Unhappy unless in Private Practice?

[Messerschmitts]

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Depends on your personality. I for one am EXTREMELY happy and satisfied working for my County, doing public psychiatry serving the undeserved. If I get a no-show, I don't worry about losing money, I just facebook or post on forums and get paid exactly the same. I like just showing up for work, seeing who they tell me to see, and get my paycheque twice a month. Easy peasy. More time to do the things I like to do. I am considering leaving because of other location related issues, but it has nothing to do with my job. I love my job. However, if you're enterprising and like total control, then PP is for you.

 

[finalpsychyear]

Depends on your personality. I for one am EXTREMELY happy and satisfied working for my County, doing public psychiatry serving the undeserved. If I get a no-show, I don't worry about losing money, I just facebook or post on forums and get paid exactly the same. I like just showing up for work, seeing who they tell me to see, and get my paycheque twice a month. Easy peasy. More time to do the things I like to do. I am considering leaving because of other location related issues, but it has nothing to do with my job. I love my job. However, if you're enterprising and like total control, then PP is for you.

I have a good amount of loans that i need to pay off which is also a large issue of why I want to do PP. I am willing to work 60-70 hrs for the first 3-4 yrs to pay down a 250k debt. I am hoping my PP can generate not a gross but a post overhead of 300k by the end of year 2. I've looked into jobs paying off your debt but i dont want to commit that many years and i also feel i can pay it off quicker this way. Then of course the luxury of starting my mondays at 930-10am, working out durin my 12-1pm lunch break is priceless for me at least. In some ways, it doesnt feel like work when i have no one telling me what to do. But that is just me.

 

[PistolPete]

Agreed. What I hate about residency is that there's always someone telling you what to do. I'm done with that!!!

 

[vistaril]

I have a good amount of loans that i need to pay off which is also a large issue of why I want to do PP. I am willing to work 60-70 hrs for the first 3-4 yrs to pay down a 250k debt. I am hoping my PP can generate not a gross but a post overhead of 300k by the end of year 2. I've looked into jobs paying off your debt but i dont want to commit that many years and i also feel i can pay it off quicker this way. Then of course the luxury of starting my mondays at 930-10am, working out durin my 12-1pm lunch break is priceless for me at least. In some ways, it doesnt feel like work when i have no one telling me what to do. But that is just me.

if you want to make 300k and are willing to work 60-70 hours per week coming out of residency(thats a lot of hours if you are actually seeing patients all those hours and not goofing off) I wouldnt start up a private practice. I'd just pick somewhere that has decent employed salaried opps and then work another 20 hours per week doing something else. You'll probably make even more than 300k. But god that would suck.

The thing about someone like yourself(or even someone like me a few years out) just starting up a private practice is that for the first 6 months or so you're going to lose a lot of income relative to just taking a job....and thats important if you are looking at just a 3 year window for doing this. If you know you want to be an outpt pp psych for 20 years in that same location....then yeah, the growing pains for a year or even a couple years are worth it. But as a 'make money now' idea? Hell no. I'm going to take a little different approach here than my usual pessimistic self and maintain that it is *possible* to have a successful and lucrative outpt private practice that is insurance based provided the following:

