Split fee?

[futuredo32]

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I have worked locums, independent contractor positions, but always at X $ per hour. I am interviewing for a really busy clinic that uses Ketamine, RTMS, great reputation, but they want me to do a 70/30 split where I pay my own malpractice, go my own prior authorizations............. I am so much more comfortable knowing I will make X dollars per week. Have those of you who have done a split fee at a clinic done ok financially?

 

[splik]

you can actually make a lot more in this kind of model if your schedule is full and you're productive. But it will also depend on the payer mix because the reimbursement will depend on the insurance. That said, if you have to do your own prior auths and get your malpractice what exactly are they covering in that 30%?!

 

[clausewitz2]

you can actually make a lot more in this kind of model if your schedule is full and you're productive. But it will also depend on the payer mix because the reimbursement will depend on the insurance. That said, if you have to do your own prior auths and get your malpractice what exactly are they covering in that 30%?!

Their boat payments, naturally

 

[TexasPhysician]

Every arrangement has pros and cons but why aren’t they doing PA’s?

 

[calvnandhobbs68]

you can actually make a lot more in this kind of model if your schedule is full and you're productive. But it will also depend on the payer mix because the reimbursement will depend on the insurance. That said, if you have to do your own prior auths and get your malpractice what exactly are they covering in that 30%?!

I’m assuming office staff, schedulers, insurance billers, EMR, office space, infrastructure for the TMS/ketamine OP would be using to bill. If it’s 1099 and not offering to cover malpractice I’m assuming not offering things like health insurance, dental, disability, etc.

Like splik said, this tends to have a lower floor (esp when you’re first getting ramped up) but a much higher ceiling depending on the reimbursement amounts. 70/30 is a pretty generous cut on their side though for this kind of setup where they don’t offer you any overt benefits at all besides infrastructure. 80/20 or 85/15 is more usual. Remember that their costs are fixed in this situation (they already have that office staff, office space, equipment, EMR, etc) and so you’re just splitting their costs further. Thus the percentage they take off you is pretty much pure gravy for them because they’re spitting their fixed costs further without adding much extra when onboarding you in terms of cost from their end if you’re a contractor.

Id counter with 85/15 and probably try to settle at least at 80/20. You need to know exactly what they’re billing to what insurance panels they take and how much they’re typically collecting for what codes. They should be able to give you a brewkdown of that easily…if they can’t that’s highly suspect. You should also know their no show rate, no show fees and collection rate on debt owed/termination policies as these all would directly affect your bottom line.

 

[TexasPhysician]

I’m assuming office staff, schedulers, insurance billers, EMR, office space, infrastructure for the TMS/ketamine OP would be using to bill. If it’s 1099 and not offering to cover malpractice I’m assuming not offering things like health insurance, dental, disability, etc.

Like splik said, this tends to have a lower floor (esp when you’re first getting ramped up) but a much higher ceiling depending on the reimbursement amounts. 70/30 is a pretty generous cut on their side though for this kind of setup where they don’t offer you any overt benefits at all besides infrastructure. 80/20 or 85/15 is more usual. Remember that their costs are fixed in this situation (they already have that office staff, office space, equipment, EMR, etc) and so you’re just splitting their costs further. Thus the percentage they take off you is pretty much pure gravy for them because they’re spitting their fixed costs further without adding much extra when onboarding you in terms of cost from their end if you’re a contractor.

Id counter with 85/15 and probably try to settle at least at 80/20. You need to know exactly what they’re billing to what insurance panels they take and how much they’re typically collecting for what codes. They should be able to give you a brewkdown of that easily…if they can’t that’s highly suspect. You should also know their no show rate, no show fees and collection rate on debt owed/termination policies as these all would directly affect your bottom line.

Except those costs aren’t fixed. More physicians mean more schedulers, office staff, advertising, office space (you don’t lease extra space until you plan on adding people to increase revenue), and even EMR costs are often per provider. Supplies and even toilet paper usage increases with more patients. Accounting fees and legal fees go up. Most such agreements are between 60/40 and 75/25. I’ve never seen 85/15 without the contractor managing significant admin burdens themselves. I wouldn’t even bother interviewing someone that asked that at my practice as the overhead is over 15%. My staff do handle PA’s and other things as well.

 

[liquidshadow22]

I’m assuming office staff, schedulers, insurance billers, EMR, office space, infrastructure for the TMS/ketamine OP would be using to bill. If it’s 1099 and not offering to cover malpractice I’m assuming not offering things like health insurance, dental, disability, etc.

Like splik said, this tends to have a lower floor (esp when you’re first getting ramped up) but a much higher ceiling depending on the reimbursement amounts. 70/30 is a pretty generous cut on their side though for this kind of setup where they don’t offer you any overt benefits at all besides infrastructure. 80/20 or 85/15 is more usual. Remember that their costs are fixed in this situation (they already have that office staff, office space, equipment, EMR, etc) and so you’re just splitting their costs further. Thus the percentage they take off you is pretty much pure gravy for them because they’re spitting their fixed costs further without adding much extra when onboarding you in terms of cost from their end if you’re a contractor.

