Any way for Psych. to make big $$$?

[zenman]

I agree with Manicsleep here. I would really like to see the research that shows PhD therapists have better therapy outcomes then other mental health providers such as clinical SW's, master level therapists, or psychiatrists. Where is that data?

I'll take it with a grain of salt, but my clinical experience doesn't support that having a PhD makes one a better or worse therapist. In fact, some of our best therapists are clinical SW's and psychiatrists and I'm at a major academic center with some very well known psychologists.

I thought studies show that it is not who or what kind of therapy but the therapeutic relationship that is most effective.

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[whopper]

It's true, and also if you look around for "top earners", it's really more about being a business person, adopting a more entreprenurial business model--e.g. if you want to make "big bucks" you should be owning a practice, hiring midlevels to see a higher volume of patients, etc. It's not what everybody wants to do, however...

Agree.

One of the advantages to not working in the private sector sector is you can focus more on psychiatry.

I spend at least an unpaid hour if not a few a week doing bullspit insurance approval, preauthorization bureaucracy. In my other gigs, a social worker or nurse did that for me. In this gig we're not big enough yet for someone to do that for me.

 

[Majesty]

I only know of one Ivy League school that has a strong clinical psych program with a strong practitioner component. Top programs are generally elsewhere. Interesting that you focused on that though.

The Ivy's are excellent schools. In general they have excellent training. It just goes to show that many many psychologists have poor training since their are graduates from schools like Alliant who barely know what schizophrenia looks like (even though I have seen it mentioned that this is a good school).

The stats I've learned in medical school are a joke in both breadth, depth, and education regarding choice of appropriate statistics, compared to what I learned as an undergrad psych major. Perhaps we learn more in the clinical years or in residency. I was told by one of the residents at one of the top psych residencies that they felt like they had to do most of their scientific training from mentors or come prepared from earlier voluntary research experiences. It's interesting that your experience seems to be different, but that's quite a stretch to say all physicians learn stats, because I was appalled by the level of stats education we're exposed to personally.

You will keep learning in school, clinical rotations and residency. You also have a bias that makes you think all your training is from undergrad but you will have relearned many of the ideas. You could be right, you may just not be at a good school.

I don't know about other areas of psychology (I assume you mean in clinical practice, because those that are actually working as researchers in related fields like social or health psych would seem to be scientists), but the education at the clinical psych PhD programs I considered all seemed to be far, far better training as scientists than medical school. Which is not to say that most physicians aren't scientists as well, just that I have trouble believing that they are "more scientisty" than psychologists that seem to have a far more direct training in science and research.

Science does not equal research.

 

[carlosc1dbz]

Manicsleep is definitely falling prey to confirmation bias, but nothing anyone writes will change that so......

The best way to make money is to find ways to maximize passive and active income and/or be recognized as an expert (and charge like it).

You are right about passive income. It is very important for wealth building. Acquiring assets that can offset your liabilities is key.

 

[DocHolliday21]

So I read this thread a good while back, and my conversation with my attending today made me think of this thread. Now, it's been awhile since I read it so I'm not sure (no way I'm reading 5 pages of posts again) but I think the idea of straight cash practices was brought up in discussion here correct?


Well here is my question, and I am not judging at all, just want some feedback that I felt uncomfortable asking the attending. Ethically, how do you feel about straight cash practice in a specialty that is in such need such as Child Psychiatry? The area that I am doing my rotation in has very few child psychiatrists (like many areas in America) which allows the very good child psychiatrists to do cash only practices and pick and choose their patients. This makes it difficult to have our patients follow up with CAPs outpatient if they are poor or have horrible insurance.


While I want to maximize my earning potential, I am somewhat troubled by the fact that there will be people in need that I will not be able to treat. Coming from a lower to low middle class household (with fam members with psych issues), I know how impossible it is for families in the lower and middle class to go to cash only psych clinics.

So then, for those wanting to someday practice cash only, how do you reason this out in your head? Is that the many many years of education + the >250K loans make it okay? Is there even a need to reason it out as medicine is a business and the point of owning a business is making the most money possible? I would like to know.

Also, would it be possible to take insurance from low and middle income families and do cash only for high income families. I don't know how practical that is, or even if it's possible, but was just wondering.


Thanks guys/gals...

 

[Therapist4Chnge]

]
So then, for those wanting to someday practice cash only, how do you reason this out in your head? Is that the many many years of education + the >250K loans make it okay? Is there even a need to reason it out as medicine is a business and the point of owning a business is making the most money possible? I would like to know.

