Thoughts on outpatient job

[surfguy84]

1099. I can set my own schedule, no requirements on number of patients to see. The group handles everything from office space to billing, good front desk support. Option to be fully tele or hybrid. Good collaboration between providers with regular case conference. About 12 docs and 3x that in phd level therapists. They target higher income patient population.

For all of this they give 60% of collected billing. They only take a single insurer and have been with them for a long time. No issues in collections. They also have very high negotiated rates with this payor. A 99214+90833 reimburses around 345. So all in I should generate close to 400/hr after the split and once full which I've been told should only take a few months.

Seems almost too good to be true..any thoughts?

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[littlefred]

Looks like kind of a concierge setup? What are the expectations on the patients that you handle (e.g. are you expected to be on-call and respond to inquiries within a set amount of time? Is it a pill mill? Why are they hiring? Are you supervising mid-levels? Are you replacing someone? Who covers when you are out?

I can think of many other questions. If I were you I would talk to one of the MD's working there to see how it realistically works out.

 

[SmallBird]

1099. I can set my own schedule, no requirements on number of patients to see. The group handles everything from office space to billing, good front desk support. Option to be fully tele or hybrid. Good collaboration between providers with regular case conference. About 12 docs and 3x that in phd level therapists. They target higher income patient population.

For all of this they give 60% of collected billing. They only take a single insurer and have been with them for a long time. No issues in collections. They also have very high negotiated rates with this payor. A 99214+90833 reimburses around 345. So all in I should generate close to 400/hr after the split and once full which I've been told should only take a few months.

Seems almost too good to be true..any thoughts?

Why does that seem too good to be true? Just convert it to RVUs. 99214 + 90833 = 3.4 RVUs. At $345 that is $100 per RVU and if you get 60% that's 60/RVU. That is below the national average for employed positions. I'm not saying it's bad, but as a contrast: our full-time outpatient docs here get $67/RVU and they are W2 (so health insurance, good retirement match) and that is for RVUs billed, not collections, and there are attached crisis centers/inpatient units you can send your patients to if needed. It might still be a good gig and you could do well but it isn't exceptional.

 

[TexasPhysician]

Sounds like a good gig from what we can tell.

 

[surfguy84]

Looks like kind of a concierge setup? What are the expectations on the patients that you handle (e.g. are you expected to be on-call and respond to inquiries within a set amount of time? Is it a pill mill? Why are they hiring? Are you supervising mid-levels? Are you replacing someone? Who covers when you are out?

I can think of many other questions. If I were you I would talk to one of the MD's working there to see how it realistically works out.

Only one mid level on staff, no supervision required. Not a pill mill, the clinics they operate appear to be well regarded in the community. Not replacing anyone they are just trying to grow their staff. Definitely more questions will need to get answered about other details though.

 

[FlowRate]

60% of collections seems low, no? Who owns the clinic? Is there an option of working toward partnership/profit sharing?

 

[calvnandhobbs68]

$345 extremely high rate for a 99214+90833. For reference that's almost 2x what the major payors around me pay for that combo. If that's true, then yeah 60% is going to come out to a lot of money still.

Why does that seem too good to be true? Just convert it to RVUs. 99214 + 90833 = 3.4 RVUs. At $345 that is $100 per RVU and if you get 60% that's 60/RVU. That is below the national average for employed positions. I'm not saying it's bad, but as a contrast: our full-time outpatient docs here get $67/RVU and they are W2 (so health insurance, good retirement match) and that is for RVUs billed, not collections, and there are attached crisis centers/inpatient units you can send your patients to if needed. It might still be a good gig and you could do well but it isn't exceptional.

Yeah but that RVU conversion rarely happens outpatient (especially with the new 2021 wRVU conversions). I haven't heard of many people actually collecting $60 per wRVU outpatient after splits. I also encourage people to just totally throw the RVU thing out the window and look at what you're just collecting per code outpatient as it makes much more sense that way.

Just throwing really crude numbers out there, say a full schedule of 30 patient hours/week of followups when full to account for some no shows if your actual scheduled patients are 32-33 hrs/week, averaging one 99214+90833 and one 99214 per hour (so two 30min followups one without a psychotherapy add on code) would be 1.92 + 1.5 + 1.92 wRVUS= 5.34 wRVUs/hr x 60/RVU= $320/hr x 30hrs/week x 48 weeks/yr= $461,376.