Id counter with 85/15 and probably try to settle at least at 80/20. You need to know exactly what they’re billing to what insurance panels they take and how much they’re typically collecting for what codes. They should be able to give you a brewkdown of that easily…if they can’t that’s highly suspect. You should also know their no show rate, no show fees and collection rate on debt owed/termination policies as these all would directly affect your bottom line.

if they are providing you with disability, health, malpratice insurance, 401k match, and some PTO- would a 70/30 to 60/40 split be more appropriate?

 

[futuredo32]

if they are providing you with disability, health, malpratice insurance, 401k match, and some PTO- would a 70/30 to 60/40 split be more appropriate?

they don't provide that

 

[TexasPhysician]

if they are providing you with disability, health, malpratice insurance, 401k match, and some PTO- would a 70/30 to 60/40 split be more appropriate?

That would shift you to being an employee. You could still be paid a percentage or bonus calculation, but the percent will be lower. I’d expect closer to 50/50.

 

[futuredo32]

Every arrangement has pros and cons but why aren’t they doing PA’s?

I don't know. They provide billing and let you use their EMR. Their office staff schedules your appointments. I think Prior Authorizations are really difficult and time consuming. They don't call in refills for you. It's a very well known respected clinic and the psychiatrist who owns the clinic has a great reputation. I have an offer from a CMH coming and that's a guaranteed salary. I am currently doing locums about 90 minutes from home and I live in a locums paid for hotel room Monday through Friday. I make a lot of money here at the locums position, but I'm doing half inpatient and half outpatient I prefer outpatient. I have been looking for adult outpatient near home for a year and there was NOTHING. Now, there is finally a lot. I am going to contact the other places I have interviewed and see if they want to make an offer. Outpatient psychiatry positions near home have been nonexistent for a year and now they are plentiful and I have been interviewing a lot. COVID killed jobs for awhile. I do have a micro practice but no business savvy. I call my micro practice my "expensive hobby." I have it because I like doing therapy and maybe some day........... I am happy for the opportunity to have outpatient psychiatrist positions near home. I really want to go home. I have never made as much money in my life as I have at this locums position, but they want me to become a hospital employed position with a three year contract and I would make less, still have to do half inpatient and I just don't like living here. The owner of the clinic seems really nice, which is a bonus. I read so much about toxic work enviornments. I am currently working with great people in a friendly facility, but it's just geographically undesirable. My psychiatrist who I see for analysis does a 70/30 split and he makes little, but they do everything including PAs for him. I am guessing because he does therapy is one reason he doesn't make much. I would just be doing med management at any of the positions I applied for. She seems pretty fixed on the 70/30 split. I would love to try to grow my own practice, but I am not business minded. I also have my practice located in a city that has more psychiatrists in Michigan than any other city but malpractice is much much higher elsewhere. Thank you for the input.

 

[calvnandhobbs68]

That would shift you to being an employee. You could still be paid a percentage or bonus calculation, but the percent will be lower. I’d expect closer to 50/50.

There are definitely places I was looking at where THAT split was 60/40. In fact, a W2 split of 60/40 is much more of the norm than 50/50 based on my experience looking and talking to others who have been recently looking.

Honestly, I wouldn’t take somewhere that tried to offer me 70/30 on a pure 1099 position. That 10% different between a W2 and 1099 usually doesn’t make up the difference unless reimbursement rate is significantly different. I’ll tell you that those 80/20 or 85/15 (or even better) jobs are out there, even if you personally wouldn’t offer that.

The larger the organization gets, the more split their fixed costs are. For instance, if you already own/lease a large portion of a building or multiple buildings and have unused office space, dropping someone in that office costs very little. You absolutely don’t need to add office staff for every new person you bring on, so while I agree with you that thats technically a variable cost, you have to add more than one clinician to make that cost increase substantially. Absolutely if you had to add a new secretary for every clinician, that’d be a pretty significant cost. Depending on the EMR many of them have group/practice licenses where incremental additions of users is pretty cheap to almost negligible (40-100 dollars a month).

 

[futuredo32]

Where I live 70/30 is the norm. One clinic was offering 50/50 and it would have included being the medical director which was an easy no for me. I went to medical school very naive and money didn't matter and I just wanted to help people, but the reality is, money does matter. I have 400k in student loans, I would actually like to buy a house, save for retirement. In my experience locums usually pays the most (200 an hour). But I am SO sick of living in a hotel. I don't want to travel around the country or state .

 

[TexasPhysician]

There are definitely places I was looking at where THAT split was 60/40. In fact, a W2 split of 60/40 is much more of the norm than 50/50 based on my experience looking and talking to others who have been recently looking.

