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The big question is here how much are you willing to put up with for a very large sum of money?
Transparent Discussion Income
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First, please unquote me.
And not direct but through shared notes. So, they "extend" my reach so to speak. I could not do what I do without them and they are good for most part.
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At my VA, physician leadership is largely going by the wayside. My bosses and their bosses are all nurses or psychologists, I get along with them pretty well. And I suspect this downward trend of physician leadership is only going to continue. I maintain that all clinical decisions are mine and mine alone. I chuckled a little when you said the NP is the real shot-caller. I don't have anything against NPs but that is unusual. But if the hours of work you are doing is not overwhelming, the amount of $$ you're making is fantastic, so possibly worth putting up with.
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Outpatient cash-only private practice with some side private practice 1:1 coaching. I work about 15-20 patient hours a week + all my own admin for now which equals about 5 hours per week (but am looking at hiring a VA) and am set to make around $300,00 this year. No call, no supervision, no desire to work more hours.
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Self-pay private practice, approximately 60 patients/week, mix of psychotherapy and medication management: $560,000 net.
Can we get a geographical region type? Nice work
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Rural midwest
How much are you charging?
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$400 new evals (90 min), $250/hour, $165/30 min
Considering your provider status, I have a lot of respect for your business skills as you're out-earning some physicians. Personally, I'm not interested in private practice but just for the sake of my curiosity, would you share what you do for patient acquisition and retention and how long it took for you to reach this point?
I highly agree with the bolded parts above.
I used to agree with this part until I saw how my partner practices. He does only 15 minute appointments and has extremely high show-rates, which is impressive especially since a bulk of patients have Medicaid. My follow-ups mostly range from 25 - 45 minutes for the add-on psychotherapy and to address whatever questions or concerns the patient has. My patient outcomes as measured by patient surveys and re-hospitalization rates are excellent. However, his show-rate still exceeds mine.
I asked him why his show-rates are so good and he told me that based on how long he has been in the area (10 years compared to 2 years for me), his no-show patients naturally filtered off from his patient list and the ones that kept on showing took up more and more space. I noticed that my show-rate has been increasing with time as well.
The most important factor is 1) patient quality (which I have minimal control over initially as my job is to take care of everyone in the community) and 2) the more time you have with one place, the more your reputation will grow and the no-show patient gets filtered off from the list and replaced with ones that consistently show and 3) the more time you have with a patient, the stronger the therapeutic alliance will be. Lindy effect at work.
I have since converted more patients into 15 minute follow ups just to test things out.
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Thank you. I’ve been in private practice for about 13 years since completing NP training (I was in private practice as a clinical psychologist for about 4 years prior to this). I was busy enough within 6 months of starting out to not have to consider taking insurance or adding a side job. My income has been at this level for the past several years and I increase my fees every 1.5 - 2 years. Patient acquisition is almost exclusively via word-of-mouth at this point and I have never done any advertising other than a PT listing and I have never taken insurance.
I will say that I have a very good reputation in the community that I believe, in part, comes from taking adequate time with each patient and treating them the way I would expect to be treated by my PCP, psychiatrist, therapist, etc. I get referrals from all over and it’s not unusual to not even know the referral source at times, “Doctor so-and-so says you’re wonderful and that I need to see you,” and I have no idea who that doc is.
In my experience, there is strong demand for integrated psychotherapy and medication management and I’m one of the very few in my area who do this (and do it well); my dual role as a clinical psychologist/PMHNP has been quite beneficial in this regard. I’m fortunate to have very strong psychotherapy training in several modalities and consider myself to be an excellent clinician. That being said, I don’t know how much better I am than the clinician next door except to say that I have never had difficulty keeping my practice full or enjoying what I do. I only see about 1 new patient/week at this point and my first new patient appointment is consistently greater than 3 months out.
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I round on the inpatient 4-5 hours per week the leave. Call is 5 days a week for admissions and orders
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deleted1100659
Well this confirms I was getting Fcked at my current job, even more glad that im leaving, lol.