Haven't heard of many people making that in insurance based outpatient practices with 2 patients per hour unless they're billing everyone with add on codes.

 

[G Sheb]

How many patients will you be seeing in an hour?
That's kind of the missing link.

 

[SmallBird]

Yeah but that RVU conversion rarely happens outpatient (especially with the new 2021 wRVU conversions). I haven't heard of many people actually collecting $60 per wRVU outpatient after splits. I also encourage people to just totally throw the RVU thing out the window and look at what you're just collecting per code outpatient as it makes much more sense that way.

Just throwing really crude numbers out there, say a full schedule of 30 patient hours/week of followups when full to account for some no shows if your actual scheduled patients are 32-33 hrs/week, averaging one 99214+90833 and one 99214 per hour (so two 30min followups one without a psychotherapy add on code) would be 1.92 + 1.5 + 1.92 wRVUS= 5.34 wRVUs/hr x 60/RVU= $320/hr x 30hrs/week x 48 weeks/yr= $461,376.

Haven't heard of many people making that in insurance based outpatient practices with 2 patients per hour unless they're billing everyone with add on codes.

I'm pretty sure the MGMA benchmarks are what people are getting paid per RVU. I just saw the data recently and the 50% is something like $62. However I think 5.34 RVU/s an hour is unlikely - some hours will be 2 x 99213's, some will be a 99213 + 99214, some will be as you laid out, some will be a 90792, so more like 4.5 RVUs/hr on average, and if you take out holidays when most outpatient jobs are closed, and CME time and vacation, it comes to around $350k a year which is about what I hear full-time outpatient jobs paying frequently.

 

[clozareal]

How many patients will you be seeing in an hour?
That's kind of the missing link.

They said they get to make their own schedule and it doesn't seem like the clinic has a requirement on number of patients per hour or how long appointments are or such.

 

[surfguy84]

I'm pretty sure the MGMA benchmarks are what people are getting paid per hour. I just saw the data recently and the 50% is something like $62. However I think 5.34 RVU/s an hour is unlikely - some hours will be 2 x 99213's, some will be a 99213 + 99214, some will be as you laid out, some will be a 90792, so more like 4.5 RVUs/hr on average, and if you take out holidays when most outpatient jobs are closed, and CME time and vacation, it comes to around $350k a year which is about what I hear full-time outpatient jobs paying frequently.

In discussion with a couple MDs there it sounds like 95% of patients are billed as 99214 with add on codes being used liberally. I will say the docs on the roster all appear quite accomplished from outward appearance, I.e. good pedigree. Every therapist is doctoral levels, neuropsychology on staff. Seems like a quality outfit.

 

[rjs2131]

That is an incredible reimbursement for 99214+90833 - not sure you can beat that. That seems higher than most cash practices for a 30-min visit (from what I've seen, somewhere in the $200-300 range depending on location) so 60% of that split will mean you are very well compensated. If you are actually taking home ~$400/hr and working full-time, you would clear 500k once you have a schedule of largely follow-ups. That definitely seems to be on the higher end (even in PP) for full-time work without weekends/call, so I would just make sure you aren't missing anything.

One other question to think about though - how long will it take you to fill only taking a single insurance? If there is plenty of demand should be fine, but I took 4-5 insurances starting out and while I was fairly "full" (30 clinical hours/week) by month 3-4, I'm still seeing around 1 new patient/day (so 1 new + 9 30-min follow-ups) and am nearing the 2 year mark. Eventually things will probably work out if there is enough demand, but good to keep in mind to set realistic expectations for year 1-2.

 

[reca]

What area is this? That’s an amazing rate for those codes.

 

[TexasPhysician]

60% of collections seems low, no? Who owns the clinic? Is there an option of working toward partnership/profit sharing?

The % doesn’t matter. The clinic may spend a ton of $ collecting patients with this high rate paying rate. Overhead can vary significantly based on many factors.

I’d take 50% at these rates over 90% at a Medicaid clinic.

 

[Merovinge]

60% of collections seems low, no? Who owns the clinic? Is there an option of working toward partnership/profit sharing?

Paying 40% for a crazy good reimbursement contract and (hopefully) a steady stream of patients with this exact insurance as well as all the overhead seems actually quite reasonable to me.