Honestly, I wouldn’t take somewhere that tried to offer me 70/30 on a pure 1099 position. That 10% different between a W2 and 1099 usually doesn’t make up the difference unless reimbursement rate is significantly different. I’ll tell you that those 80/20 or 85/15 (or even better) jobs are out there, even if you personally wouldn’t offer that.

The larger the organization gets, the more split their fixed costs are. For instance, if you already own/lease a large portion of a building or multiple buildings and have unused office space, dropping someone in that office costs very little. You absolutely don’t need to add office staff for every new person you bring on, so while I agree with you that thats technically a variable cost, you have to add more than one clinician to make that cost increase substantially. Absolutely if you had to add a new secretary for every clinician, that’d be a pretty significant cost. Depending on the EMR many of them have group/practice licenses where incremental additions of users is pretty cheap to almost negligible (40-100 dollars a month).

They are out there, but what they provide has always been significantly less which actually can lower revenue per hour. 85/15 doesn’t leave money for advertising to keep you full. Expect to slowly grow. It generally does not support dedicated staff to do vital signs, PA’s, help draft letters, etc. I’ve been offered 80/20 before. I was expected to do vitals and type brief letters to send to PCP’s on my own time to help get referrals. When you begin adding up extra time doing other things, I’d rather be seeing patients and getting paid.

The percent I pay is lower than 80%, but I keep everyone full. If anyone wants more hours, I’ll fill them. Advertising some months can be thousands. Credit card fees can be 3% alone. One additional staff is $40k give or take.

Large groups can lower the additional incremental costs, but how many large cash groups are you seeing? Are you basing this on insurance practices FT?

I’m not arguing that there is a right percentage or wrong percentage. It’s just important for people to understand what the business cut is being used for. If a business can find me patients billing $1500/hr, I’d take 33%. That same practice that can only guarantee 5 hours/week and has a non-compete better offer a much higher %.

Unrelated to your post: Keep in mind that the average salaried psychiatrist is collecting under 50%. A psychiatrist paid $300k at a large company can easily be billing $1 million

 

[calvnandhobbs68]

Where I live 70/30 is the norm. One clinic was offering 50/50 and it would have included being the medical director which was an easy no for me. I went to medical school very naive and money didn't matter and I just wanted to help people, but the reality is, money does matter. I have 400k in student loans, I would actually like to buy a house, save for retirement. In my experience locums usually pays the most (200 an hour). But I am SO sick of living in a hotel. I don't want to travel around the country or state .

I bet you can hit over 200 an hour with a split depending on the reimbursement mix. You just have to be very aware of how you code. Hourly pay doesn’t incentivize you to maximize coding.

 

[calvnandhobbs68]

They are out there, but what they provide has always been significantly less which actually can lower revenue per hour. 85/15 doesn’t leave money for advertising to keep you full. Expect to slowly grow. It generally does not support dedicated staff to do vital signs, PA’s, help draft letters, etc. I’ve been offered 80/20 before. I was expected to do vitals and type brief letters to send to PCP’s on my own time to help get referrals. When you begin adding up extra time doing other things, I’d rather be seeing patients and getting paid.

The percent I pay is lower than 80%, but I keep everyone full. If anyone wants more hours, I’ll fill them. Advertising some months can be thousands. Credit card fees can be 3% alone. One additional staff is $40k give or take.

Large groups can lower the additional incremental costs, but how many large cash groups are you seeing? Are you basing this on insurance practices FT?

I’m not arguing that there is a right percentage or wrong percentage. It’s just important for people to understand what the business cut is being used for. If a business can find me patients billing $1500/hr, I’d take 33%. That same practice that can only guarantee 5 hours/week and has a non-compete better offer a much higher %.

Unrelated to your post: Keep in mind that the average salaried psychiatrist is collecting under 50%. A psychiatrist paid $300k at a large company can easily be billing $1 million

For sure, I have to do anything detailed in terms of prior auths and vitals myself. It’s basically drop into an office and run a mini private practice on your own. They do do a bit of advertising for me. I agree there’s no “right or wrong” percentage….all depends on what you’re being reimbursed, how good they are at collections, etc.

The other practices I was looking at were all private insurance based (no cash only).

 

[Sushirolls]

PAs really shouldn't be such a focus of this thread. Just know the insurance hot spots. I've done 3 in the past 12 months for a panel of ~150.

 

[clausewitz2]

PAs really shouldn't be such a focus of this thread. Just know the insurance hot spots. I've done 3 in the past 12 months for a panel of ~150.

For a certain category of medications (SSRIs above FDA indicated dose for OCD) i have just given up on PAs and tell people i will not do them. Thankfully with good rx this rarely costs them more than 20 bucks a month so I've never had anyone object

 

[TexasPhysician]

PAs really shouldn't be such a focus of this thread. Just know the insurance hot spots. I've done 3 in the past 12 months for a panel of ~150.

CAP with ADHD is unavoidable. My staff do PA’s daily.

