RVUs and the like

[smalltownpsych]

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Schedule 8 to get 6 seems a reasonable goal for someone in private practice. Not what I would want to do (for similar reasons to erg) but if that is someone's goal I don't think its incredibly unreasonable. 8-5, notes during lunch/no-shows (since you've eliminated that 15 minute "gap" you get when scheduling 45 minute sessions).

That said, there are some other issues I think may play into this that I am hoping someone else can comment on. I'd think ONLY doing 60 minute sessions would raise flags with insurers. I think our collection rate on these is lower, presumably for that reason. Standard of care issues and all that. Neither insurance nor our billing staff seems to understand that the length of session is more dependent on the length of session is more dependent on the patient's tendency to keep talking despite repeated attempts to shuffle them out the door than it is on medical necessity, problem severity or anything else. I suspect the same is true in medicine/primary care practices.

That said - if I can I'll do back-to-back 60 minute sessions on my clinic days. Bmed/primary care type settings it makes financial sense to pile in 30 minute sessions if patient flow allows. I might do this with CBT-I patients too. Both models would pay better than 45-minute sessions would.

I do about 50/50 with 45 verses 60 minutes with the occasional 30 minute thrown into the mix. Often the longer time is clinically indicated especially with trauma patients. We don't dive right in to the trauma, open up the wounds, and then usher them out the door while they are still bleeding which is about how it would work to keep it within 45 minutes. Also, many patients think of therapy as an hour so 55 minutes makes sense to them. Also, United Behavioral Health will deny any claim for 60 minute session without prior auth.

 

[WisNeuro]

That's it?
The VA doesn't give you 4 weeks off at least? (on top of holidays)?

I get 19.5 vacation days a year, on top of all Federal US holidays. We get plenty, but as Erg said, sometimes we like to bank some of those up.

 

[AcronymAllergy]

That's it?
The VA doesn't give you 4 weeks off at least? (on top of holidays)?

VA starts (for non-physicians and non-nurses) at 4 hours per pay period, which = 104 hours/year, which = 13 days/year. It jumps up to 6 hours per pay period after 3 years, and then 8 hours (which physicians and nurses start at) after...12 or 15 years maybe?

 

[Therapist4Chnge]

VA starts (for non-physicians and non-nurses) at 4 hours per pay period, which = 104 hours/year, which = 13 days/year. It jumps up to 6 hours per pay period after 3 years, and then 8 hours (which physicians and nurses start at) after...12 or 15 years maybe?

Wow..,I didn't realize there was such a large disparage in the VA system between earned time off between physicians and psychologists. I believe it is pretty close at my AMC, though we avoided weekend coverage. 😀

 

[erg923]

Wow..,I didn't realize there was such a large disparage in the VA system between earned time off between physicians and psychologists. I believe it is pretty close at my AMC, though we avoided weekend coverage. 😀

Physicians are not title 38. Their leave is in days, not hours.

I get 6 hours annual leave, and the 4 hours sick leave per pay period. To me it builds up pretty quick, but then again we not have done Disney, Disney cruise, etc yet.

 

[deleted343839]

My system has a similar accrual system based on years in service, but there is no distinction between MDs and PhDs - faculty are faculty.

 

[AcronymAllergy]

My system has a similar accrual system based on years in service, but there is no distinction between MDs and PhDs - faculty are faculty.

Yeah, with VA, it's mostly just that (as erg said) physicians and nurses are title 38 while psychologists are hybrid title 38. Thus, there's some greater flexibility for psychologists in some areas, but in others (e.g., wages, leave accumulation), they're the same as title 5 employees (i.e., traditional civil service employees).

 

[Ollie123]

My system has a similar accrual system based on years in service, but there is no distinction between MDs and PhDs - faculty are faculty.

Same here. I started at 20 vacation, 13 holiday, 13 sick which is quite nice for Year 1. That said, true to it being a faculty position - leave is pretty much discretionary anyways. No one seems to know where we enter it or how it is being tracked.

 

[erg923]

Same here. I started at 20 vacation, 13 holiday, 13 sick which is quite nice for Year 1. That said, true to it being a faculty position - leave is pretty much discretionary anyways. No one seems to know where we enter it or how it is being tracked.

So, does the RVU targets historically account for leave usage?

VA RVU targets are partly so low because I think the factor in the "average" amount of leave usage (per fiscal year) for psychologists across all VAs.

 

[Sanman]

I am at 6 holidays and 15 days combined (sick vacation, educational). I really need go think about applying to the VA.

 

[WisNeuro]

I am at 6 holidays and 15 days combined (sick vacation, educational). I really need go think about applying to the VA.

You can also bank up to 240 vacation hours and sick leave hours roll over with no cap. Also, most places will give you authorized absence (no vacation days used) for going to conferences if you are on business (presenting VA research, interviewing for postdocs, etc).

 

[erg923]

I am at 6 holidays and 15 days combined (sick vacation, educational). I really need go think about applying to the VA.

Dude, that blows!

 

[erg923]

You can also bank up to 240 vacation hours and sick leave hours roll over with no cap. Also, most places will give you authorized absence (no vacation days used) for going to conferences if you are on business (presenting VA research, interviewing for postdocs, etc).

all sick leave hours rolls over, I think.

I came into VA with 85 hours of sick leave since I only used like 2 days when I was an intern in the VA system.

 

[WisNeuro]

all sick leave hours rolls over, I think.

I came into VA with 85 hours of sick leave since I only used like 2 days when I was an intern in the VA system.

Yeah, you can get sick leave hours from training (intern, postdoc), you just have to stay on some HR's to make sure they impute it once you are full-time. I'm at almost 400 hours, I think.

 

[erg923]

Yeah, you can get sick leave hours from training (intern, postdoc), you just have to stay on some HR's to make sure they impute it once you are full-time. I'm at almost 400 hours, I think.

Don't you ever got to the Dr or the dentist? lol

 

[WisNeuro]

Don't you ever got to the Dr or the dentist? lol

I rarely call in sick. And when I schedule dentist/dr appts, I always do it as early as possible, or as late as possible, so it usually only eats an hour or two at most.

 

[Sanman]

Dude, that blows!

It certainly does. The worst part is that it was exactly the same when I interviewed at competing companies in the area.

 

[erg923]

It certainly does. The worst part is that it was exactly the same when I interviewed at competing companies in the area.

? That seems very skimpy. Most of my friends in various other fields are offered waaaaay better PTO benefits than that.

 

[Sanman]

Welcome to geriatrics, where the jobs are plenty...but good jobs are rare. One major company I interviewed at and turned down offered me an 80k salary with similar time off and wanted 12 units of 90834 per day. Slave wages for that kind of work...and they employ more than 200 psychologists.

 

[erg923]

and wanted 12 units of 90834 per day.

Kill me now..

 

[Harry3990]

wanted 12 units of 90834 per day

Wow... That does not even remotely sound feasible. I'm curious how that would even work practically. I wonder if they would see clients back-to-back without even 10 minutes for note taking between in order to make the workday a bit shorter (i.e., 9-10 hours instead of 12).

 

[WisNeuro]

Welcome to geriatrics, where the jobs are plenty...but good jobs are rare. One major company I interviewed at and turned down offered me an 80k salary with similar time off and wanted 12 units of 90834 per day. Slave wages for that kind of work...and they employ more than 200 psychologists.

I can't imagine why people accept these kinds of jobs.

 

[Sanman]

Wow... That does not even remotely sound feasible. I'm curious how that would even work practically. I wonder if they would see clients back-to-back without even 10 minutes for note taking between in order to make the workday a bit shorter (i.e., 9-10 hours instead of 12).

Well it is advertised as an 8 hr job (40 min a session adds up to 8 hrs). What you have to realize is that these requirements are used to change billing habits as well. The 90832 daily requirements were more humane.

Wisneuro,

People take the jobs because they have bills to pay. I worked for a large company prior as well when I was newly graduated (luckily a more humane one). Many of those people were people with other interests that could not find a local job in their area of interest or people in PP looking to make some more reliable money part-time. Being a dual income couple limited my search as well. Otherwise I would likely be in a VA position already.

 

[psych844]

I gotta say that's a scary situation. You would hope the 5-7 year investment to become a Clinical Psych would result in good working conditions, some independence, and some flexibility..otherwise the investment makes no sense.

 

[WisNeuro]

Flexibility folks, it's important.

 

[Sanman]

I gotta say that's a scary situation. You would hope the 5-7 year investment to become a Clinical Psych would result in good working conditions, some independence, and some flexibility..otherwise the investment makes no sense.