Last week was seeing 16-18 pts a day, 20 min slots, most of which I had never seen before all above average to high acuity (community setting). never again...
But yeah this is great for younger attendings, especially those graduating soon. Gives a good baseline of what they should look for which often can be hard to discern when you're just starting out
Last week was seeing 16-18 pts a day, 20 min slots, most of which I had never seen before all above average to high acuity (community setting). never again...
But yeah this is great for younger attendings, especially those graduating soon. Gives a good baseline of what they should look for which often can be hard to discern when you're just starting out
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At my prior job I was making $180K/year despite bringing in about $600K a year. The institution didn't know what they were doing, were heavily mismanaged, one key central person in the center of the department was IMHO sabotaging the department and didn't know WTF he was doing but the university let him stay in that position. It wasn't U of Cincinnati, but my employer afterwards.
The head of the department, it wasn't his fault. He was as screwed as the rest of us. Kind of like there's a general, there's a captain, and in between there's a colonel screwing things up but the colonel is really in the real position of running the nuts and bolts of the department, and the university wouldn't let the general get rid of the colonel.
Left that job, and now make almost 3x what I made at the prior job while working about half as much.
A thread like this one back then would've likely had me change my mind and leave sooner.
The head of the department, it wasn't his fault. He was as screwed as the rest of us. Kind of like there's a general, there's a captain, and in between there's a colonel screwing things up but the colonel is really in the real position of running the nuts and bolts of the department, and the university wouldn't let the general get rid of the colonel.
Left that job, and now make almost 3x what I made at the prior job while working about half as much.
A thread like this one back then would've likely had me change my mind and leave sooner.
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60 patients per week sounds like a lot of work, especially if something like half of those are combined treatment (therapy.) Sounds like you're likely working hard for that money. I may end up seeing a max of 60 pts in a week but that would be 100% 30-min med management appointments.
Maybe people are reluctant to post about it or aren't doing it much but I'm a little surprised there aren't more psychiatrists posting ITT about doing combined treatment. Seems like going rate for a psychiatrist doing that sort of work would be $300+ per hour in any metro that would support cash pay pts interested in dynamic psychotherapy (or others).
That's the one thing I miss in my current job, I had put extra effort into my therapy training in residency, especially dynamic training, but I feel like I'm getting rusty the more time I go without a therapy panel. After I vest everything with the current job next year that will be the big question--stay with the org where I might have room to grow into other interests (admin, informatics) or switch to half time so that they'll let me start a side practice. (Not to derail the thread.)
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Do you think forensic work would be more compatible with locums work rather than private practice? Or is Forensics really so all-consuming that it cannot be effectively juggled with another substantial employment commitment?
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Yep, I work a lot. About 40 - 45 contact hours/week. Mostly because I enjoy it but also because the demand is so high, especially since the pandemic. People are waiting months to be seen in many locations.
Agreed. In my metro area, I know of only 3 psychiatrists who promote themselves as doing combined treatment. Only one of whom does it with any frequency from what I can tell.
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Do you mean 4-5 hrs per day?
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Can’t answer what I do not know. I expect it is hard to find. Got lucky in that aspect. And in general not good look to be disrespectful of others. It’s changed now so quote as much as you like.
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deleted456421
My own details: Locums at a state hospital and community clinic. $200/hr at the first and $210/hr at the second. Soon to start a permanent job that pays even better.
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So I seem to get a lot of mixed signals on this forum. I've seen many people that doing cash-only practice is very hard and would take 10 or something years to fill. What is everyone's opinion about that? I practiced in Brazil before coming here and every treatment was combined, as we were very heavily trained in psychodynamics, but I always wondered if I could do a cash practice here.
Currently in residency in the USA gain, so salary is around 60k lol
Heavily dependent on specific location and how many other psychiatrists are vying for patients, and what proportion of population is affluent enough, or if not affluent willing to budget, to see a psychiatrist for $300/month.