 

[AD04]

I have worked locums, independent contractor positions, but always at X $ per hour. I am interviewing for a really busy clinic that uses Ketamine, RTMS, great reputation, but they want me to do a 70/30 split where I pay my own malpractice, go my own prior authorizations............. I am so much more comfortable knowing I will make X dollars per week. Have those of you who have done a split fee at a clinic done ok financially?

If you want to make this long-term, look at the integrity and capability of the person you are working with. The split can be renegotiated. Payment isn't just in terms of $. Payment is also in terms of quality of life and enjoyment of work and learning.

If you get busy enough, you won't have time to do your own prior authorization. I sure don't have time for that and the stuff I do is really high yield. The support staff will make or break your practice and the amount of money you will make. It doesn't sound like the support staff will be doing much for you in this gig.

As @TexasPhysician said, high split of a low collection amount is still a low pay.

To reduce the risk of this flaming out, don't make this your only gig. Do other things and grow this if it meets or exceeds your expectations.

By the way, if you're looking at maximizing income, it depends on how you practice. If you are slow and can't see many patients a day and are terrible at retaining patients (due to inability to build rapport), you might make more from a salary position. If you are efficient and patients come back to see you and know how to bill, it will be from a productivity-based model. It will be from productivity-based models where you are able to earn more than $200 / hr. But there are a lot of components you have to get right.

 

[futuredo32]

If you want to make this long-term, look at the integrity and capability of the person you are working with. The split can be renegotiated. Payment isn't just in terms of $. Payment is also in terms of quality of life and enjoyment of work and learning.

If you get busy enough, you won't have time to do your own prior authorization. I sure don't have time for that and the stuff I do is really high yield. The support staff will make or break your practice and the amount of money you will make. It doesn't sound like the support staff will be doing much for you in this gig.

As @TexasPhysician said, high split of a low collection amount is still a low pay.

To reduce the risk of this flaming out, don't make this your only gig. Do other things and grow this if it meets or exceeds your expectations.

By the way, if you're looking at maximizing income, it depends on how you practice. If you are slow and can't see many patients a day and are terrible at retaining patients (due to inability to build rapport), you might make more from a salary position. If you are efficient and patients come back to see you and know how to bill, it will be from a productivity-based model. It will be from productivity-based models where you are able to earn more than $200 / hr. But there are a lot of components you have to get right.

I'm really good at rapport building I plan to moonlight one or two weekends per month and keep my micro practice. I wish I had the business savvy to have my own full time practice It is unfortunate that there's no one to do PAs. Maybe a salaried job is a better idea. I do need to brush up on coding. Thank you

 

[futuredo32]

Unrelated to your post: Keep in mind that the average salaried psychiatrist is collecting under 50%. A psychiatrist paid $300k at a large company can easily be billing $1 million

As in a hospital? I have a tiny practice and insurance pays about $60 for med visits and $150 at best for therapy visits. I prefer outpatient

 

[TexasPhysician]

As in a hospital? I have a tiny practice and insurance pays about $60 for med visits and $150 at best for therapy visits. I prefer outpatient

$60 is terrible. Even small organizations/groups that I’ve seen have negotiated above that for 99213. Many organizations are scheduling 3-5 insurance patients per hour. Some will no show and bill a no show fee. 4 99214 patients would collect $400-500 without add on codes. The psychiatrist on salary earns under $200/hr

 

[futuredo32]

$60 is terrible. Even small organizations/groups that I’ve seen have negotiated above that for 99213. Many organizations are scheduling 3-5 insurance patients per hour. Some will no show and bill a no show fee. 4 99214 patients would collect $400-500 without add on codes. The psychiatrist on salary earns under $200/hr

60 bucks is what I get from the better paying insurance companies, Cigna pays $40. My fear with overbooking is that they would all show.......................

 

[calvnandhobbs68]

As in a hospital? I have a tiny practice and insurance pays about $60 for med visits and $150 at best for therapy visits. I prefer outpatient

Good god yeah @TexasPhysician has it right…60 dollars is a terrible average. I’ve seen 70 bucks for 99213s but you should be able to either see a 99213 in 15 minutes or be doing a psychotherapy add on code if that’s a 30 minute slot. 99214s are typically substantially more than 60 dollars. However, the fact that you’re saying “med visits” without specifying code level again makes me wonder if you’re really maximizing coding.

40 dollars is straight up Medicaid rates no joke. You need to drop that insurance and tell them to go to their local CMHC cause that’s probably the only other person in your area who will take whatever terrible insurance plan that is.

So to reiterate, if you’re looking at a practice with a split fee setup, you should be able to have a transparent look at their billing coding averages and reimbursement/collections/no show rate/etc before you even consider signing up with them.

