So, Private Pratice docs: How is it with the ACA and new CPT codes?

[fiatslug]

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Is reimbursement better or worse or too soon to tell? I know the effects of ACA (which I completely support, FWIW) and the new CPT codes are very different beasts and affect practice and reimbursement differently.

Do you have a sense yet if it's better or worse?

Mainly I'm asking because I have a very sweet HMO job that I lerve/could never imagine leaving 85-90% of the time, but OMFG it is impossible to get time off approved and it's making me very cranky 😡

 

[vistaril]

Is reimbursement better or worse or too soon to tell? I know the effects of ACA (which I completely support, FWIW) and the new CPT codes are very different beasts and affect practice and reimbursement differently.

Do you have a sense yet if it's better or worse?

Mainly I'm asking because I have a very sweet HMO job that I lerve/could never imagine leaving 85-90% of the time, but OMFG it is impossible to get time off approved and it's making me very cranky 😡

regardless of whether it's better or worse(the few people I've spoken to say overall it's a tad worse), the general theme over the next several years is going to be clear- we will be squeezed.

Also, keep in mind that 'sweet HMO jobs' aren't immune from all that is going on. Physicians who are salaried and work for hmos are still highly dependent on things like reimbursement rates and their trends. If they plummet, over time those 'sweet HMO' salaries will plummet as well.

 

[F0nzie]

Ahh... the OP is heading toward rationalization. The last refuge for an unsound thought. The answer is NO. Insurance companies are still screwing us over more than ever and will continue to do so as long as they are paying the bills. A small boost in CPT revenue might seem nice, but this does not change the fact that... you are still being held hostage.

I am not currently in private practice (I will be in exactly 3 months), but I have enough anecdotal evidence and advice from others in the field to not make such a stupid decision as to get paneled up with insurance companies.

If autonomy is what you want, it makes more sense to go out-of-network and compete in the cash/concierge market and set the rates yourself. Sink or swim in this model. If you succeed, you can free yourself from all of this nonsense.

If you do plan on accepting insurance, join a group practice where the overhead can be shared so that your hourly rate can be optimized. For a bit of autonomy and flexibility, split your work with 1/2 time or 3/4 time work (for benefits) and add independent contracting on the side to supplement your income.

 

[vistaril]

Ahh... the OP is heading toward rationalization. The last refuge for an unsound thought. The answer is NO. Insurance companies are still screwing us over more than ever and will continue to do so as long as they are paying the bills. A small boost in CPT revenue might seem nice, but this does not change the fact that... you are still being held hostage.

I am not currently in private practice (I will be in exactly 3 months), but I have enough anecdotal evidence and advice from others in the field to not make such a stupid decision as to get paneled up with insurance companies.

If autonomy is what you want, it makes more sense to go out-of-network and compete in the cash/concierge market and set the rates yourself. Sink or swim in this model. If you succeed, you can free yourself from all of this nonsense.

If you do plan on accepting insurance, join a group practice where the overhead can be shared so that your hourly rate can be optimized. For a bit of autonomy and flexibility, split your work with 1/2 time or 3/4 time work (for benefits) and add independent contracting on the side to supplement your income.

I'm as upset at the way things are as anyone, but how are insurance companies screwing us over or holding us hostage? Just because they aren't reimbursing us as much as we would like does not mean they are doing those things....

I agree with you about the group practice bit. Any psychiatrist who works alone and has to pay a staff person, phone, rent, etc all by himself and is billing insurance and only seeing 16 or so patients in a day is simply a financial disaster...and likely making less net money than many nurses. If you're going to be in solo pp in psych and take insurance, you better be ready to do some serious grinding.....And if you go solo and don't take insurance(and therefore presumably have no staff), that brings other considerations and problems into play.....plus, you better be *darn good* at what you do...people paying a few hundred bucks per hour for a service better be seeing some tangible benefits from your therapy.

 

[nitemagi]

I'm as upset at the way things are as anyone, but how are insurance companies screwing us over or holding us hostage? Just because they aren't reimbursing us as much as we would like does not mean they are doing those things....