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I know multiple people who make $400-$500/hr as cash pay doing both. They are very slow growing, may only see 1-2 people a day for over a year in the beginning, but overhead is low and even 5 pts (1 hr visits) a week is still much more than you make during residency. Most of them have side jobs as they are building their practice. The thing is, or so they've said, after residency, especially if you are relocating, you're building your name from the ground up and it's hard to attract that level of patients that are both wealthy, but don't have an EAP/employment based insurance (self-employed) or are truly wealthy enough that they'd pay you that much and not pay the elite psychiatrist charging $1k for intakes. It's not a big group you're targeting, and it take substantially longer to build a practice on them. The only good news is if you charge a lot, you don't need nearly as many. Charging $100-$300 is probably more doable as a lot of people might already have high deductibles getting them close to that kind of cost level.
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This is like asking why some new restaurants thrive and some go bankrupt. If there is demand, you market well, you provide a quality service, and you manage overhead, you can grow quickly. Alternatively, I’ve seen some close shop due to it taking forever to build.
I do clinical work 20-30 hours/week. Net around $460k. I’m not the only psychiatrist in my cash practice. Instead of doing more clinic yet, I’ve elected to be more entrepreneurial. These activities take up my time with no benefit yet. If I wanted more hours, I could fill them almost immediately.
My rate is probably pretty average. A solo colleague charges 2x my rate in the same city to high end families and can fill hours instantly. Others charge less than me and can’t get patients.
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Can someone help me understand the quality of the patient who pays $500 per week for therapy? What is going on in that session? CBT, other evidence- based therapy is pretty easy and someone could probably find this in the million self-help videos/books out there. It also should only last like 4 months. If it’s analysis, they’re doing that 4x per week? Also, how does someone with that much money tolerate EBM (aka, “I don’t recommend Xanax for your PTSD” or “no, you don’t late late onset ADHD”).
I can imagine *maybe* if you’re an amazing hypnotherapist or taking on a very complex case like @splik does. Maybe I’m just a Midwest peasant lol.
I can imagine *maybe* if you’re an amazing hypnotherapist or taking on a very complex case like @splik does. Maybe I’m just a Midwest peasant lol.
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So some of this might be dictated by referral patterns as well. My wife has 0 interest in providing therapy... she never liked doing it in residency/fellowship and has no current plans to add it to her PP. But if she did I'm not sure how much she could offer because 60%+ of her referrals are from therapists/Psychologists in the community who would just send their referrals to the army of NPs in the area if they were afraid she'd steal their therapy patients. She charges more than $300 per hour and is growing about as fast as she'd want to.
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Reminds me of a guy I met while back in Boston. Academic faculty at MGH and charged $1k/hr to do family therapy for anorexia in his side practice.
I would be interested in more specific detail from others actually doing that sort of work, as well.
The main exposure I had to cash combined practice was some of my dynamic supervisors in residency (although some of them actually took insurance.) And, their having been my dynamic supervisors, the model was weekly therapy that's somewhat expected to last for quite a while. I think culturally it was somewhat normal for wealthier individuals to have an insight-focused long-term therapy. Which is very different from a concrete 12-week CBT to improve a few target sx. Patient selection for doing that sort of work should ultimately prevent some of those issues you've identified, at least as far as your combined treatment patients go.
Yea 4-5 hours daily each week
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Read through some of your previous posts. Really admire your smart and diligent career progression. Much respect.
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Thank you.
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deleted1100659
you are living the dream that im dreaming, lol. Is this a large city/nice area?
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Seems side gigs are the way...
Employed jobs will not get you to the upper 400s.
Seems this thread conforms with general surveys. Typical facility jobs can get you to the low 300s+/-. 200s would be a lower-salary job.
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Desirable city in the Southwest.
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I'm not the model for making bank and most of my patients are covered under insurance, but I do have a couple of patients paying just about this rate cash for psychotherapy +/- med management, because they have insurance plans that I don't take. They do get a fair amount back by submitting superbills to their insurance I think.