 

[Merovinge]

Good god yeah @TexasPhysician has it right…60 dollars is a terrible average. I’ve seen 70 bucks for 99213s but you should be able to either see a 99213 in 15 minutes or be doing a psychotherapy add on code if that’s a 30 minute slot

With current billing guidelines it's actually tough for psychiatry to be seeing patients for 99213's, I imagine at least 90 if not 95% of patients meet at least 99214 coding criteria if done appropriately

 

[Sushirolls]

As in a hospital? I have a tiny practice and insurance pays about $60 for med visits and $150 at best for therapy visits. I prefer outpatient

I'm currently in the drop phase with one company that was paying similar for a 99213 and barely better for a 99214.

A big volume of my patient panel, but when I review the relative work involved for these patients to the payment, just isn't worth it. Frustrating when knowing I jumped thru the hoops they wanted to get higher rates but nothing. No response. Even had one person say they would expedite things after I submitted my Out of Network / drop letter. Still nothing.

 

[michaelrack]

With current billing guidelines it's actually tough for psychiatry to be seeing patients for 99213's, I imagine at least 90 if not 95% of patients meet at least 99214 coding criteria if done appropriately

do the new coding criteria apply to non-medicare patients?

 

[futuredo32]

She is really nice. She's someone I would be friends with under different circumstances. (I don't really socialize with peers or especially my boss.) She was more conversational and actually said she'd like to be friends. We went to the same high school. She is VERY successful. She has a house on a lake and owns part of the building. She's looking for a forever employee, I was hoping more to learn from her so I could have a practice like hers one day. She's willing to let me do anything I want, therapy (I have a micro practice because I like doing therapy), I am interested in becoming BC in addictions, she's all for that. She said I could create my own practice within her practice. She appears to be one of the nicest people I have ever met. She broke things down financially. With me paying for my own malpractice because of the country she practices in, I am better off taking the salaried position at a CMH, the insurance might be worth taking instead of keeping my own, I would have CME money, paid vacations, sick days, pension at CMH. Medicine was a second career for me. I would like to actually buy a house. I have 400k in student loans. I'm trying IVF (not insurance covered and very expensive). If medicine wasn't a late in life choice from me, this would be an amazing experience for me. But, she would have to start me off a day a week and build (and honestly I don't understand this, if she advertised now that she has a psychiatrist coming in August, one would think she could fill me). She is willing to do 60/40 for a year and pick up my malpractice for that year, but financially for me, I am better off with the position at CMH which is a good job, just wouldn't teach me how to have a very successful practice, not that she is offering that I am lacking in business know how 100% and was hoping to pick it up working for someone like her. . She is looking for a forever psychiatrist. This is , in my opinion a dream job. She's willing to hire a psychiatrist and let them practice psychiatry however they want, any niche you may want to create, she will help, even do therapy which has never ever been offered to me at a position. Want to do RTMS, she can get you working a half day there. She uses Spiravato. One down side is that you have to do your own prior authorizations. The no show rate is low but they only charge $35 for no shows. I am dying to work for her, but financially, it doesn't make sense. If anyone is looking to work in a nice area in a beautiful setting in Metro Detroit (nice suburb, not Detroit itself), pm me. She is super flexible and will let you work full time, part time. This is an amazing position for someone in a better financial position than I am. I am dreading emailing her to say no. I would love to find her an amazing psychiatrist. I feel awful telling her no.

 

[calvnandhobbs68]

Okay so the point of your stream of consciousness rambling is that you don’t think you want the position. Got it.

For anyone else looking at this, I don’t know why OP is getting so hung up on malpractice insurance but I’ve found a lot of people tend to do the same thing when thinking about 1099 positions. Malpractice is almost negligible for psychiatry and absolutely not worth taking a 10% pay cut for (I have my quote sheet in front of me: around 6-9k/year on average for fully mature claims made policies, not actually much more than that for occurrence based but you pay more the first few years). Health insurance, employment tax (Medicare/SS) and 401k are all far bigger costs if you’re self employed (but all costs except for the taxes themselves of course are deductible).

 

[Candidate2017]

I have worked locums, independent contractor positions, but always at X $ per hour. I am interviewing for a really busy clinic that uses Ketamine, RTMS, great reputation, but they want me to do a 70/30 split where I pay my own malpractice, go my own prior authorizations............. I am so much more comfortable knowing I will make X dollars per week. Have those of you who have done a split fee at a clinic done ok financially?

I've interviewed with clinics around my area and the starting split is usually 70/30, sometimes as low as 60/40. Then on a full panel you can negotiate to 80/20. No benefits or malpractice etc. Just office space, EMR, secretarial and billing support. The full panel people are doing more than ok, $400,000-$500,000 is the usual amount they tell me. Malpractice premiums seem to be around $6000-$9000 and prior auths are no big deal unless you prescrible like an NP or are child psych with lots of Adderall patients.

Not sure why you feel it's an either/or proposition between this person's PP clinic and CMHC. You can work part time at the CMHC while building up your base at the PP.

 

[clausewitz2]

do the new coding criteria apply to non-medicare patients?