I agree with you about the group practice bit. Any psychiatrist who works alone and has to pay a staff person, phone, rent, etc all by himself and is billing insurance and only seeing 16 or so patients in a day is simply a financial disaster...and likely making less net money than many nurses. If you're going to be in solo pp in psych and take insurance, you better be ready to do some serious grinding.....And if you go solo and don't take insurance(and therefore presumably have no staff), that brings other considerations and problems into play.....plus, you better be *darn good* at what you do...people paying a few hundred bucks per hour for a service better be seeing some tangible benefits from your therapy.

I have no staff, work alone, pay rent and manage my own phone and am not a financial disaster.

The OP was asking "Private Practice docs."

Did you suddenly finish residency, Vistaril?

 

[vistaril]

I have no staff, work alone, pay rent and manage my own phone and am not a financial disaster.

The OP was asking "Private Practice docs."

Did you suddenly finish residency, Vistaril?

you also dont accept insurance iirc....so read that part of my post again.

Also, your pp is not full time(or even close to it)

 

[F0nzie]

Don't worry Vistaril... you don't have to be "darn good". We went over this in your "other revenue streams" thread.

 

[vistaril]

Don't worry Vistaril... you don't have to be "darn good". We went over this in your "other revenue streams" thread.

so what are you planning to do next year fonzie? Did you take a medmgt salaried position or are you going to go out there on your own and try to actually do some real work with patients?

 

[nitemagi]

you also dont accept insurance iirc....so read that part of my post again.

Also, your pp is not full time(or even close to it)

Correct. Nor do I pretend that it is. But I'm also not the one making dramatic scary posts about business models I have no direct experience with...

Check yourself.

 

[vistaril]

Correct. Nor do I pretend that it is. But I'm also not the one making dramatic scary posts about business models I have no direct experience with...

Check yourself.

I get the sense that you jumped in here(and intentionally applied my words innapropriately) to start something up....not all that interested in that so I'll pass.

There are ways, as I implied initially, where one can make a private practice model work. To set aside a small amount of time and deal with cash pay patients is one example of making a private practice model(on a small/part time scale) work, because doing it this way has several advantages. Additionally, if one has an insurance model and joins other providers who can share overhead, they can easily make this work if they can make things up with volume(ie see 4 pts an hour)....

the model that really doesn't work is one a lot of people want....where you have real overhead costs that are not insignificant and take insurance and are not doing high volume work(ie 2 pts per hour for followups).....that model only works in VA world where nothing really makes sense from a $ standpoint(which is why people who can put up with the beaurocracy of working in a VA doing outpt work are often very satisfied)....

 

[Armadillos]

I get the sense that you jumped in here(and intentionally applied my words innapropriately) to start something up....not all that interested in that so I'll pass.
..

 

[F0nzie]

so what are you planning to do next year fonzie? Did you take a medmgt salaried position or are you going to go out there on your own and try to actually do some real work with patients?

Both.

Working 20 hours per week at an SMI clinic.

I am also preparing myself to compete in the cash/concierge market to continue to provide psychotherapy.

You?

 

[dl2dp2]

vis,

you also underestimated how out-of-network benefits are handed out in many markets. yes there is usually a deductible ($1000?) but after that say 80-90% of sessions are paid for. often middle class people, especially unionized, who have good insurance have that kind of arrangement (i.e. cops, other govt employees, etc.) To give you an idea, BCBS POS reimburses 85% of $227-$350 per 45min for med+therapy out of network.

so yes, people have to make a commitment and pay $1000+ a year for weekly therapy, but a lot of people are willing to do that and $1000 is not the same as $10000

even if you do take insurance, if you bill 20 min at medicare rates, you achieve very similar results. so yes, you have to "grind" a bit, but suppose you only take 1 or 2 well reimbursed insurance for only psychopharm, the economics still tilts in your favor.

no matter how you cut it, the 200k 45hr a week model is pretty average in this field. of course you won't make your "fiancee"s colonoscopy rates. this isn't derm afterall.