The biggest risk of this job in my mind is if that single insurance changes it's reimbursement, if they even cut it say 25% that would dramatically impact your take home. Would be painful to work for a few years, get a full panel and then have this contract revert closer to the mean. Then 60% would be really tough to swallow and this change is entirely out of your control.

 

[Stagg737]

Agree with most above that this seems like a pretty great position. What is support staff like? Who handles patient questions/calls? Prior auths? Etc.

I'm pretty sure the MGMA benchmarks are what people are getting paid per RVU. I just saw the data recently and the 50% is something like $62. However I think 5.34 RVU/s an hour is unlikely - some hours will be 2 x 99213's, some will be a 99213 + 99214, some will be as you laid out, some will be a 90792, so more like 4.5 RVUs/hr on average, and if you take out holidays when most outpatient jobs are closed, and CME time and vacation, it comes to around $350k a year which is about what I hear full-time outpatient jobs paying frequently.

If this happens on a regular basis then I'd argue it's either poor scheduling or poor coding/billing. True 99213 patients in psych don't really need to be seen by a psychiatrist unless insurance or someone is requiring it for stimulants, and those are some of the only patients who I'd argue it's completely reasonable to regularly schedule as 15 minute f/ups; so it should be 3-4x 99213/hr for those patients...

 

[calvnandhobbs68]

I'm pretty sure the MGMA benchmarks are what people are getting paid per RVU. I just saw the data recently and the 50% is something like $62. However I think 5.34 RVU/s an hour is unlikely - some hours will be 2 x 99213's, some will be a 99213 + 99214, some will be as you laid out, some will be a 90792, so more like 4.5 RVUs/hr on average, and if you take out holidays when most outpatient jobs are closed, and CME time and vacation, it comes to around $350k a year which is about what I hear full-time outpatient jobs paying frequently.

$350,000/$60 per RVU= 5833 RVUs/4.5 per hour= 1296hr/yr
Even if you divide that by 46 weeks/year (so allowing for like 6 weeks of vacation/CME time, random days off and random sick days per year) that's about 28-29 average actual hours of patient contact time per week.
That's not typical, so that's what I mean when I say whatever you're seeing as MGMA data doesn't make a ton of sense. Not hearing of many outpatient jobs paying 350K/year to see <30 hours of patients per week at 2pph + 6 weeks off per year.

Also another reason why straight RVUs are a pretty bad way to measure this because some places, especially academics, terribly undercode. So they'll just bill everyone as 99213s/99214s for instance because they have very little incentive for productivity metrics and will artificially inflate "compensation per RVU". What really matters is just what you're collecting per code outpatient.

 

[splik]

$350,000/$60 per RVU= 5833 RVUs/4.5 per hour= 1296hr/yr
Even if you divide that by 46 weeks/year (so allowing for like 6 weeks of vacation/CME time, random days off and random sick days per year) that's about 28-29 average actual hours of patient contact time per week.
That's not typical, so that's what I mean when I say whatever you're seeing as MGMA data doesn't make a ton of sense. Not hearing of many outpatient jobs paying 350K/year to see <30 hours of patients per week at 2pph + 6 weeks off per year.

Also another reason why straight RVUs are a pretty bad way to measure this because some places, especially academics, terribly undercode. So they'll just bill everyone as 99213s/99214s for instance because they have very little incentive for productivity metrics and will artificially inflate "compensation per RVU". What really matters is just what you're collecting per code outpatient.

There is no artificial inflation for RVUs in academics. the conversion fact is a set dollar amount determined by the hospital not the department, it is not related to the salary, and in my experience the conversion factor in academics is actually quite low once they've deducted the dean's tax and departmental taxes (and in some institutions even divisional taxes). For example, at my last institution they were offering a measly $40 per wRVU when we switched to the RVU model which is when I knew I had to leave. Also most clinician educator jobs are salaried not production so aren't included in the RVU figures.

The RVU model is just one model of compensation and it tends to apply mostly to certain hospital systems and multispecialty clinics. These institutions are often able to negotiate 3x Medicare rates for their private insurance contracts, don't accept medicaid, and often have a smaller share of medicare pts, and thus are able to offer $60-70/wRVU. I actually don't know that many people who work in RVU systems but those that do (outside of academics) are making over $400/hr once they've established their panels. And they often are doing 24-32 hours of patient contact time per week.