Well, there is some flexibility in when and where you work, but everything is being driven by money now. I work with PT, OT, SLP, NP/PA, and physician colleagues that are all under similar rvu reqiurements and pressure to get billable minutes in. Everyone still talks about quality as long as long as it does not affect the bottom line. Yet, how could it not. The negative point for psychologists is that reimbursements are so low that the workload at these places is getting silly. You can opt to see less pts, but then you are not salaried and are considered a part-time employee (less than 48 rvu units per week). Keep in mind that these are all private companies, so it is all about the dollar. Many of the larger groups are owned by venture capital groups.

 

[smalltownpsych]

Well, there is some flexibility in when and where you work, but everything is being driven by money now. I work with PT, OT, SLP, NP/PA, and physician colleagues that are all under similar rvu reqiurements and pressure to get billable minutes in. Everyone still talks about quality as long as long as it does not affect the bottom line. Yet, how could it not. The negative point for psychologists is that reimbursements are so low that the workload at these places is getting silly. You can opt to see less pts, but then you are not salaried and are considered a part-time employee (less than 48 rvu units per week). Keep in mind that these are all private companies, so it is all about the dollar. Many of the larger groups are owned by venture capital groups.

You need to move out of town. I work hard, but I get paid to do it. They are making big bucks off you and they deliberately cloud the numbers with this rvu garbage to try and keep you from figuring that out. Figure out what they are billing for each code, add that up for a month and subtract your gross pay. If it is less than 60 percent then if it were me, I would begin my exit plan. My last job I loved, but when they gave me a bump from 80k to 82k, after I had solidly increased their revenue by about 40% over the course of two years, I started looking and found a new job within a month. The VA system is much better than what you are describing. Fire up that resume and since it sounds like these companies are controlling your local market, you might have to move. Don't forget to ask for those expenses to be paid.

 

[AcronymAllergy]

Well, there is some flexibility in when and where you work, but everything is being driven by money now. I work with PT, OT, SLP, NP/PA, and physician colleagues that are all under similar rvu reqiurements and pressure to get billable minutes in. Everyone still talks about quality as long as long as it does not affect the bottom line. Yet, how could it not. The negative point for psychologists is that reimbursements are so low that the workload at these places is getting silly. You can opt to see less pts, but then you are not salaried and are considered a part-time employee (less than 48 rvu units per week). Keep in mind that these are all private companies, so it is all about the dollar. Many of the larger groups are owned by venture capital groups.

Agreed, although as smalltownpsych mentioned, I think part of the issue is also perhaps that companies know psychologists don't think they're making their employers much money, and so might use that to their advantage when negotiating salary and raises.

Also, while getting better reimbursement for our billing codes would be ideal, it would also come with its own set of drawbacks. Our psychiatrist colleagues, for example, make much more for the med management codes than do we, but in similar settings, they're being asked to see 3-4 pts/hour, every hour, all day, in addition to likely being on call. Even with better pay, that's also a recipe for burnout.

 

[erg923]

Well, there is some flexibility in when and where you work, but everything is being driven by money now. I work with PT, OT, SLP, NP/PA, and physician colleagues that are all under similar rvu reqiurements and pressure to get billable minutes in. Everyone still talks about quality as long as long as it does not affect the bottom line. Yet, how could it not. The negative point for psychologists is that reimbursements are so low that the workload at these places is getting silly. You can opt to see less pts, but then you are not salaried and are considered a part-time employee (less than 48 rvu units per week). Keep in mind that these are all private companies, so it is all about the dollar. Many of the larger groups are owned by venture capital groups.

Do you at least have a window office? I dont have a window.

 

[Sanman]

You need to move out of town. I work hard, but I get paid to do it. They are making big bucks off you and they deliberately cloud the numbers with this rvu garbage to try and keep you from figuring that out. Figure out what they are billing for each code, add that up for a month and subtract your gross pay. If it is less than 60 percent then if it were me, I would begin my exit plan. My last job I loved, but when they gave me a bump from 80k to 82k, after I had solidly increased their revenue by about 40% over the course of two years, I started looking and found a new job within a month. The VA system is much better than what you are describing. Fire up that resume and since it sounds like these companies are controlling your local market, you might have to move. Don't forget to ask for those expenses to be paid.

To be clear, this is not about me. I make significantly more than quoted and my schedule is not as crazy due to testing that I do. I also don't work for that company. However, this is not about me. It is about large companies depressing the market for us as the local competition bases pay and rvu reqs based on this company. Not that moving would help too much. That company is in multiple states.


I'm not moving anywhere right now anyhow. I just bought a house and my wife has a not easily replaced job that pays well. Additionally, after a few years here, I am well known enough in the area, that I get called with job offers . I am also moving a bit to the administrative side of things. However, I do keep my eyes open for interesting positions that offer lighter workloads and better benefits.

 

[Sanman]

Do you at least have a window office? I dont have a window.

I have all the windows I want as I don't have an office in the nursing homes. 🙁
I am building a nice office in my house though.

 

[erg923]

To be clear, this is not about me. I make significantly more than quoted and my schedule is not as crazy due to testing that I do. I also don't work for that company. However, this is not about me. It is about large companies depressing the market for us as the local competition bases pay and rvu reqs based on this company. Not that moving would help too much. That company is in multiple states.


I'm not moving anywhere right now anyhow. I just bought a house and my wife has a not easily replaced job that pays well. Additionally, after a few years here, I am well known enough in the area, that I get called with job offers . I am also moving a bit to the administrative side of things. However, I do keep my eyes open for interesting positions that offer lighter workloads and better benefits.

Not sure what your personal plans are, but I cannot overstate the benefits of no call, a 40 hour work week, and separation of work from life once you have children.

I do side work outside my VA job, but I can do it from home at anytime. Usually during naps. 🙂

 

[Sanman]

Not sure what your personal plans are, but I cannot overstate the benefits of no call, a 40 hour work week, and separation of work from life once you have children.

I do side work outside my VA job, but I can do it from home at anytime. Usually during naps. 🙂

Yeah, it does sound pretty good. There is a really a lot to like about my particular job, but the workload expectations are a bit crazy. We'll see whether some changes to my position mean more work from home time and flexibility. If not, I always have my eye out if there are open positions at the VA in something related to my interests (no thank you on straight mental health). We have bit of time to sort things out before we plan on little ones. However, once that happens, we can't both be working 60+ hrs.

 

[erg923]

Yeah, it does sound pretty good. There is a really a lot to like about my particular job, but the workload expectations are a bit crazy. We'll see whether some changes to my position mean more work from home time and flexibility. If not, I always have my eye out if there are open positions at the VA in something related to my interests (no thank you on straight mental health). We have bit of time to sort things out before we plan on little ones. However, once that happens, we can't both be working 60+ hrs.

I would also avoid general mental health positions in VA. PCMHI provides lower productivity targets and enormous flexibility in your scheduling practices, don't have to work about answering cosnults, etc.

 

[AcronymAllergy]

I would also avoid general mental health positions in VA. PCMHI provides lower productivity targets and enormous flexibility in your scheduling practices, don't have to work about answering cosnults, etc.

By and large, I've found embedded positions in the VA (e.g., in SCI, Neurology, PM&R) to be better than general MH, although the latter can vary significantly based on supervisors and the relationship with other disciplines. This has also held true at the small handful of AMC's at which I've trained--psychologists embedded in other services tend to be more appreciated than those in the psychiatry/behavioral sciences departments. Small N's all around, though.

Where I am now, for example, I wouldn't at all mind working in the general Behavioral Health service. Psychology here has a historically strong presence, and BH supervisors and administrators (many of whom are psychologists) tend to be supportive and reasonable. But I've certainly worked in VAs (and non-VA hospitals) where that wasn't the case. Unfortunately, it can be tough to get a feel for the general atmosphere, especially if most/all of the interviewing and pre-hire contact occurs via telephone.

 

[smalltownpsych]

To be clear, this is not about me. I make significantly more than quoted and my schedule is not as crazy due to testing that I do. I also don't work for that company. However, this is not about me. It is about large companies depressing the market for us as the local competition bases pay and rvu reqs based on this company. Not that moving would help too much. That company is in multiple states.


I'm not moving anywhere right now anyhow. I just bought a house and my wife has a not easily replaced job that pays well. Additionally, after a few years here, I am well known enough in the area, that I get called with job offers . I am also moving a bit to the administrative side of things. However, I do keep my eyes open for interesting positions that offer lighter workloads and better benefits.

Lots of downward pressure on our salaries so am glad you're not in that boat. Since we don't have much help from our organizations about all we can do is negotiate and fight as individuals and encourage our peers to do the same. Also, makes me wonder if part of the downward pressure in the area is from local FSPSs flooding the market.

 

[erg923]

12 90834s for a medicare population would be something like 12X$60.00. Is that about right?

