And I find it even more interesting that the 'common knowledge' (as voiced) among veterans is just how impossible it is to get service-connected for PTSD and how the VA system and its providers are dedicated (supposedly motivated) to denying it to those who have it. Inverted reality.
Maybe the ‘get off your butt and get a job’ crowd hasn’t discovered this group yet
...and no way would we have the numerical majority of folks in a 'mental health product line' not seeing patients or having caseloads.
When you have evals with your direct supervisor, do they talk more about RVUs, clinic utilization, encounters, etc?
I’m in a private hospital and I think it’s just different. Many VA providers wouldn’t put up with the stuff in the private sector. But I agree that the patient entitlement wouldn’t fly. I read somewhere the huge amount of money that is wasted when Veterans (regularly) no-show to colonoscopies. The expense being the provider and the anesthesia team, and there’s no negative repercussions whatsoever.
The main thing I'd recommend is just to be sure you're coding correctly to adequately capture the time you're spending with patients. You can definitely try checking with other psychologists to see what they're doing, or even reach out to your psychology chief to see if they have advice.
For a 53+ min session, you get 3.0 RVUs while a 38-52 min session is only 2.0 RVUs. And 1.5 RVUs for 16-37. These differences over a whole year is pretty substantial so accurately coding can definitely help if you haven't been as attentive in this respect. Good luck!
Just make sure that you routinely end a psychotherapy session with an extremely complex client who probably has no-showed and cancelled so many times that this is the ONE appointment you've had with them in the last three months PRECISELY at minute 53 or 54 into the session so you can both max out on your RVU stats/score and have a whole five minutes between clients to (1) use the restroom; (2) complete your scoring of your wonderful 'outcome metrics' self-report instruments; (3) complete your chart note; (4) update their 'treatment plan' in mental health suite; and (5) prepare for your next session by reading their chart. Takes a pretty high skillset.
Hell, we've had recurrent problems with clerks erroneously scheduling us OUTSIDE of our clinic grids, even (don't ask me how). Regardless of our attempts at self-advocacy and trying to get the problem addressed, it still happens on occasion. At that point, you're screwed because you can either commit the 'sin' of canceling a veteran at the last minute (once YOU, not the CLERK) discover the scheduling error or you can just 'eat' it and work overtime.
One thing I have not learned much about but would be helpful is the Voodoo of making and editing the clinics in the LEAF system so they can't do such things. I think that it may have to do with how overbooks are setup.
That must be specific to your site. I've never heard of that rule (at least at my site). Heck, at my site you're expected to use the full time to maximize RVU's (that is, if you ask leadership on Mondays, Tuesdays, or Wednesdays...ask them on Thursdays or Fridays, it's the opposite--e.g., you need to leave time for yourself in between sessions so you are to stop at 45 mins). Who knows.
My understanding is that it's not uncommon for VA to bill insurance, and they theoretically attempt to bill whenever possible (and appropriate). I vaguely recall them mentioning this when discussing why providers shouldn't just automatically check that a visit is service-connected when it may not be. But considering most patients seeing MH providers in VA are service-connected for MH diagnoses, it may not come into play as much for psychologists. Anecdotally, in all my time at VA, I got exactly two emails about insurance that required additional information on my part (e.g., how long I spent administering each test), and the end result was that the insurance company said I could've billed for more. So I suspect MH providers are, more commonly, at the mercy of the billing folks at their own VA in terms of what actually needs to go into the notes. But to your point, no, I don't ever remember hearing of anyone at my VA needing to justify using the 53+ minute codes, either.
Oh, yes, I also had to put in my own LEAF requests, but there was maybe one person who actually had the ability to build the grids. For our clinic, it used to be more, but then they started yanking that ability, as well as scheduling keys, from lots of folks.
I think 'leadership' tacitly believes that we have 'separate' fixed slots (time periods) for F2F and separate fixed slots for virtual. In practice, however, that would be a logistical nightmare to schedule and there is no way that our clerks would ever work that hard. Plus, it would be quite inefficient, in my opinion. Scheduling is difficult enough as is. They do, of course, monitor percentages of F2F vs. virtual and yell at people who don't have 'enough' utilization of telehealth appointments in their clinics.
That sucks and I'm sorry that you experienced this. However, this type of situation is the exact reason I started this thread so long ago. There is, typically, ZERO meaningful, consistent communication on 'what we should be doing' between the system and providers and providers are often so isolated from one another (and, as a result, we don't frequently even communicate among ourselves). As a result, we are often confused about what we are even supposed to be doing, let alone how to do it. As a rule, people in the trenches are terrified to ask questions of admin/'the system' for fear of standing out (and being hammered down like an errant nail sticking out of a board) or appearing rebellious or 'problematic' as an employee.
What kind of gulag-type mentality does your leadership have?? Jeeeez I would have been out of there ages ago. As a leader on my site, I welcome questions. You get solutions that way.
Ugh. They theoretically should know but that isn’t always the case from my experience.
Yup. I have seen or maybe even have a PowerPoint created by Cliff that has no restrictions on 53+ min coding.
Every facility is different but what I’ve experienced more is providers becoming indifferent either because it can be challenging to figure out the right way to do things due to the top down hierarchy of VA where everybody has to ask the person directly above them and you’re not even sure if/when you’ll get a firm answer.
Fun fact: Those same 'Expert Consensus' guidelines that VA/DoD published indicate that group therapy for PTSD actually sucks. Barely better than 'no treatment.' Also, they explicitly state that organizations/clinics SHOULD NOT utilize the group format as some sort of 'solution' to access issues. The FULL guidelines actually explicitly state these things. However, I suspect that in the vast majority of VA hospital systems, providers/veterans are pressured to do the exact opposite of what these guidelines state.
I mean, right on p. 45 of the most recent (and I know it's currently being updated, but still...) VA/DoD Expert Consensus Guidelines, it clearly states:
I really like this one, too:
