some very wealthy patients from Ann Arbor and Saline and some very poor patients from Ypsi, Belleville. And I have quite a few that drive over an hour.

Yeah I did my undergrad at Michigan-- the only reason I'd live there again is to be on faculty at Michigan (not in my immediate plans) at which point I'd keep my clinical duties confined to the medical center/UM health system. Compared to other top tier institutions they pay their faculty rather well