Okay so the point of your stream of consciousness rambling is that you don’t think you want the position. Got it.

For anyone else looking at this, I don’t know why OP is getting so hung up on malpractice insurance but I’ve found a lot of people tend to do the same thing when thinking about 1099 positions. Malpractice is almost negligible for psychiatry and absolutely not worth taking a 10% pay cut for (I have my quote sheet in front of me: around 6-9k/year on average for fully mature claims made policies, not actually much more than that for occurrence based but you pay more the first few years). Health insurance, employment tax (Medicare/SS) and 401k are all far bigger costs if you’re self employed (but all costs except for the taxes themselves of course are deductible).

My health insurance is actually about 60% of my malpractice premium, but the later still comes out to about $7600 per year and is occurence-based. We are not neurosurg or ob/gyn.

 

[calvnandhobbs68]

My health insurance is actually about 60% of my malpractice premium, but the later still comes out to about $7600 per year and is occurence-based. We are not neurosurg or ob/gyn.

With a family on an ACA Silver plan my health insurance premiums are definitely coming out to more than that

 

[clausewitz2]

With a family on an ACA Silver plan my health insurance premiums are definitely coming out to more than that

Very region specific I imagine. I've got an ACA gold plan and factoring in dependents in costs basically the same as my malpractice (i was counting the portion just covering me in above estimates).

 

[futuredo32]

I've interviewed with clinics around my area and the starting split is usually 70/30, sometimes as low as 60/40. Then on a full panel you can negotiate to 80/20. No benefits or malpractice etc. Just office space, EMR, secretarial and billing support. The full panel people are doing more than ok, $400,000-$500,000 is the usual amount they tell me. Malpractice premiums seem to be around $6000-$9000 and prior auths are no big deal unless you prescrible like an NP or are child psych with lots of Adderall patients.

Not sure why you feel it's an either/or proposition between this person's PP clinic and CMHC. You can work part time at the CMHC while building up your base at the PP

CMH wants full time. Malpractice in the country in the clinic where she is costs 10 k a month I think. She's estimating I will make 25-35k a month.. She's the one who quoted 10 k a month malpractice, which would bring me down to 15-25k a month , malpractice is really expensive in the location where her office is located. I have a micro practice an hour from home because malpractice is so much less.

 

[calvnandhobbs68]

CMH wants full time. Malpractice in the country in the clinic where she is costs 10 k a month I think. She's estimating I will make 25-35k a month.. She's the one who quoted 10 k a month malpractice, which would bring me down to 15-25k a month , malpractice is really expensive in the location where her office is located. I have a micro practice an hour from home because malpractice is so much less.

Go actually get malpractice quotes. Literally just go google "malpractice insurance michigan" and talk to a broker who will give you rates for like 8 different companies. It takes like 20 minutes. Your malpractice insurance is not going to be 10K a MONTH. Neurosurgery malpractice isn't 10k a month.

Also, why do you keep saying country? Do you mean county? Don't you work in Michigan? Malpractice isn't really county specific. It is state specific because of tort reform, damage caps, etc.

 

[futuredo32]

Go actually get malpractice quotes. Literally just go google "malpractice insurance michigan" and talk to a broker who will give you rates for like 8 different companies. It takes like 20 minutes. Your malpractice insurance is not going to be 10K a MONTH. Neurosurgery malpractice isn't 10k a month.

Also, why do you keep saying country? Do you mean county? Don't you work in Michigan? Malpractice isn't really county specific. It is state specific because of tort reform, damage caps, etc.

I have malpractice insurance already and I want to keep them. I DO mean county and it is VERY county specific in Michigan. Wayne, Oakland, and Macomb are the highest. I drive a freaking hour to my micro practice because it is so county specific.

 

[futuredo32]

Okay so the point of your stream of consciousness rambling is that you don’t think you want the position. Got it.

For anyone else looking at this, I don’t know why OP is getting so hung up on malpractice insurance but I’ve found a lot of people tend to do the same thing when thinking about 1099 positions. Malpractice is almost negligible for psychiatry and absolutely not worth taking a 10% pay cut for (I have my quote sheet in front of me: around 6-9k/year on average for fully mature claims made policies, not actually much more than that for occurrence based but you pay more the first few years). Health insurance, employment tax (Medicare/SS) and 401k are all far bigger costs if you’re self employed (but all costs except for the taxes themselves of course are deductible).

Unless things have changed, it's really expensive in certain counties in Michigan. Wayne Oakland and Macomb county have high malpractice rates which is likely why Ann Arbor (in Washtenaw county) has more psychiatrists BY FAR than any other county in Michigan. There are pages and pages in the book of psychiatric providers for Michigan.