Are you providing ethical and medically sound services? Does your patient benefit from seeing you compared to not seeing you? It isn't your job to save the world or work on a sliding scale. Most other professions charge what the market dictates, so why should someone in a helping profession be punished? Mechanics and lawyers charge an arm and a leg for things.

 

[Manicsleep]

I think this is where the 'patient' becomes really important.

If those people have insurance and the kids are insured under something other than medicare then they can still bill their insurance, even if you charge them cash. I think this is still possible under medicare but I don't know how it works.

However, if you are the only provider and someone has an emergency situation, obviously it is unethical to let them suffer. You have to just take the loss. Work with a sliding scale etc. Be careful though, you will see people driving up in nice cars, wearing nice clothes, then stating "I can't afford it."

 

[michaelrack]

Well here is my question, and I am not judging at all, just want some feedback that I felt uncomfortable asking the attending. Ethically, how do you feel about straight cash practice in a specialty that is in such need such as Child Psychiatry? The area that I am doing my rotation in has very few child psychiatrists (like many areas in America) which allows the very good child psychiatrists to do cash only practices and pick and choose their patients. This makes it difficult to have our patients follow up with CAPs outpatient if they are poor or have horrible insurance.

...

The solution to your ethical dilemna is to have a cash-only private practice and to spend 1-2 half days a week working at a community mental health center or similar setting.

 

[DocHolliday21]

Great point michaelrack,

I was just talking to someone indicating that would be the best resolution of my dilemma, and something that I would be happy doing. To maximize earning potential and still feel like I'm contributing to all classes in the population, it would be a nice compromise of the two.


Ha, T4C, I always think of mechanics when I think of how ridiculous some services cost in this country.


Thanks everyone for your input. It has been helpful.

 

[digitlnoize]

Great point michaelrack,

I was just talking to someone indicating that would be the best resolution of my dilemma, and something that I would be happy doing. To maximize earning potential and still feel like I'm contributing to all classes in the population, it would be a nice compromise of the two.

Ha, T4C, I always think of mechanics when I think of how ridiculous some services cost in this country.

Thanks everyone for your input. It has been helpful.

You should read some of the things written on the "Access Healthcare" practice model (for FM). This guy has a cash FM practice (~$50/visit), and was surprised to find that around 1/2 his patients were quite poor. Turns out that if they know the cost upfront, they're more likely to scrape together the money...

The trick on our end, I think, lies in finding the magic price point. Certainly, some car repairs are expensive, but an oil change (i.e. med check) is not.

For example, 20 minute appointment slots, 8h/day, 5d/wk at $50/appt works out to ~$300k/yr net. If you run a fairly low overhead practice, you should still be able to take home >$200k/yr at this price point and still be very affordable to people who may not have many resources. The trick lies in not being greedy and charging the usually >$100 fees we CAN get for this service. Easier said than done.

 

[whopper]

However, if you are the only provider and someone has an emergency situation, obviously it is unethical to let them suffer. You have to just take the loss. Work with a sliding scale etc. Be careful though, you will see people driving up in nice cars, wearing nice clothes, then stating "I can't afford it."

Question for all of you.

Is it unethical to have a cash only practice, and someone can't make a payment during a visit. What would you do? Deny them care? The person is your patient because you've seen them before.

If you already have an answer to the above, what about the following circumstances 1-there are very few psychiatrists in the area and none can take this person 2-the person needs a refill on a medication of possible abuse where if the medication is suddenly stopped, disastrous results could occur such as Suboxone or Ativan 3-There are other doctors available in the area, but you know most of them would not treat the person appropriately based on prior experience.

Another question for all of you: have you ever found any data showing that occasionally seeing a patient at a reduced rate could be considered unethical? That was discussed once in a lecture I had in residency but I never saw anything in print that supported this.

 

[Manicsleep]

I would see my own patient in an urgent or worse situation (I would define running out of meds such a situation) if they werent able to pay me. However, I would bill them.

I would not see the second situation, unless emergent, in my private clinic. We have a separate clinic for that. If I was the only one there, I would probably set up a separate time slot where I would acecpt indigent patients.

The 3rd situation would not arise. I probably would not judge other's practices in that manner (not the same as me looking at others practice patterns and saying WTF?!!). If I really felt they were damaging their patients I think its my obligation to report them or at least talk to them.