1) you pick an area whose reimbursements are good. This is very important. My reimbursements here are very very low. Most of the country in fact has psych reimbursements(and where there arent mh carveouts just e/m reimbursements in general) that are middling to sucky. You think outpt internists crank out 5-6 99214s per hour because they love to? No...because thats the only way to make bank with these non-procedure codes. Don't pick one of these areas. Also be skeptical when someone says "here a 99xxx pays xxx". Ask them point blank "what was the average reimbursement YOU RECIEVED on the last 10 of these you submitted". And 8/10 times they work for the VA or a state job and are just quoting you what they heard from someone who heard or whatever. Or if they actually are self employed in pp and deal with actual reimbursement issues they are quoting you their highest paying panel, without telling you that only 15% of their patients come from that panel.
2) even when you do find a location with some good reimbursements per code, there is usually going to have to be some culling of panels and plans and getting yourself big enough(and learning how the game is played) to negotiate some decent contracts. I've worked at places before that did this, and their codes paid better than the numbers I would get if I just got on the panel tommorrow. And the thing is it took them a couple years to learn the ropes, grow, figure out how the game is played so they could go from being horribly screwed over to only being somewhat screwed over.
3) if you want to make bank you are probably going to have to practice a model that isn't going to be ideal or what you want to do. The reality is you are going to make more money seeing f/us every 20 mins than every 30 or 40 minutes. Sorry. that's life. I swear to god one of these days I'm going to see someone post that they are now scheduling patients for 2 hour followups and this is financially feasible because they bill with the new 99218 code and a 90Ipoopunicorns psychotherapy add on. Take this with a grain of salt. People I know taking insurance and making what I consider decent money are practicing high volume med mgt. Thats not neccessarily a bad thing....it just is what it is. And likewise I know a few people taking insurance and enjoying life seeing fewer patients for longer....but they aren't making the same money. They also have a very paired down overhead(but again it's hard to get your overhead too low if you are going with an insurance based model)
4) You are going to underestimate expenses and overhead. Sorry, you just are. You're not going to run a psych practice that sees a good number of patients and takes insurance panels for a very very low overhead/percentages of possible collections lost model. If you think you have found all the ways that you are going to be nickel and dimed and expenses to get a gross down to a net, you haven't....because I guarantee you there are more.

 

[finalpsychyear]

if you want to make 300k and are willing to work 60-70 hours per week coming out of residency(thats a lot of hours if you are actually seeing patients all those hours and not goofing off) I wouldnt start up a private practice. I'd just pick somewhere that has decent employed salaried opps and then work another 20 hours per week doing something else. You'll probably make even more than 300k. But god that would suck.

The thing about someone like yourself(or even someone like me a few years out) just starting up a private practice is that for the first 6 months or so you're going to lose a lot of income relative to just taking a job....and thats important if you are looking at just a 3 year window for doing this. If you know you want to be an outpt pp psych for 20 years in that same location....then yeah, the growing pains for a year or even a couple years are worth it. But as a 'make money now' idea? Hell no. I'm going to take a little different approach here than my usual pessimistic self and maintain that it is *possible* to have a successful and lucrative outpt private practice that is insurance based provided the following:

1) you pick an area whose reimbursements are good. This is very important. My reimbursements here are very very low. Most of the country in fact has psych reimbursements(and where there arent mh carveouts just e/m reimbursements in general) that are middling to sucky. You think outpt internists crank out 5-6 99214s per hour because they love to? No...because thats the only way to make bank with these non-procedure codes. Don't pick one of these areas. Also be skeptical when someone says "here a 99xxx pays xxx". Ask them point blank "what was the average reimbursement YOU RECIEVED on the last 10 of these you submitted". And 8/10 times they work for the VA or a state job and are just quoting you what they heard from someone who heard or whatever. Or if they actually are self employed in pp and deal with actual reimbursement issues they are quoting you their highest paying panel, without telling you that only 15% of their patients come from that panel.
2) even when you do find a location with some good reimbursements per code, there is usually going to have to be some culling of panels and plans and getting yourself big enough(and learning how the game is played) to negotiate some decent contracts. I've worked at places before that did this, and their codes paid better than the numbers I would get if I just got on the panel tommorrow. And the thing is it took them a couple years to learn the ropes, grow, figure out how the game is played so they could go from being horribly screwed over to only being somewhat screwed over.
3) if you want to make bank you are probably going to have to practice a model that isn't going to be ideal or what you want to do. The reality is you are going to make more money seeing f/us every 20 mins than every 30 or 40 minutes. Sorry. that's life. I swear to god one of these days I'm going to see someone post that they are now scheduling patients for 2 hour followups and this is financially feasible because they bill with the new 99218 code and a 90Ipoopunicorns psychotherapy add on. Take this with a grain of salt. People I know taking insurance and making what I consider decent money are practicing high volume med mgt. Thats not neccessarily a bad thing....it just is what it is. And likewise I know a few people taking insurance and enjoying life seeing fewer patients for longer....but they aren't making the same money. They also have a very paired down overhead(but again it's hard to get your overhead too low if you are going with an insurance based model)
4) You are going to underestimate expenses and overhead. Sorry, you just are. You're not going to run a psych practice that sees a good number of patients and takes insurance panels for a very very low overhead/percentages of possible collections lost model. If you think you have found all the ways that you are going to be nickel and dimed and expenses to get a gross down to a net, you haven't....because I guarantee you there are more.