I will say that MGMA and other salary surveys are imperfect due to small sample sizes and the wide variation in practice settings, payment models and patient populations etc. Also the point of these surveys is to depress compensation so they are likely to be an underestimate of compensation in the private sector. However they are better than nothing and the rough numbers do align with what I'm seeing.

 

[clausewitz2]

Based on my cut of what my current employer collects if I worked 5 days a week and saw 12 follow-ups daily for 30 min each (so about six hours), would easily clear $400k yearly at 46 weeks/year, so this is in line with my expectations.

 

[calvnandhobbs68]

There is no artificial inflation for RVUs in academics. the conversion fact is a set dollar amount determined by the hospital not the department, it is not related to the salary, and in my experience the conversion factor in academics is actually quite low once they've deducted the dean's tax and departmental taxes (and in some institutions even divisional taxes). For example, at my last institution they were offering a measly $40 per wRVU when we switched to the RVU model which is when I knew I had to leave. Also most clinician educator jobs are salaried not production so aren't included in the RVU figures.

I'm not saying there are inherently some higher set dollar amounts for RVUs in academics. X salary for up to X base amount of RVUs + bonus $/RVU over that amount is common. If the incentive over that base RVU/salary amount isn't good enough to work for, people won't even try for it. I've seen plenty of academic attendings clearly not even seem to care what they're billing and do things like bill straight 99213s/99214s for everyone. If your base salary doesn't change until you get to that incentive cutoff and you're doing something like producing 3.2 wRVUs per patient hour cause you don't care how you bill, when you convert salary to RVUs it could look like you're "making more" per RVU (even though what's actually happening is you're just undercoding cause you don't care about producing over your base salary and want to write simple notes).
MGMA may not capture it this way but this is one way $/RVU data can get weird and another reason why RVUs are a dumb way to measure things in general.

Based on my cut of what my current employer collects if I worked 5 days a week and saw 12 follow-ups daily for 30 min each (so about six hours), would easily clear $400k yearly at 46 weeks/year, so this is in line with my expectations.

I would say I'd get close to that at 12 followups/day with 50% 90833s for 46 weeks per year. I'd also say though I feel I'm in a pretty favorable compensation model. My point was that saying OPs proposed setup is "below national average for employed positions" in terms of take home pay doesn't really seem to match up with what I'd seen looking around at multiple outpatient offers. I'd say it's a pretty good setup actually on a $/hr basis and the biggest risk is what @Merovinge said where if the one insurer decides to stop playing ball, you're kind of hosed.

 

[SmallBird]

I'm not saying there are inherently some higher set dollar amounts for RVUs in academics. X salary for up to X base amount of RVUs + bonus $/RVU over that amount is common. If the incentive over that base RVU/salary amount isn't good enough to work for, people won't even try for it. I've seen plenty of academic attendings clearly not even seem to care what they're billing and do things like bill straight 99213s/99214s for everyone. If your base salary doesn't change until you get to that incentive cutoff and you're doing something like producing 3.2 wRVUs per patient hour cause you don't care how you bill, when you convert salary to RVUs it could look like you're "making more" per RVU (even though what's actually happening is you're just undercoding cause you don't care about producing over your base salary and want to write simple notes).
MGMA may not capture it this way but this is one way $/RVU data can get weird and another reason why RVUs are a dumb way to measure things in general.



I would say I'd get close to that at 12 followups/day with 50% 90833s for 46 weeks per year. I'd also say though I feel I'm in a pretty favorable compensation model. My point was that saying OPs proposed setup is "below national average for employed positions" in terms of take home pay doesn't really seem to match up with what I'd seen looking around at multiple outpatient offers. I'd say it's a pretty good setup actually on a $/hr basis and the biggest risk is what @Merovinge said where if the one insurer decides to stop playing ball, you're kind of hosed.

I think I agree with that. That OP had asked if this was too good to be true. My point was that if you viewed this position in terms of $/RVU it gave you a number which, unless we totally discard the MGMA data, is clearly not so unrealistic and some people report getting even more than this /RVU. I don't understand your point about '$ collected' as MGMA reports on what people get in $/rvu, not what they bill. I do agree that other factors like how many RVUs you are likely to be able to bill and the specifics of the setup make a huge difference.