720 per day? These companies don't give you an office/space, so what's their overhead besides your benefits?

 

[Therapist4Chnge]

By and large, I've found embedded positions in the VA (e.g., in SCI, Neurology, PM&R) to be better than general MH, although the latter can vary significantly based on supervisors and the relationship with other disciplines. This has also held true at the small handful of AMC's at which I've trained--psychologists embedded in other services tend to be more appreciated than those in the psychiatry/behavioral sciences departments. Small N's all around, though.

This has also been my experience.

I actively avoided psychology and psychiatry departments when I was reviewing job options. I'd also add college counseling to that list because the pay is typically very poor...as in not much more than fellowship salaries.

 

[Ollie123]

I think a good sign of how a department functions is the number of psychologists in leadership/admin roles.

My current department (psychiatry) is actually a fabulous place for psychologists. We've taken over🙂 The best funded teams are all psychologists-led. You look at the department and a reasonable portion of the leadership are also psychologists (division chiefs, vice-chair of blah blah, etc.). The psychiatry department at another local institution has a very different reputation. No psychologists in leadership. They are afforded little respect. It operates from a pretty purely biological framework. I lucked out.

 

[Sanman]

12 90834s for a medicare population would be something like 12X$60.00. Is that about right?

720 per day? These companies don't give you an office/space, so what's their overhead besides your benefits?

There are generally office space for administrative/billing staff. Clinicians rarely step foot in it though. They also cover some form of note (paperwork or laptop/tablet stipend given if it is electronic) for the facility, recruiters for the bigger places (I get calls and emails weekly) and sales marketing people (they need to market services to the nursing homes as well). I have run the numbers and spoken to people (who says research skills don't come in handy) and the breakdown for most of these companies is that they are offering 50-60% in billables in most cases, similar to what these monster private practices offer in some cities. No particularly good or terrible. The salary still beats counseling centers and CMHCs (I had a colleague working for $40k licensed). The problem really is that in many of these places clinicians are seen as easily replaced commodities as they will hire anyone with a license and not necessarily a qualified person due to the demand. The higher level is a bit different, but to do the work a body (Psychologist or LCSW depending on setting) with a license will do.

 

[psych844]

Just from my experience with working for the government...I think admin people hate life, and this frustration can lead to being totally difficult to work with.

 

[Justanothergrad]

Schedule 8 to get 6 seems a reasonable goal for someone in private practice. .

Yup. that's been my experience in practice. Expect a 20-25% no-show rate.

And just hope those 20-25% aren't on your 3 hour blocks slatted for an individual assessment.... cause those are painful no-shows.

 

[WisNeuro]

Yup. that's been my experience in practice. Expect a 20-25% no-show rate.

And just hope those 20-25% aren't on your 3 hour blocks slatted for an individual assessment.... cause those are painful no-shows.

Man, a 20-25% no-show rate sounds nice. I think I'm closer to 30-35%. Luckily I schedule most of my evals early week and can usually schedule a Thursday or Friday eval if I get a no-show Mon or Tues.

 

[Justanothergrad]

Man, a 20-25% no-show rate sounds nice. I think I'm closer to 30-35%. Luckily I schedule most of my evals early week and can usually schedule a Thursday or Friday eval if I get a no-show Mon or Tues.

I round down. Its a self-care thing.

Also...
Don't schedule if it's raining. No one wants to come in if the weather is bad.
Don't schedule when its sunny either. People want to go outside and don't want to go to an appointment.

 

[AcronymAllergy]

Man, a 20-25% no-show rate sounds nice. I think I'm closer to 30-35%. Luckily I schedule most of my evals early week and can usually schedule a Thursday or Friday eval if I get a no-show Mon or Tues.

The additional downside is the requirement to reschedule no-shows X number of times, which more often than not eats into another day of productivity. One of the reasons (among others) that I'm currently booked out to mid-June.

And yes, rain raises the no-show rate significantly. Sun, at least here, less so. My appointments are almost always in the morning, so they're finished in time to still enjoy the weather.

 

[Sanman]

You think rain is bad. Winter time in the north east is really no fun. I still remember digging my car out of the snow and making it to the office for an entire day of no shows once in PP. School holiday time can be rough as well. Looking back, it is easiest to go with the flow. If you don't feel like working, your clients often don't feel like coming in either.

 

[PsychMajorUndergrad18]

When i first click on this thread i thought it said RUV haha