 

[vistaril]

vis,

you also underestimated how out-of-network benefits are handed out in many markets. yes there is usually a deductible ($1000?) but after that say 80-90% of sessions are paid for. often middle class people, especially unionized, who have good insurance have that kind of arrangement (i.e. cops, other govt employees, etc.) To give you an idea, BCBS POS reimburses 85% of $227-$350 per 45min for med+therapy out of network.

so yes, people have to make a commitment and pay $1000+ a year for weekly therapy, but a lot of people are willing to do that and $1000 is not the same as $10000

even if you do take insurance, if you bill 20 min at medicare rates, you achieve very similar results. so yes, you have to "grind" a bit, but suppose you only take 1 or 2 well reimbursed insurance for only psychopharm, the economics still tilts in your favor.

no matter how you cut it, the 200k 45hr a week model is pretty average in this field. of course you won't make your "fiancee"s colonoscopy rates. this isn't derm afterall.

I think you underestimate the degree of the negative trend happening in insurance now.....hell, that deductible for many insurances for psych isn't that far out of line for *in network* coverage.....insurers can always tell patients no for out of network psychopharm/therapy.....

Im just less optimistic than you.

 

[vistaril]

Both.

Working 20 hours per week at an SMI clinic.

I am also preparing myself to compete in the cash/concierge market to continue to provide psychotherapy.

You?

havent really decided yet......I'll probably take a medmgt job at an SMI clinic, but they make you see a lot of patients there. How many patients do you have to see per hour at your SMI clinic?

 

[F0nzie]

1.5 hours per intake and 30 min follow ups. No overbooking. I had to do a bit searching and negotiating for this setup. I'm happy with my decision. We'll see how it goes...

 

[vistaril]

1.5 hours per intake and 30 min follow ups. No overbooking. I had to do a bit searching and negotiating for this setup. I'm happy with my decision. We'll see how it goes...

so 2 pts per hour for followups with smi patients? What do you get per hour? That's an incredible gig. If you ever get tired of it send it my way.

 

[F0nzie]

They offered 95k. I said "thank you for your time". They called back.

110k. So probably a little over 100/hr.

 

[vistaril]

They offered 95k. I said "thank you for your time". They called back.

110k. So probably a little over 100/hr.

impressive....I wish I could find something that good. I can find smi gigs for similar money but not with 30 minute followups or 1.5 hour intakes. Actually, most of the smi jobs Im looking at the psych is expected to do *very little* of the intake....was told that we just cost too much for that to happen.

 

[vistaril]

impressive....I wish I could find something that good. I can find smi gigs for similar money but not with 30 minute followups or 1.5 hour intakes. Actually, most of the smi jobs Im looking at the psych is expected to do *very little* of the intake....was told that we just cost too much for that to happen.

also, you're going to have a lot of downtime on some of these patients(if that places actually adheres to reasonable smi criteria) with 30 minute followups......I'd bring a book or something.

 

[F0nzie]

I had one smi clinic ask me if I could do intakes in 30. Walked out on them. They didn't call me back either.

Heck I had 1 inpatient offer that asked that I see up to 75 patients per day every 5th weekend. Walked out on them too.

Negotiating a job is kinda like buying a new car. Rule #1 always walk out the first time.

 

[vistaril]

I had one smi clinic ask me if I could do intakes in 30. Walked out on them. They didn't call me back either.

Heck I had 1 inpatient offer that asked that I see up to 75 patients per day every 5th weekend. Walked out on them too.

Negotiating a job is kinda like buying a new car. Rule #1 always walk out the first time.

I've had a number of smi clinics want me to do 30 minute intakes, but everything is tee'd up for you......at least one person, usually two(with one being an lcsw) has done the full assessment and gotten everything I would need. The note would also be completely done and my only job is just to place a 1 sentence addendum and sign off on what the caseworkers and lcsw have already put in.

Im not sure how that particular smi clinic is paying it's bills unless what they are pulling from the state mh budget is unusually large.....if they are paying you $110/hr and giving you 1.5 hrs on an intake, that is $165(plus benefits if you are getting benefits) tied up in the psychiatrist alone for that intake.....that doesnt count all the other support staff they have(most of whom are doing other things, but still.....)......I would just be curious to see the internals and where exactly the funding source for what they are doing is coming from and what % of it is from grants, state mh support, bundled care, and direct medicare billing.