 

[finalpsychyear]

I would say this is a a 10k/wk job once your fully booked 40 clinical hours taking into consideration of no shows and various codes, federal holidays etc. I think it will take you at least 12-18 mo to build it up to this if there is already that much demand. If that's the case you may be at a run rate to that per week amount by the end of year 2 and actually pulling those numbers in year 3 for the whole year.

 

[heartsink]

The biggest risk of this job in my mind is if that single insurance changes it's reimbursement, if they even cut it say 25% that would dramatically impact your take home. Would be painful to work for a few years, get a full panel and then have this contract revert closer to the mean. Then 60% would be really tough to swallow and this change is entirely out of your control.

This is the most salient question in my mind. How often does this happen in the outpatient world?

 

[surfguy84]

This is the most salient question in my mind. How often does this happen in the outpatient world?

This group has been with this insurer for 10+ years now, I suppose that doesn't mean it can't happen at some point, but it appears stable. In fact they increased their rates >5% this past year.

I guess I'm not overly concerned with that happening though. If rates were slashed, I would just leave and find another job. I'm also doing inpatient work so it's not like my income is highly dependent upon this job.

 

[finalpsychyear]

This group has been with this insurer for 10+ years now, I suppose that doesn't mean it can't happen at some point, but it appears stable. In fact they increased their rates >5% this past year.

I guess I'm not overly concerned with that happening though. If rates were slashed, I would just leave and find another job. I'm also doing inpatient work so it's not like my income is highly dependent upon this job.

So if your already doing inpt work there's little risk here adding this gig. Good luck let us know how it goes. If it works out more than likely you'll dump the inpt job and do outpatient full time unless your trying to break the bank and start rounding 5-6am to do it all.

 

[Merovinge]

I'd say talk to preferably 2 of the non-partner docs, see how it is for them, and provided there aren't any stupid non-competes get started ASAP and let us know how it goes.

This setup is a good answer to recent thread about what 5 psychiatrists could do to leverage their cooperation. I think it was a big mistake to take on the 1 NP for this group, having 30 doctor level psychologists and 12 MDs is quite the selling point of an all doctorate level group. I'd refer to this kind of group in a heartbeat.

 

[FlowRate]

The % doesn’t matter. The clinic may spend a ton of $ collecting patients with this high rate paying rate. Overhead can vary significantly based on many factors.

I’d take 50% at these rates over 90% at a Medicaid clinic.

Please let me know if you disagree, but spending $200k per FT psychiatrist on overhead seems like quite a lot, even with high rent facilities and fancy marketing to appeal to their niche clients. But really my point was more about seeing if there are any options for partnership/profit sharing. I think it's fair to assume that such a successful organization IS generating profit for whoever is running the show and that the 40% isn't just bare minimum to cover overhead.

 

[TexasPhysician]

Please let me know if you disagree, but spending $200k per FT psychiatrist on overhead seems like quite a lot, even with high rent facilities and fancy marketing to appeal to their niche clients. But really my point was more about seeing if there are any options for partnership/profit sharing. I think it's fair to assume that such a successful organization IS generating profit for whoever is running the show and that the 40% isn't just bare minimum to cover overhead.

The owner doesn’t hire unless the owner profits. Owners have admin time that is added with every hire. More staff to interview, payroll, manage schedules, contracts, negotiations, etc. Unless you expect to earn $100k off a new psychiatrist starting year 2, you should walk and find another psychiatrist. This is a business. If you expect a group to take on another psychiatrist for $50k, think again. It isn’t worth it. You want to find a group that’s fair, but still profits off you. Otherwise they’ll replace you.

The other $100k is overhead. Billing company will take 5% off the top. Rent space, add an extra staff to handle significant extra volume, benefits for staff, prior authorizations, furniture, cleaning company, etc.

 

[calvnandhobbs68]

The other $100k is overhead. Billing company will take 5% off the top. Rent space, add an extra staff to handle significant extra volume, benefits for staff, prior authorizations, furniture, cleaning company, etc.