I appreciate your thoughts. I don't feel most of it applies to my situation. Insurance pays well here from the several contracts ive personally looked through and negotiated. Your area may be a different ball game as the numbers you quoted are worse than even medicaid pays in my area for example. Only 5-6 psych docs for a population of 50-60k and half of them are over 60 in the area im looking at. I called 3 of them to see how long wait times were and they were all 2-3 months. I've been reading about business and private practice for a few hours everyday and spending time with PP docs as residency winds down.

Boards are in september so i want it slowish for the first 3 months anyways as i considered not even starting till october. I dont think it will be slow for the second 3 months as i plan to market and talk to pcps and therapists in early july. Regardless, so long as i can make at least my 55k resident salary for 2016 as i'll already be half way there before i start thats just fine for me.

Im already getting calls for scheduling pts and this is from being on 1 panel for <1 week. Im paying 500 to rent a room with utilities from a pcp who says she has a ton of pateints for me.

Lets see what happens and maybe you were right after all. Then again I've usually succeeded in ventures I've actually planned out and put considerable energy and effort into so i'm optimistic but come july 2017 i think we will have a final answer.

 

[vistaril]

I appreciate your thoughts. I don't feel most of it applies to my situation. Insurance pays well here from the several contracts ive personally looked through and negotiated. Your area may be a different ball game as the numbers you quoted are worse than even medicaid pays in my area for example. Only 5-6 psych docs for a population of 50-60k and half of them are over 60 in the area im looking at. I called 3 of them to see how long wait times were and they were all 2-3 months. I've been reading about business and private practice for a few hours everyday and spending time with PP docs as residency winds down.

Boards are in september so i want it slowish for the first 3 months anyways as i considered not even starting till october. I dont think it will be slow for the second 3 months as i plan to market and talk to pcps and therapists in early july. Regardless, so long as i can make at least my 55k resident salary for 2016 as i'll already be half way there before i start thats just fine for me.

Im already getting calls for scheduling pts and this is from being on 1 panel for <1 week. Im paying 500 to rent a room with utilities from a pcp who says she has a ton of pateints for me.

Lets see what happens and maybe you were right after all. Then again I've usually succeeded in ventures I've actually planned out and put considerable energy and effort into so i'm optimistic but come july 2017 i think we will have a final answer.

1) the numbers in a lot of states will show that some insurers pay less than medicaid. especially in states with carveouts. not sure if your state has mh carveouts or not. The difference is that it's usually a lot easier to do the psychotherapy add on with insurance as opposed to medicaid...so even when insurance pays less it can still pay more for the same visit.

2) You are a final year resident and you have already 'negotiated' contracts? Ummm...I guess that's...interesting.

3) long wait times and a 'shortage' of psychiatrists(I'd actually say 1 psych per 10k total population isn't all that much of a shortage but whatever) doesn't always correlate with pay at all. Some of the areas with the greatest 'shortage' and supposed need have the crappiest outpt reimbursements. In medicine in general(and especially MH) this supply and demand curve, especially on an outpt basis, just doesn't exist in a classic model like it does with say....opening a nail salon.