 

[fiatslug]

I have no staff, work alone, pay rent and manage my own phone and am not a financial disaster.

The OP was asking "Private Practice docs."

Did you suddenly finish residency, Vistaril?

Thank you nitemagi! Residents, appreciate your two cents, but really was looking for actual practicing PP docs.

 

[vistaril]

Thank you nitemagi! Residents, appreciate your two cents, but really was looking for actual practicing PP docs.

well I work outpt in a private practice clinic....same dynamic really(except Im paid a salary equivalent to a percentage of revenue).....if you're looking for full time pp outpatient psychiatrists, I don't think we have many who post regularly here so you aren't likely to find much success.

 

[F0nzie]

I have been following these threads for 5 years and people seem to disappear after their first couple of years as an attending. They probably get tired of the same rants that have been covered extensively with over a decade's worth in archives.

Most of what I learn comes from attendings. I tend to be more skeptical about anything I read online. I don't even trust half of what you guys say. 😉 But I come in here with an open mind.

Here's a link to a psychiatrist in private practice who is planning on quitting and believes that private practice has expired.

The shrink rap blog written by psychiatrists currently in private practice has some honest opinions about insurance.

 

[F0nzie]

"Clinicians are being urged to register with the American Psychiatric Association (APA) any incidents they have encountered with insurers refusing to pay for services in accordance with the new psychiatry section of the American Medical Association's (AMA's) Current Procedural Terminology (CPT) codes — in hope that the organization can help solve problems or, if needed, initiate litigation.

Although the new billing and documentation codes went into effect January 1 of this year, there have been reports that some insurance companies have been rejecting bills or reducing rates because of misunderstandings or disagreements over the codes.

"CPT code changes were intended to more accurately reflect the work psychiatrists do and improve patient access to care, but instead have been used as an excuse by some payers to discriminate against psychiatric patients and their psychiatrists in violation of the Mental Health Parity and Addiction Equity Act," states the organization in an email communiqué sent to APA members last week.

The memo goes on to state that the APA Board of Trustees has committed the finances and staff needed to first understand a particular situation and then to correct the abuses "using all reasonable means, including litigation."

"We believe that the whole process and manipulation of rates is a means to deny access to care and mental health treatment to people who are already paying for it," Colleen M. Coyle, general counsel for the APA, told Medscape Medical News."

Link to the full article

I have supervision with a psychiatrist that is in solo private practice accepting most insurances that had his rates reduced with the new CPT code changes. This is the **** you go through.

 

[vistaril]

I have been following these threads for 5 years and people seem to disappear after their first couple of years as an attending. They probably get tired of the same rants that have been covered extensively with over a decade's worth in archives.

Most of what I learn comes from attendings. I tend to be more skeptical about anything I read online. I don't even trust half of what you guys say. 😉 But I come in here with an open mind.

Here's a link to a psychiatrist in private practice who is planning on quitting and believes that private practice has expired.

The shrink rap blog written by psychiatrists currently in private practice has some honest opinions about insurance.

I read the first one about the death of private practice and that is an EXCELLENT article.

And all the salaried psychiatrists(like myself in the future) should be worried about this because this will have an effect on our salaries as well(in terms of bringing them down)

 

[Armadillos]

Im still confused about this whole insurance issue, anecdotally from talking to friends in my area who see a psychiatrist occasionally, very few private practice psychiatrists in my area will bill insurance. They charge patients some fee they determine and then the patients mail in reciepts to the insurance company and get reimbursed back like 60-70% of the visit cost. Is this not the norm in most of the country for private practice?

(I do probably live in a "weird" area because it is a small rather affluent pocket in an otherwise poor area, so the poor folks go to the university or state/county mental health places and the affluent people do what I mentioned above).

 

[vistaril]

Im still confused about this whole insurance issue, anecdotally from talking to friends in my area who see a psychiatrist occasionally, very few private practice psychiatrists in my area will bill insurance. They charge patients some fee they determine and then the patients mail in reciepts to the insurance company and get reimbursed back like 60-70% of the visit cost. Is this not the norm in most of the country for private practice?