Guarantee a group like this has an in house billing person, otherwise they’d be bleeding tons of money on billing (at 5% of what they’re generating even salary+ benefits for a dedicated billing staff you could hit with 3-5 FT psychiatrists). Most of the rest of what you’re putting in there is fixed overhead that doesn’t incrementally change much going from 12 to 13 psychiatrists. You do not really need to add “extra staff” for every additional psychiatrist…I current have an admin assistant that handles admin/scheduling/basic phone triage and basic prior auth stuff for 4 psychiatrists. Therapists/psychologists need even less admin support.

I mean yeah overhead is a thing but a group like this doesn’t or shouldn’t have 100K of added overhead per person.

 

[TexasPhysician]

Guarantee a group like this has an in house billing person, otherwise they’d be bleeding tons of money on billing (at 5% of what they’re generating even salary+ benefits for a dedicated billing staff you could hit with 3-5 FT psychiatrists). Most of the rest of what you’re putting in there is fixed overhead that doesn’t incrementally change much going from 12 to 13 psychiatrists. You do not really need to add “extra staff” for every additional psychiatrist…I current have an admin assistant that handles admin/scheduling/basic phone triage and basic prior auth stuff for 4 psychiatrists. Therapists/psychologists need even less admin support.

I mean yeah overhead is a thing but a group like this doesn’t or shouldn’t have 100K of added overhead per person.

Sure they may have in house billing people which is still an expense. Adding clinical staff eventually reaches a point where you add more billing staff.

If you over-rented/purchased to add for growth, that is great planning. It also means you’ve been running extra overhead on space, electric bills, etc for months to years. That is still $ lost.

We are running 1 admin/psych right now. No additional for therapists. Staff do vitals, screening tests with patients, schedule, PA’s (frequent with child work), pull charts, answer phones, send records, type reports (some contracts we have require this), relay messages, assist with pharmacy problems, etc. They stay busy.

I always expect to pay more than I think in overhead to ensure it is covered. The first 1-2 years of building a new psych will result in much less revenue. There won’t be $200k to work with. If the psych decides to leave early, we have recruiting costs, contract negotiation costs with a new psych, staff to notify and coordinate transfers, etc. That is more lost $.

With child work, we have an attorney on retainer to prevent court days which would pull us out of the office. I’ve paid another attorney to win a labor dispute which was thousands lost in attorney fees.

Credit card fees knock out 2-4%. Then there are credit card chargeback disputes. While not common, I got one today from a disgruntled patient. If I lose the dispute resolution process, it’ll essentially wipe out all profit from this psychiatrist for the week. Despite having thorough documentation, some of these disputes are impossible to win.

My point is that there are tons of expenses that people don’t think of when running an efficient practice for psychiatrists. It isn’t just add a new psychiatrist and pad your pocket with $200k.

I get that I’m coming from the owner perspective here. By all means negotiate for the best deal for you. I’m just saying that you need to keep in mind that there may not be a lot of room to work with depending on how the clinic is run. If I didn’t provide near as much support, I could pay more, but the psychiatrists would have more admin time to keep patients.

 

[calvnandhobbs68]

Sure they may have in house billing people which is still an expense. Adding clinical staff eventually reaches a point where you add more billing staff.

If you over-rented/purchased to add for growth, that is great planning. It also means you’ve been running extra overhead on space, electric bills, etc for months to years. That is still $ lost.

We are running 1 admin/psych right now. No additional for therapists. Staff do vitals, screening tests with patients, schedule, PA’s (frequent with child work), pull charts, answer phones, send records, type reports (some contracts we have require this), relay messages, assist with pharmacy problems, etc. They stay busy.

I always expect to pay more than I think in overhead to ensure it is covered. The first 1-2 years of building a new psych will result in much less revenue. There won’t be $200k to work with. If the psych decides to leave early, we have recruiting costs, contract negotiation costs with a new psych, staff to notify and coordinate transfers, etc. That is more lost $.

With child work, we have an attorney on retainer to prevent court days which would pull us out of the office. I’ve paid another attorney to win a labor dispute which was thousands lost in attorney fees.

Credit card fees knock out 2-4%. Then there are credit card chargeback disputes. While not common, I got one today from a disgruntled patient. If I lose the dispute resolution process, it’ll essentially wipe out all profit from this psychiatrist for the week. Despite having thorough documentation, some of these disputes are impossible to win.

My point is that there are tons of expenses that people don’t think of when running an efficient practice for psychiatrists. It isn’t just add a new psychiatrist and pad your pocket with $200k.