 

[splik]

CMH wants full time. Malpractice in the country in the clinic where she is costs 10 k a month I think. She's estimating I will make 25-35k a month.. She's the one who quoted 10 k a month malpractice, which would bring me down to 15-25k a month , malpractice is really expensive in the location where her office is located. I have a micro practice an hour from home because malpractice is so much less.

presumably you already have malpractice insurance? It will be tied to the location you were in when you got it, not this clinic. You would just increase the coverage to full time rate. does not matter whether it is more expense in the clinic location as that should not affect your rate if you already have coverage. No psychiatrist should be paying $120k a yr for malpractice, we are not a surgical specialty.

 

[futuredo32]

I do have malpractice insurance. I have tried this before with other independent contractor jobs and either said no because of the cost of malpractice or one job added me to his because he had a large clinic and I paid for it and it was only 2k a year for part time. This psychiatrist won't add me to her policy. . It changes depends based on location in Michigan. It's based on county. Perhaps malpractice in other states do things differently. I use the Doctor's Company and for part time in the less expensive county it's 1400 quarterly. I don't have any claims, but I graduated in 2015. I carry 1 million 4 million. Maybe I need a different malpractice carrier. She is SO nice, she's willing to wait and let me contact my malpractice company and see how much it would be. Locums is easy. They take care of everything. And they pay well.

 

[AD04]

I am dying to work for her, but financially, it doesn't make sense.

I think you're making the right choice for you by choosing the CMHC. You would make more in the salary position or hourly position, not in a production position. I can tell your strength isn't in business (and that's ok). You had the micropractice for years without growth. Your reimbursements are not competitive. You didn't make a dent in your student loans even though you had it for years. You need to do work that takes advantage of your strength instead of trying to shore up your weakness.

If I were you, I'll work full-time in the CMHC. Maybe even pick up extra shifts on the weekends for extra money. Assuming you have federal student loans, I would apply for PSLF so your loan is forgiven after 10 years of payment under the PAYE or REPAYE program. (Make sure you save some money to pay the tax bill when your loan is forgiven.)

She is really nice. She's someone I would be friends with under different circumstances. (I don't really socialize with peers or especially my boss.) She was more conversational and actually said she'd like to be friends. We went to the same high school. She is VERY successful. She has a house on a lake and owns part of the building. She's looking for a forever employee, I was hoping more to learn from her so I could have a practice like hers one day.

Don't feel bad about saying no to her. If she's really kind and not just superficially nice, she'll take the rejection well. This type of split fee arrangement is very common so you'll easily find another like it in the future.

She has an incentive to be nice to you as she'll make money off of you if you sign on with her. My first job out of residency was something similar. The owner was super nice during recruiting. Promised this and promised that. Empty promises but sounded nice at the time. When I gave my notice that I was leaving, the niceness quickly faded and I still remember the insults.

The full panel people are doing more than ok, $400,000-$500,000 is the usual amount they tell me.

Can you break this down into math? If not, this is just pie in the sky.

Not sure why you feel it's an either/or proposition between this person's PP clinic and CMHC. You can work part time at the CMHC while building up your base at the PP.

If you really want to work with her, what you can do is work for CMHC 4 days / week (10 hours / day). This is still full time. Then work with her 1 day / week.

 

[futuredo32]

Thank you, my bigger question is how do you grow a CLINIC and that needs a new thread

 

[clausewitz2]

I think you're making the right choice for you by choosing the CMHC. You would make more in the salary position or hourly position, not in a production position. I can tell your strength isn't in business (and that's ok). You had the micropractice for years without growth. Your reimbursements are not competitive. You didn't make a dent in your student loans even though you had it for years. You need to do work that takes advantage of your strength instead of trying to shore up your weakness.

If I were you, I'll work full-time in the CMHC. Maybe even pick up extra shifts on the weekends for extra money. Assuming you have federal student loans, I would apply for PSLF so your loan is forgiven after 10 years of payment under the PAYE or REPAYE program. (Make sure you save some money to pay the tax bill when your loan is forgiven.)



Don't feel bad about saying no to her. If she's really kind and not just superficially nice, she'll take the rejection well. This type of split fee arrangement is very common so you'll easily find another like it in the future.

She has an incentive to be nice to you as she'll make money off of you if you sign on with her. My first job out of residency was something similar. The owner was super nice during recruiting. Promised this and promised that. Empty promises but sounded nice at the time. When I gave my notice that I was leaving, the niceness quickly faded and I still remember the insults.



Can you break this down into math? If not, this is just pie in the sky.



If you really want to work with her, what you can do is work for CMHC 4 days / week (10 hours / day). This is still full time. Then work with her 1 day / week.

I kind of agree with @AD04 here. I think you will do better in a setting where you don't have to think very much about reimbursement or anything financial.

That said, you really should reach out to other malpractice carriers, they will be quite eager to give you free quotes. 10k per month is ludicrous and may be a misunderstanding on your part. Remember when you thought your accountant was telling you that something being tax-deductible meant it was literally free?

 

[Merovinge]

I kind of agree with @AD04 here. I think you will do better in a setting where you don't have to think very much about reimbursement or anything financial.