4) what kind of staff are you going with? Who is going to schedule your outpts? Who is going to take all the calls about med questions, refills, PAs, and the 20 other things they will need your office for? What kind of records/emr system are you going with? How are you going to submit your claims? Who is going to cross-check every pt/claim?

If you take most insurances and medicare I don't doubt that you will be able to get patients. That's generally not the biggest issue most outpt based psychiatrists(hell health care providers in general) have. It's all the other stuff.....and that stuff often takes a little time to work the kinks out.

 

[vistaril]

I appreciate your thoughts. I don't feel most of it applies to my situation. Insurance pays well here from the several contracts ive personally looked through and negotiated..

huh? you just said earlier in the thread that they paid crappy? And now they pay good? After a resident who is not even board eligible yet has 'negotiated' with them? Maybe over the last month you've at least managed to figure out what CAQH is......

 

[finalpsychyear]

huh? you just said earlier in the thread that they paid crappy? And now they pay good? After a resident who is not even board eligible yet has 'negotiated' with them? Maybe over the last month you've at least managed to figure out what CAQH is......

That caqh comment was funny I'll give you that you silly duck.😉

Like i said i applied to 12 or maybe a few more i can't remember exactly. A few did offer low rates. Crappy is relative. The lowest i have seen were medicaid and 2 others who offered 70/95 total for meds E3/therapy. I have walked away from them. Trying to be more reasonable with my terminaology. After hearing about your situation i have tried to be more appreciative. Remember e3+ther is over 130 total per medicare rates where i am and the ones i am taking pay around that +- 5-10 dollars. Listen, i didn't know anything about being able to negotiate as a sole provider. I was under the impression only large groups could do so.With the advice of several on here I was mistaken. Yeah, a few didn't budge and i walked.

I have only been paneled by 1 but am waiting to be credentialed by 2 others. The pcp offered that if i pay her a flat fee of $1000/month that she will provide billing (she has her own) and 1 staff (not dedicated) to help out in scheduling/phone calls for me at least initially. It may or may not increase after 6 mo-1yr.. i think she is being generous as i am just starting out but also i know her (sisters friend). They use a free EMR. I expect to do a lot of the staff stuff myself early on as well. emr+mal+rent+staff+util = roughly 20k overhead at least for the first 1 year i hope. For phone im using a spare cell phone as my office line and magic jack as another line. Also im sure i could use google voice if i disable the vmail translator.

I'm sensing that you are skeptical of what i am saying which is fine. Not sure what incentive I have to seek help on this board just for fun. Im sure there are more expenses and what not but this is so far what i've gathered. I'll keep learning till june 30 and beyond of course.

 

[vistaril]

That caqh comment was funny I'll give you that you silly duck.😉

Like i said i applied to 12 or maybe a few more i can't remember exactly. A few did offer low rates. Crappy is relative. The lowest i have seen were medicaid and 2 others who offered 70/95 total for meds E3/therapy. I have walked away from them. Trying to be more reasonable with my terminaology. After hearing about your situation i have tried to be more appreciative. Remember e3+ther is over 130 total per medicare rates where i am and the ones i am taking pay around that +- 5-10 dollars. Listen, i didn't know anything about being able to negotiate as a sole provider. I was under the impression only large groups could do so.With the advice of several on here I was mistaken. Yeah, a few didn't budge and i walked.

I have only been paneled by 1 but am waiting to be credentialed by 2 others. The pcp offered that if i pay her a flat fee of $1000/month that she will provide billing (she has her own) and 1 staff (not dedicated) to help out in scheduling/phone calls for me at least initially. It may or may not increase after 6 mo-1yr.. i think she is being generous as i am just starting out but also i know her (sisters friend). They use a free EMR. I expect to do a lot of the staff stuff myself early on as well. emr+mal+rent+staff+util = roughly 20k overhead at least for the first 1 year i hope. For phone im using a spare cell phone as my office line and magic jack as another line. Also im sure i could use google voice if i disable the vmail translator.