I get that I’m coming from the owner perspective here. By all means negotiate for the best deal for you. I’m just saying that you need to keep in mind that there may not be a lot of room to work with depending on how the clinic is run. If I didn’t provide near as much support, I could pay more, but the psychiatrists would have more admin time to keep patients.

I mean idk sounds like a lot of admin staff, that's basically as efficient from an admin perspective as being your own solo psychiatrist with your own full time admin assistant (which isn't very efficient). I do my own vitals, I give people my own screening tests, my admin assistant will start PAs but I finish them in CoverMyMeds (also maybe PAs are way more common for you guys for some reason but I find if I don't start people on brand name stimulants all the time I pretty much manage to avoid these...insurance companies have been weird about Strattera recently though). She still does all that other stuff for me and 2 other full time and 1 part time psychiatrist.

I mean yeah office space costs money but people have also been pretty desperate to lease out office space lately...I can throw a rock and hit 3 vacant office spaces for lease right now around our business park and multiple smaller one person office spaces I could use for solo private practice if I was inclined.

I see 2pph on average the hours I have patients scheduled with 1 new patient a day right now. I think if I were seeing full patient panels of 3-4pph then yeah, we'd probably need to increase admin support to increase efficiency but I'd also be billing more.

The attorney on retainer thing is interesting but wouldn't say that's a common overhead expense. I've not yet been called for any court date in the last 1.5 years. I've headed off a couple court situations by basically telling parents ahead of time "don't bother trying to get me to come into court for you guys BTW cause you're welcome to my notes and I'm just going to read off my notes in court despite whatever your attorney says".

Credit card fees totally fair. Not sure how a chargeback for one patient "wipes out all profit" from a psychiatrist for the week though unless it's like months of appointments? If you're having a psychiatrist BILL 400K/yr (which is pretty conservative) for example at a 70/30 split even if you divided by a full 52 weeks/yr that's still $2300/wk on the owner split end. Even if you spent 50% of that on overhead that's still $1150 for that week.

Totally agree it's not "add a new psychiatrist and pad your pocket with another 200K" but it goes both ways...the whole reason why it's so easy to go do your own solo private practice in psychiatry is because overhead is actually not such a significant problem for psychiatry.
Also, are you directly employing these psychiatrists? Cause the OP's setup is a straight percentage split so doubt there's any "admin time" or anything...similar for me I take an hour for lunch every day but that's just basically an hour losing money I could be seeing patients, it's not paid time.

 

[TexasPhysician]

I mean idk sounds like a lot of admin staff, that's basically as efficient from an admin perspective as being your own solo psychiatrist with your own full time admin assistant (which isn't very efficient). I do my own vitals, I give people my own screening tests, my admin assistant will start PAs but I finish them in CoverMyMeds (also maybe PAs are way more common for you guys for some reason but I find if I don't start people on brand name stimulants all the time I pretty much manage to avoid these...insurance companies have been weird about Strattera recently though). She still does all that other stuff for me and 2 other full time and 1 part time psychiatrist.

I mean yeah office space costs money but people have also been pretty desperate to lease out office space lately...I can throw a rock and hit 3 vacant office spaces for lease right now around our business park and multiple smaller one person office spaces I could use for solo private practice if I was inclined.

I see 2pph on average the hours I have patients scheduled with 1 new patient a day right now. I think if I were seeing full patient panels of 3-4pph then yeah, we'd probably need to increase admin support to increase efficiency but I'd also be billing more.

The attorney on retainer thing is interesting but wouldn't say that's a common overhead expense. I've not yet been called for any court date in the last 1.5 years. I've headed off a couple court situations by basically telling parents ahead of time "don't bother trying to get me to come into court for you guys BTW cause you're welcome to my notes and I'm just going to read off my notes in court despite whatever your attorney says".

Credit card fees totally fair. Not sure how a chargeback for one patient "wipes out all profit" from a psychiatrist for the week though unless it's like months of appointments? If you're having a psychiatrist BILL 400K/yr (which is pretty conservative) for example at a 70/30 split even if you divided by a full 52 weeks/yr that's still $2300/wk on the owner split end. Even if you spent 50% of that on overhead that's still $1150 for that week.