That said, you really should reach out to other malpractice carriers, they will be quite eager to give you free quotes. 10k per month is ludicrous and may be a misunderstanding on your part. Remember when you thought your accountant was telling you that something being tax-deductible meant it was literally free?

I suspect it's 10k/year which got misinterpreted. I remember seeing the HoA on my house when buying and thinking "hell no" and then finding out it was annual instead of monthly, which ends up being super reasonable.

 

[futuredo32]

I kind of agree with @AD04 here. I think you will do better in a setting where you don't have to think very much about reimbursement or anything financial.

That said, you really should reach out to other malpractice carriers, they will be quite eager to give you free quotes. 10k per month is ludicrous and may be a misunderstanding on your part. Remember when you thought your accountant was telling you that something being tax-deductible meant it was literally free?

You have a good memory. I have learned to like, not love psychiatry. Business savvy is not my strength, but that doesn't mean it couldn't be. I like the freedom and autonomy of my own private practice and would like the financial benefits of owning a clinic. I am waiting to hear from my malpractice carrier.

 

[hallowmann]

I suspect it's 10k/year which got misinterpreted. I remember seeing the HoA on my house when buying and thinking "hell no" and then finding out it was annual instead of monthly, which ends up being super reasonable.

This is instantly what came to mind.

Also, I thought the same thing when I saw my HOA fees listed as $$$/mo. I was like wow, I hope we're getting a lot for that. Come time to sign the mortgage it was actually $$$/year and the HOA was so inactive that they had a surplus and I didn't start getting charged it until my 3rd year here.

 

[Candidate2017]

Can you break this down into math? If not, this is just pie in the sky.

The par for insurance in my area is well into the 300s hourly insurance reimbursement, whether you do three 20 min med mgt visits/hour or two 30 med therapy combined visits. 7.5 to 8 patient hours a day, 5 days a week. I know 2 psychiatrists from these clinics. The PP owners, usually social workers or psychologists, are very saavy and make $500,000 to $1 mil off their cut from psychiatrists and have no use for someone looking for part time work.

I'm not sure why you think this is pie in the sky. Back in med school the student gossip about the richest doctors at our hospital were the inpatient psychiatrists. They were rumored to push high six figs working cardiology hours (cover 2 units, take call, work 5.5-6 days a week).

 

[AD04]

@Candidate2017 As long as you understand the math behind it. What you have written is a good start. There is a difference between theoretical and actual after accounting for split and inefficiencies and no shows and collections and whatnot.

 

[Mass Effect]

I don't know. They provide billing and let you use their EMR. Their office staff schedules your appointments. I think Prior Authorizations are really difficult and time consuming. They don't call in refills for you.

I'm confused by this. Aren't the refills through EMR so really all you have to do is sign?

I'm currently in the drop phase with one company that was paying similar for a 99213 and barely better for a 99214.

A big volume of my patient panel, but when I review the relative work involved for these patients to the payment, just isn't worth it. Frustrating when knowing I jumped thru the hoops they wanted to get higher rates but nothing. No response. Even had one person say they would expedite things after I submitted my Out of Network / drop letter. Still nothing.

Which company is this that's paying so little for 99213-4? That's crazy low.

CMH wants full time. Malpractice in the country in the clinic where she is costs 10 k a month I think. She's estimating I will make 25-35k a month.. She's the one who quoted 10 k a month malpractice, which would bring me down to 15-25k a month , malpractice is really expensive in the location where her office is located. I have a micro practice an hour from home because malpractice is so much less.

I'll join the chorus in telling you that you likely misunderstood. 10k/month really isn't a thing in psych, even in the richest places in the country, unless your would-be boss has been severely taken advantage of and doesn't know it. Malpractice rates for psych should be under 10k/year for reference. If it's more, I'd walk.

 

[futuredo32]

I'm confused by this. Aren't the refills through EMR so really all you have to do is sign?




Which company is this that's paying so little for 99213-4? That's crazy low.



I'll join the chorus in telling you that you likely misunderstood. 10k/month really isn't a thing in psych, even in the richest places in the country, unless your would-be boss has been severely taken advantage of and doesn't know it. Malpractice rates for psych should be under 10k/year for reference. If it's more, I'd walk.

At the clinic where I work you need to fill out forms for prior authorizations or call. The clinic where I am a locums, the receptionists do everything for refills and all I have to do is click. At this other private clinic, your patients email you and you use therapy notes to write that you filled it and some other system to prescribe. For my micro practice I use paper charts and rx pads. I usually do 99213, my biller said 99214 will trigger audits. I'm waiting for a quote. I only asked for it last Monday............ I pay 6400 a year for part time malpractice in a county that is cheaper. I know it's outrageous in other counties.

 

[Sushirolls]

~$2500/year for part time clinical hours, less than 20hrs. This is for the preferential occurrence based coverage.