I do pretty straightforward CBT for depression/anxiety (I use David Burns' TEAM-CBT model) as well as CBTi and ERP for OCD and it is never intended to be long term, although some patients do like to stick around and sometimes will identify another goal and go for a second course of treatment once we have reached their original goal.
The people I have who are doing this are all reasonably clever individuals who are doing well financially but have been in therapy before and became impatient with receiving relatively ineffective services from the previous people they worked with. You mention that it isn't hard to find someone who does CBT; and it's true that it isn't hard to find someone who *says* they do CBT; however if you ask your med management patients about what is going on in their psychotherapy visits you are likely to hear some very disappointing descriptions.
I'm very goal-oriented and measurement-based/feedback-informed, and I usually achieve good results, and I think the individuals who have chosen to pay cash to see me for psychotherapy are aligned with me in this mindset and appreciate this way of working.
Regarding the med-seeking, I have a very specialized patient population and I just don't see this much anymore since I stopped doing general outpatient psychiatry. So it hasn't been an issue.
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You make some interesting points. I agree that patient quality, the maturing of the patient census and building therapeutic alliance are big factors. Naturally, the patients who feel a connection are going to be the ones staying for awhile. Although, I think at least for my patients, they would not like the 15 min med check and there may be some drop off--but overtime, but it could select for a patient population that's good with short visits. I've found that many patients don't like short visits though, even if they swear up and down they're here for a med check. Unless it's a super straightforward in and out case and the patient is on board with that. Depends on the patient too I guess, at the end of the day if the patient feels it is worth coming back, that's probably the end point. But, often in psychiatry there's something that comes up and a good assessment at least for me, takes longer than 10-15 min to formulate a well informed plan or often the patient leaves feeling rushed, not listened to, that we just throw pills at everything, etc. The other thing is, your colleague who takes Medicaid, could it also be that there's a network deficiency of high quality Medicaid providers so that's another incentive to keep good attendance? So in conclusion, a number of factors: patient quality, therapeutic relationship, patient's individual goals/agenda, cost/insurance network status, quality of care (at least to a certain extent, I know some psychiatrists who cannot stay even halfway full to save their lives and I can see why).
I personally am a huge supporter for working with the right insurance networks. They can pay pretty darn nice, are cost saving to the patient, and can be an avenue for providers to exercise our voice because a good working relationship is in the best interest of both parties and through positive feedback does seem to incentivize some insurance companies to pay more reasonably and not be as difficult with paying us. Some insurance companies *cough cough* don't give a ______. Those I work less and less with and let their network deficiency grow. One is calling our office all the time nearly begging us to take some of their patients (this has escalated over the years) and um....I'll be trying to negotiate the rate again this year. Hopefully they'll start getting the picture.
Speaking of patient quality, I have a cute story. I love it when my patients know their insurance well. We had a claim that processed wrong as out of network and I was about to appeal this with the insurance company. Patient beat me to it, she left a message saying she got her insurance to reprocess it and payment should be coming. Makes my job easy and talk about saving money on staff costs! lol.
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Idk, I looked into a few employed positions where hitting $450k+ was expected, the catch was that you EARN that money and will be working more than what we typically consider a typical "full time" position, whether through increased hours or patient volume. However, there are some employed positions out there bringing in about that much with a reasonable patient load, I know one or two people on this site who have such positions.
I think it's pretty safe to say that making <$250k in a full time position and you're getting hosed (outside of academics) with significant potential to earn more for those who are savvy or willing to work for it.
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Forensic work is like being an actor. You may never work. You may get a gig once a year. You may be so in demand that you're working all the time.
A reason why I don't do that much forensic work is because I found very solid sources of income that are "birds in the hand." E.g. my practice practice is packed. My addiction practice work gelled very well with my practice practice.
I likely would've been doing more forensic work had I stayed in Cincinnati but so far the gigs I've had in my current city had a lot of less than ethical agendas going on with the lawyers involved, and the justice system in Missouri is screwed up too. An average wait time for a lawyer of 10 months is unconstitutional yet going on here.
There was a forced labor jail in St. Louis. When was this? 100 years ago?