Totally agree it's not "add a new psychiatrist and pad your pocket with another 200K" but it goes both ways...the whole reason why it's so easy to go do your own solo private practice in psychiatry is because overhead is actually not such a significant problem for psychiatry.
Also, are you directly employing these psychiatrists? Cause the OP's setup is a straight percentage split so doubt there's any "admin time" or anything...similar for me I take an hour for lunch every day but that's just basically an hour losing money I could be seeing patients, it's not paid time.

If I did my own vitals, completed PA’s, and monitored screening tests, I’d need to reduce my volume by 1-2+ patients per day to finish at the same time. I’d rather lose a higher percent of revenue and see more patients for higher daily earnings.

I know other psychiatrists that are happy with low volume taking home 85% of gross that earn much less than anyone in my clinic.

The great thing about psych is that there are many ways to run a clinic. Everyone needs to figure out what works for them. I’ve seen overhead at around 5% on up to 50% in psych. You can do everything virtual from home and have patients mail checks to avoid credit card fees. You could take every insurance including Medicaid, high COL area in person, many support staff, and not cut costs.

 

[Stagg737]

I'd say talk to preferably 2 of the non-partner docs, see how it is for them, and provided there aren't any stupid non-competes get started ASAP and let us know how it goes.

This setup is a good answer to recent thread about what 5 psychiatrists could do to leverage their cooperation. I think it was a big mistake to take on the 1 NP for this group, having 30 doctor level psychologists and 12 MDs is quite the selling point of an all doctorate level group. I'd refer to this kind of group in a heartbeat.

Idk, I'd argue that having 1 NP who can continue to see those regular 99213's that the psychiatrists have stabilized isn't a bad idea. You can keep those 3-month stimulant refill patients in-practice, have them seen for a 15-20 minute f/up by the NP 3 times a year, and see their physician once a year to check in. If insurance is reimbursing that well, a 99213 probably pulls in $75/pt, at 3-4/hr that's $225-$300/hr. If that NP works 30 hours a week 45 weeks/yr it's an additional $300k-$400k/yr. Even if you pay that NP $200k salary, you're still bringing in an extra $100k+ per year and keeping patients in-house.

Idk, I don't know how others' practices are set up, but the patients I've had who were stable on their stimulants for years don't really want to spend 30+ minutes talking to me just to get their meds refilled and with that many therapists in the group the NP could be purely med-management for straightforward cases.

 

[clausewitz2]

Idk, I don't know how others' practices are set up, but the patients I've had who were stable on their stimulants for years don't really want to spend 30+ minutes talking to me just to get their meds refilled and with that many therapists in the group the NP could be purely med-management for straightforward cases.

Maybe I set expectations early with 90 minute intakes but I haven't had many of these folks complain about appointment length. There's almost always something more going on than just 'my Addys are fine, thanks', although admittedly it often falls into the realm of things brief IPT or problem-solving therapy can handle. I've yet to meet someone with ADHD who doesn't have an intense anxiety about making mistakes and messing things up, for example, and the emotion regulation problems associated with ADHD can definitely complicate their relationships with others.


I have certainly had those patients who are functioning just fine and have very little to say to me. I send them on their merry way back to their PCP. Still, this has been like.. 1-2 in the past 2.5 years? I get more GAD folks like this, distinctly incurious about the sources or mechanisms of their distress but very invested in avoiding discomfort.

 

[Stagg737]

Maybe I set expectations early with 90 minute intakes but I haven't had many of these folks complain about appointment length. There's almost always something more going on than just 'my Addys are fine, thanks', although admittedly it often falls into the realm of things brief IPT or problem-solving therapy can handle. I've yet to meet someone with ADHD who doesn't have an intense anxiety about making mistakes and messing things up, for example, and the emotion regulation problems associated with ADHD can definitely complicate their relationships with others.


I have certainly had those patients who are functioning just fine and have very little to say to me. I send them on their merry way back to their PCP. Still, this has been like.. 1-2 in the past 2.5 years? I get more GAD folks like this, distinctly incurious about the sources or mechanisms of their distress but very invested in avoiding discomfort.

Most of the ones I'm thinking of were patients I saw in med school rotations pre-pandemic. A lot of them had been on the same (reasonable) dose for 5+ years. It's not that they would complain about long appointments, they just seemed to appreciate getting in and out fairly quickly. This was also a very different patient population than what I saw in residency, which was higher acuity and very little of the higher functioning worried well.