Regarding unethical lowering of fees. Hmm, that is interesting. I remember this discussion as well but I don't remember it being unethical. One of the things we discussed was that some physicians (me included) don't charge other physicians for my time. I think if you are playing favorites, it could be unethical. You have to evaluate and be aware of your countertransference.

 

[edieb]

The Ivy's are excellent schools. In general they have excellent training. It just goes to show that many many psychologists have poor training since their are graduates from schools like Alliant who barely know what schizophrenia looks like (even though I have seen it mentioned that this is a good school).


Yes, and the medical schools in the Caribbean have SUCH high standards. What a joke!


BTW, my school isn't an Ivy Ph.D.; however, I have 20 + experimental research publications, including many that have appeared in top journals, many book chapters, etc. Just because a school isn't an IVY, doesn't mean it's bad.

 

[Doc Samson]

Also, would it be possible to take insurance from low and middle income families and do cash only for high income families. I don't know how practical that is, or even if it's possible, but was just wondering.


Thanks guys/gals...

If you take insurance, you have to accept that insurance for all their members, regardless of their ability to pay you an out of pocket fee. All those high income families are going to have insurance.

 

[Manicsleep]

Yes, and the medical schools in the Caribbean have SUCH high standards. What a joke!
BTW, my school isn't an Ivy Ph.D.; however, I have 20 + experimental research publications, including many that have appeared in top journals, many book chapters, etc. Just because a school isn't an IVY, doesn't mean it's bad.

10,000 plus hours of work in an American residency mean anything to you? How about USMLE steps 1, 2 and 3? The ABPN boards? Anyone who can do that is no joke. For you to even suggest that on a psychiatry forum is evidence of stupidity, ignorance or both.

 

[ffchst]

Just for discussion... Either forensic psych. or interventional pain (why else would an anesthesiologist go through another year to get paid less)...

 

[digitlnoize]

Question for all of you.

Is it unethical to have a cash only practice, and someone can't make a payment during a visit. What would you do? Deny them care? The person is your patient because you've seen them before.

Is it unethical for a grocery store or restaurant to deny a hungry person food, just because they can't pay?

Is it unethical to deny a homeless person housing because they can't pay?

Is it unethical to deny a naked person clothing because they can't pay?

These are basic human needs (or "rights," if you prefer that term), more basic than medicine, and yet those professions get to deny service to the needy all the time. Why do we get the short end of the stick?

 

[billypilgrim37]

Is it unethical for a grocery store or restaurant to deny a hungry person food, just because they can't pay?

Is it unethical to deny a homeless person housing because they can't pay?

Is it unethical to deny a naked person clothing because they can't pay?

These are basic human needs (or "rights," if you prefer that term), more basic than medicine, and yet those professions get to deny service to the needy all the time. Why do we get the short end of the stick?

You are free to go to work as a grocery clerk, tailor, or a realtor if you don't like it.

 

[whopper]

s it unethical for a grocery store or restaurant to deny a hungry person food, just because they can't pay?

Is it unethical to deny a homeless person housing because they can't pay?

Is it unethical to deny a naked person clothing because they can't pay?

We have a "fiduciary" responsibility to patients as the law points out. That's why the above analogies do not work. That's why our legal and ethical responsibilities are supposed to be considered sacred to those we serve. That's why an ER doctor must give treatment to someone in acute need of care in the hospital regardless of the person's ability to pay. Completely aside from the law--I agree with the ethics behind the laws.

And that's why I brought up what I did. I have not seen much guidance on the issue. I am having patients that can't make payments that are seeing me out of pocket, and I know for a fact that many of the very few psychiatrists in the area give poor care. (There's only 2 other private practice doctors--both of whom have been investigated more than once for poor care).

I've looked into the issue of seeing someone at a reduced rate and have found nothing from major organizations such as the APA considering their stance on it. I may just call the APA myself and ask them what is their policy if any.

 

[Manicsleep]

Just for discussion... Either forensic psych. or interventional pain (why else would an anesthesiologist go through another year to get paid less)...

It isn't just about money. The anesthesiologist might like anesthesiology.

 

[Manicsleep]

Is it unethical for a grocery store or restaurant to deny a hungry person food, just because they can't pay?

Is it unethical to deny a homeless person housing because they can't pay?

Is it unethical to deny a naked person clothing because they can't pay?

These are basic human needs (or "rights," if you prefer that term), more basic than medicine, and yet those professions get to deny service to the needy all the time. Why do we get the short end of the stick?

People in The USA have these needs met. They should have them met if they arent. However, if resources to meet these needs are used in another manner or not used, offhand I can't really think what we can do unless there is mental illness.