I've heard of that model before....but a lot of insurances don't play ball that way. If you are going to run that sort of practice, you have to view it for what it is(cash pay) and know that you are going to miss out on substantial numbers of patients who either won't take a chance/hassle with sending in the invoice themselves and hope to reimbursed or have insurance that will not allow reimbursement to patient rather than direct to provider.

 

[JourneyAgent]

I have been following these threads for 5 years and people seem to disappear after their first couple of years as an attending. They probably get tired of the same rants that have been covered extensively with over a decade's worth in archives.

Most of what I learn comes from attendings. I tend to be more skeptical about anything I read online. I don't even trust half of what you guys say. 😉 But I come in here with an open mind.

Here's a link to a psychiatrist in private practice who is planning on quitting and believes that private practice has expired.

The shrink rap blog written by psychiatrists currently in private practice has some honest opinions about insurance.

Thanks for the links.

I thinks it's a natural process to move on from conversations that are specific to different stages of the career. I appreciate the attendings and residents here. But can totally understand how it would get old.

 

[jettavr6]

Although the new billing and documentation codes went into effect January 1 of this year, there have been reports that some insurance companies have been rejecting bills or reducing rates because of misunderstandings or disagreements over the codes.

This is certainly a major problem right now, but I think will be resolved in the next few months. Without doubt, we are getting squeezed right now, but the changing of the CPT codes to regular E/M codes moves mental health towards "parity." What many psychiatrists who take insurance are doing, is to use the regular new patient codes 99201-205 and tack on the appropriate modifiers.

As someone mentioned above, shared resources and decreased overhead makes it possible for a psychiatrist to do well in an outpatient private practice. Reimbursement will always change, sometimes for the better and sometimes for the worse. Regardless, I think Psychiatry is an excellent field to go into at the current time, and will be for the next 5 years going forward.

In my situation, I practice both pain management and psychiatry. For psychiatry, I mainly do medication management, but try to get some supportive therapy in as much as I can. Most of the therapy portion I refer out to a psychologist friend and my patients tend to be very happy with this arrangement. Insurance reimbursement varies according to payor, and they do try to play every trick in the book to deny payment. Having your patients become proactive in calling the insurance companies and advocating for themselves helps a lot.

Just for comparison, the pain side of my practice has taken a big hit in terms of reimbursements. If one looks at reimbursements from other specialties vs. psychiatry, it's still pretty good for psychiatry.

None of this compares to an outpatient cash practice. If one has the reputation, and a good client base - that's the way to go.

 

[fiatslug]

One of my colleagues who works child inpt and has a (small) child outpt practice says she thinks reimbursements are going up for her with the new codes--not sure how much the "interactive complexity" piece raises things for child. I know in my practice (adults, PH setting), I'm for sure doing HR, BP and weights at initial evals now. It's useful information to have (I wish we had a medical assistant doing them, but oh well!). I also make sure to document and bill for psychotherapy + E/M, because it's a part of my practice.

ETA: she had the option of becoming an employed physician vs continuing to be a contract employee for her inpt work, and she chose the latter, though she was initially tempted by salary/perks/vacation/etc.

 

[Indodo]

Bump.

Is anyone doing routine physical exams every 6 months or anything like that? A colleague suggested that I could more easily bill a level 4 if I included that with my 6 month vitals/labs.

I usually bill level 3 or 4 but usually based on time.

Also, any help with modifiers or a place where I can find help? Concrete is better than abstract.

 

[michaelrack]

Bump.

Is anyone doing routine physical exams every 6 months or anything like that? A colleague suggested that I could more easily bill a level 4 if I included that with my 6 month vitals/labs.

I usually bill level 3 or 4 but usually based on time.

Also, any help with modifiers or a place where I can find help? Concrete is better than abstract.

For return patient visits, physical exam doesn't have much to do with billing. Typically docs bill return pts based on history and medical decision making. I don't know much about psychiatric billing, but I do have a lot of experience with billing for seeing sleep d/o pts.