No less than a year ago. I am not joking. This is freaking real.
As a physician, if exposed to stuff like this, you're ethically obligated to do something about it. I tried. Was literally told by higher up people they don't care, nor do the citizens of the state and nothing will be done. That was another reason why I left my job. I wasn't in it for the money, which was pathetic pay for what I was bringing in. People who work in academia often times do it cause they're answering to a higher calling such as wanting to advance the field, teach, be a pillar of the community. When higher ups in my own academic institution even said things to effect of why care about inmates with some efforts to fix some of the situations mentioned above, and they were financially screwing me, I thought to myself this is a majorly corrupt institution and to stay in it was enabling this problem.
I had no bones in that institution. The pay sucked, they weren't treating me well, they weren't doing the right thing, so why stay there? I left to a new world of over double the pay, much less work, doing something I believe in, and feeling better that I wasn't contributing to a dysfunctional situation. Hey it's one thing to sell out. They weren't even paying me off to be a corrupt cog in a dysfunctional machine. They were asking me to take crap pay, work my tail off, while they sold themselves out.
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Yeah, like the person on this thread who said they made 635k first year out of residency working 35 hours inpatient. Would love to know more about that set up
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Forgot to answer this.
What I was told by the software company and my own billing person was utilizing the software would meet the criteria for a 99215 despite that about 30 minutes would be done with the software.
I haven't used it yet and I'm still a bit hesitant cause if this doesn't work it's several thousands of dollars. If I do it I'll put up more information but my biller told me other psychiatrists are using it and it's getting the 99215's in and it's not only kosher it leads to better practice cause that software seems awesome.
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Even if it is kosher, if someone is billing more 99215 than average, insurances have a higher chance of starting an audit. I fear the clawback, especially if they feel what was rendered is not medically necessary which is so subjective when you’re talking about arguing with insurance.
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Unless you are committing fraud, you should bill for whatever you do. Ignore the audit risk. Even if there is a clawback, they are going to take back what you shouldn’t have received anyway. If you are found to be correct, they probably don’t bother you for quite some time. Every time you downcode to a 99214 instead of a 99215, you lose what $30? 100x and you lose $3000 right there.
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Yeah I don't see how this works though. Time based 99215 requires 40+ minutes of work by the physician, that can be doing whatever but it explicitly excludes "staff time" (that is, time spent with other staff who are not the billing provider). If you look at all the info out there about the time based coding rules, it's pretty clear...explicitly to prevent stuff like this from happening.
Now, if you sat in the room the whole time with them, you could call this all face to face time and pretty easily bill a 99215. But you have to be physically present in the room and state you "administered testing" or something. I've looked at something similar myself when I was interested in doing TOVAs/CPTs for ADHD and that's basically how you bill for this as a physician (psychologists bill it under their neuropsych testing codes).
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touché sir! But I respectfully present this other route. Let's say the fee schedule for 99213 we get an increase of say...$1.75. Calculate that at 20 visits a week, 48 weeks a year gives us about $1680 more. Factor in some rockstar insurance rates from the smaller insurances who are willing to pay $50.64 more for a 99213 and $20 more (conservative number here) for 90833. That's $70.64 more per patient visit. You have 20 patients with this insurance and see them twice a year, that's another $2825.60 per year. These are using conservative numbers considering it's only using 99213 (and an underquote of patient volume). We can earn more and stay away from the radar. I personally never had a clawback but have heard horror stories, will never know the accuracy of them unless there's a clawback that happens to this office. But...I have so little faith in some insurance companies, a very dark view actually. Especially with the publicity with UHC. If UHC can do that, I'd imagine they'd be hard to stop. I have to find the source but I believe United also made some structural changes so they can also be their own medical reviewer for standard of care when assessing if reimbursement is appropriate versus having to go through a third party. So...United is regulating United? Sounds like conflict of interest to me.
Another route I like going is being paneled on as many insurances as possible. Insurances only care about their own claims. But when you have multiple payers, it divides up your claim history. Whereas if an insurance company sees a big chunk of money going to one entity, they're more likely to look at you. And likely with good documentation, with little consequence. But...it's a nuisance, stressful, does bear some administrative cost to get them the records they ask for, etc. More insurances you're on, more opportunities to negotiate rates. It's good to be in the know of which insurances are becoming more widely used and explore their rates. Newer insurances are more interested in boarding on providers because they have so few and you have some serious negotiating power. Like 150% of the medicare rate, was surprised they said yes! Some of these newer ones are growing and getting used by more major employers of health systems, banking firms, etc. Also, Medicare and Medicaid rates in this region are baller for therapy. Which makes billing simple since it almost always pays in full. So baller rate + low overhead due to minimal billing = win. Another reason it's good to work with a variety of insurances is to help the ethical ones win/grow. If we all just stuck with the Goliaths, they only get more power over the healthcare system.
A Breakdown of UnitedHealthcare’s Recent Parity Settlements | The Kennedy Forum
In an unprecedented move, the U.S. Department of Labor (DOL) recently teamed up with an individual state to bring joint enforcement actions under the Mental Health Parity and Addiction Equity Act of…
www.thekennedyforum.org
UnitedHealth must reprocess thousands of illegally denied mental health claims, judge orders - MedCity News
In a trial last year, a federal judge found that a UnitedHealth subsidiary had illegally denied mental health and substance use disorder claims. The same judge has now ordered the payer to reprocess all the claims and reform its guidelines.
UnitedHealth must reprocess thousands of illegally denied mental health claims, judge orders
But then the later outcome was:Court Says Insurer Doesn't Have To Reconsider Thousands Of Claims - KFF Health News
United Behavioral Health had been required to reconsider tens of thousands of denied claims for mental health, drug and alcohol care but an appeals court has now overturned the earlier rulings. Mount Sinai, the American Hospital Association, the NIH, and more are also in the news.
khn.org
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Are you sure this is still the case? Recently, there has been a change in some testing codes where you cannot bill for time of administration for computer administered measures. There is a code for computer administration, but it's almost nothing. Only thing you can really bill for here is the time spent interpreting and integrating test results into documentation.
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I see a lot of patients in those hrs with NPs doing the notes as shared notes. You also forgot about my weekend per month. I took less than a week vacation all year
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Medicare Unmasked: Behind the Numbers
Search Medicare billing records of over one million doctors and medical providers—a type of data long kept confidential. Then read our Pulitzer Prize-winning investigation into the motives and practices of America's health care providers.
This data is 7 years old, but probably still relevant. Can anyone explain how these top earners bill so much?
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This includes everything. So like, you bill ECT it may end up being a hospital fee plus ECT plus sedation but you're only making 100 bucks while the hospital makes 3kMedicare Unmasked: Behind the Numbers
Search Medicare billing records of over one million doctors and medical providers—a type of data long kept confidential. Then read our Pulitzer Prize-winning investigation into the motives and practices of America's health care providers.graphics.wsj.com
This data is 7 years old, but probably still relevant. Can anyone explain how these top earners bill so much?
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Nah I’m not sure it’s the case at all haha that’s just what I was seeing the TOVA company suggest billing this as since it was normed with a clinician in the exam room while the patient was taking the test, so they consider the test to be only valid if the patient is supervised during administration and use this as justification that you can bill for that time. The computer based code 96146 is only supposed to be used when the patient is taking a test unassisted, with a single automated instrument with automated result only, so they argue that this would not meet this criteria (ex would be something like the ASEBA online scales where you basically have the patient fill out responses unassisted and then the computer scores and you interpret the results). But who knows if this would hold up.
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- Reaction score
- 23,786
I'd double check this. The guidance we've always gotten from CMS on the new codes is that 96146 is for any computerized instrument, doesn't matter if you are in the room or not. We've also always been told that you do not get time for self-reports/questionnaires unless there is a valid reason that you need to actually verbally administer the instrument or accommodate a sensory deficit in some way.