I'm sensing that you are skeptical of what i am saying which is fine. Not sure what incentive I have to seek help on this board just for fun. Im sure there are more expenses and what not but this is so far what i've gathered. I'll keep learning till june 30 and beyond of course.

No I'm not skeptical. I mostly believe what you are saying. I just don't think you know what you are really doing or are properly anticipating how things are going to go. And I think you are sorta worried about the wrong things. For example, how are you going to even collect this money? You do realize that deductibles are often very high right? And that just because you get 90 dollars or whatever for a specific code doesn't mean that money just magically shows up in your acct after you submit the paperwork right? You're going to have to actually collect a good deal of it from the patient themselves....because their deductible may be 3500 for example. Good luck with that....and thats just a starting point.

I mean think about it....you're talking about doing some serious code churning(which is what you are going to have to do to make good money) and you have as part of this plan: a spare cell phone, an undedicated(and undedicated seems to be an appropriate word because it seems its also uncompensated) 'staff', google voice, and some sketchy billing arrangement with a pcp you are renting a closet from. And you have absolutely no experience doing this.....and you're going to pull it all off smoothly? Just think about it.....if you want to do this, I'd consider working for an outpt group initially to learn more about the business side of things.

 

[finalpsychyear]

No I'm not skeptical. I mostly believe what you are saying. I just don't think you know what you are really doing or are properly anticipating how things are going to go. And I think you are sorta worried about the wrong things. For example, how are you going to even collect this money? You do realize that deductibles are often very high right? And that just because you get 90 dollars or whatever for a specific code doesn't mean that money just magically shows up in your acct after you submit the paperwork right? You're going to have to actually collect a good deal of it from the patient themselves....because their deductible may be 3500 for example. Good luck with that....and thats just a starting point.

I mean think about it....you're talking about doing some serious code churning(which is what you are going to have to do to make good money) and you have as part of this plan: a spare cell phone, an undedicated(and undedicated seems to be an appropriate word because it seems its also uncompensated) 'staff', google voice, and some sketchy billing arrangement with a pcp you are renting a closet from. And you have absolutely no experience doing this.....and you're going to pull it all off smoothly? Just think about it.....if you want to do this, I'd consider working for an outpt group initially to learn more about the business side of things.

Thanks. Wait i thought since I"m taking insurance I get the full payment directly from the insurance company? Isn't collecting from the patient something you do when you take cash only and then bill as an out of network provider as a courtesy to the patient?

 

[vistaril]

Thanks. Wait i thought since I"m taking insurance I get the full payment directly from the insurance company? Isn't collecting from the patient something you do when you take cash only and then bill as an out of network provider as a courtesy to the patient?

sure....the insurance company is going to pay you immediately and then attempt to collect the deductible from the patient later.

These are things that you simply have to know before you go out there as an insurance based outpt provider. Getting patients and refilling their Zoloft and Klonopin and Lamictal and shooting the breeze with them about the walking dead is *easy*. My 12 year old cousin could do that. Efficiently running a business where the margins are becoming tighter and more and more costly red tape is popping up? that's harder.

The reality is that in an insurance based outpt practice, a *large* percentage of your collections(depending on the area maybe over half) is still going to come from the patient's pockets and not the insurance company. Why? Because you have these things called copays and deductibles. Both over the last half decade have gone up....and they keep going up. When I was doing outpt med mgt I was seeing more and more patients with 50, 65, and even 75 dollar copays. They have to pay that **** even if they have reached their deductible(if their deductible and out of pocket max are different and they often are). So if you have an 84 dollar code you are submitting and a 65 dollar copay, well guess how much you are 'collecting' from the insurance company? 19 freaking dollars......oh and thats if they have met their deductible. Deductibles have skyrocketed on many plans to the point that unless they have already had major medical **** going on, they probably havent met it...depending on the time of year. And hell they are probably going to reject your claim the first go around anyways because you listed the secondary dx above the primary dx as compared to the note.....so you may not even get that 19 dollars. But don't worry....I'm sure that 'not dedicated' staff girl you have will work her ass off to resubmit it.

I'm not trying to be debbie downer...just being real.

 

[cookymonster]

Why do you want to take insurance?

Running a solo insurance-based practice straight out of residency sounds like a disaster waiting to happen. Everyone I know who has done private practice took only cash, and they filled right away by virtue of being well-known in the community for 10+ years, or they started small (a few evenings a week) and brought most of the bacon home from another flexible, often part-time job (at a CMHC or VA for example) and phased out of that as their PP grew. This also sounds like the course most of the PP posters took. Another obvious benefit to doing it that way is you'll be a lot more proficient at running a practice by the time your practice has a significant volume.

If you really can't stand being tied down to an employer even on a short-term basis, you could take a 7-on 7-off locum job and work on building your PP in your weeks "off."

 

[finalpsychyear]

Why do you want to take insurance?

Running a solo insurance-based practice straight out of residency sounds like a disaster waiting to happen. Everyone I know who has done private practice took only cash, and they filled right away by virtue of being well-known in the community for 10+ years, or they started small (a few evenings a week) and brought most of the bacon home from another flexible, often part-time job (at a CMHC or VA for example) and phased out of that as their PP grew. This also sounds like the course most of the PP posters took. Another obvious benefit to doing it that way is you'll be a lot more proficient at running a practice by the time your practice has a significant volume.

If you really can't stand being tied down to an employer even on a short-term basis, you could take a 7-on 7-off locum job and work on building your PP in your weeks "off."

Just got off the phone with the PCPs secretary who will be assisting me. My pcp has a NP as well so i think they have good volume of patients in general. She said they have already filled up my first week of seeing patients in middle of July. 40 new patients in week 1, granted they are medicare/workers comp/1 priv. panel mix so far. They are mostly referrals from the pcp but several others who are calling or patients family etc. My goal is not to have more than 300 new patients for the first 3 months which i plan to see monthly as i am studying for boards. I am still waiting to panel on a few others and i haven't even started really marketing myself to therapists and other pcps. I'm taking this as a huge positive as i had no idea they were already scheduling for me.

sure....the insurance company is going to pay you immediately and then attempt to collect the deductible from the patient later.

These are things that you simply have to know before you go out there as an insurance based outpt provider. Getting patients and refilling their Zoloft and Klonopin and Lamictal and shooting the breeze with them about the walking dead is *easy*. My 12 year old cousin could do that. Efficiently running a business where the margins are becoming tighter and more and more costly red tape is popping up? that's harder.

The reality is that in an insurance based outpt practice, a *large* percentage of your collections(depending on the area maybe over half) is still going to come from the patient's pockets and not the insurance company. Why? Because you have these things called copays and deductibles. Both over the last half decade have gone up....and they keep going up. When I was doing outpt med mgt I was seeing more and more patients with 50, 65, and even 75 dollar copays. They have to pay that **** even if they have reached their deductible(if their deductible and out of pocket max are different and they often are). So if you have an 84 dollar code you are submitting and a 65 dollar copay, well guess how much you are 'collecting' from the insurance company? 19 freaking dollars......oh and thats if they have met their deductible. Deductibles have skyrocketed on many plans to the point that unless they have already had major medical **** going on, they probably havent met it...depending on the time of year. And hell they are probably going to reject your claim the first go around anyways because you listed the secondary dx above the primary dx as compared to the note.....so you may not even get that 19 dollars. But don't worry....I'm sure that 'not dedicated' staff girl you have will work her ass off to resubmit it.

I'm not trying to be debbie downer...just being real.

Medicare has a deductible of like 150 or somthing which im certain will be met when i start seeing patients in july. They pay 20% after that of the allowable unless they have secondary. Workers comp has no deductible and no copay. I do appreciate your criticism and pointing things out im not looking for. Im not looking for just cheerleaders but people like you who can see potential issues arising. Keep it coming and dont hold back. Your just motivating me even more.