BTW: I think a healthy body and mind are both excellent resources.

 

[DocHolliday21]

Question.

If say you take cash only and charge $200 for 1hr appt and $100 for 30min appt, wouldn't that save money for the patients? For example, if they paid $100 for that 30min appt, then had the insurance company reimburse them the $70 dollars they normally would give the doctor, the patient essentially ends up paying only $30 correct? Which is cheaper then the $40-50 most insurance companies require as a copay to see a specialist.

Am I missing something here?

 

[F0nzie]

Question.

If say you take cash only and charge $200 for 1hr appt and $100 for 30min appt, wouldn't that save money for the patients? For example, if they paid $100 for that 30min appt, then had the insurance company reimburse them the $70 dollars they normally would give the doctor, the patient essentially ends up paying only $30 correct? Which is cheaper then the $40-50 most insurance companies require as a copay to see a specialist.

Am I missing something here?

Yes, yes you are missing something . The insurances companies I've dealt with at my institution have a $15 co-pay regardless if it's a 1 hr or a 30 min appointment. The difference we're talking about here is $15 out-of-pocket vs. $100-$200 out-of-pocket, which is a significant amount of money for the average american. Out-of-network benefits do not reimburse as well as in-network and some insurances don't even reimburse out-of-network providers. You will need to instruct patients to contact their insurance company to determine their out-of-network benefits.

Keep in mind, you can't set your own rates for patients that are contracted through insurance companies. For example, if your insurance company decides to pay you $120 for an intake and +15 copay (this is the average at my institution), then $135 is all you get for the intake. If you want to set your own rates, the patient has to be paying out-of-pocket.

The bottom line is:
1. Out-of-pocket patient will be paying anywhere between 5-15X more to a cash psychiatrist than your average psychiatrist who accepts insurance.
2. The patient seeks reimbursement from their insurance company and may not get paid for months, or not get paid at all.

 

[DocHolliday21]

huh...okay thanks for the info. i guess copays can vary by a lot. didn't realize they went as low as $15. most of them around here are $40 or 50.

 

[jojo100]

Im going to revive this thread again...any updates? re: pain (anesthesia or headache/chronic pain) vs sleep?

 

[PrideNeverDie]

i was planning on working a sub-40 hr week in my family's private practice and look at other investments

anyone else feel that this is a much better path to generate wealth?

i love psychiatry, but i don't see many ways to generate passive income
i feel that the key to gaining wealth is through passive income

this way i can continue doing what i love (psychiatry) and still be able to have the time and flexibility to invest or spend time with the family

any suggestions on great gigs that are sub-40 hr work weeks

 

[DrAwsome]

i was planning on working a sub-40 hr week in my family's private practice and look at other investments

anyone else feel that this is a much better path to generate wealth?

i love psychiatry, but i don't see many ways to generate passive income
i feel that the key to gaining wealth is through passive income

this way i can continue doing what i love (psychiatry) and still be able to have the time and flexibility to invest or spend time with the family

any suggestions on great gigs that are sub-40 hr work weeks

Can't psychs do suboxone patients? In my understanding that generates a good chunk of change.

 

[OldPsychDoc]

Can't psychs do suboxone patients? In my understanding that generates a good chunk of change.

This was discussed to death some time ago.
http://forums.studentdoctor.net/showthread.php?t=718511&highlight=piss+merchant

 

[Chimed]

i was planning on working a sub-40 hr week in my family's private practice and look at other investments

anyone else feel that this is a much better path to generate wealth?

i love psychiatry, but i don't see many ways to generate passive income
i feel that the key to gaining wealth is through passive income

this way i can continue doing what i love (psychiatry) and still be able to have the time and flexibility to invest or spend time with the family

any suggestions on great gigs that are sub-40 hr work weeks

What other specialty would generate passive income?

You could always start and run a group practice. That would generate extra income; but I'm not sure that's what you mean by passive.

 

[TexasPhysician]

What other specialty would generate passive income?

You could always start and run a group practice. That would generate extra income; but I'm not sure that's what you mean by passive.

He meant passive income from not practicing medicine. Buy and manage a Krispy Kreme or thousands of other businesses. Once you set it up, get a trusted GM to run it.

 

[DrAwsome]

This was discussed to death some time ago.
http://forums.studentdoctor.net/showthread.php?t=718511&highlight=piss+merchant

Well I'm not in psych so I don't know the details, sorry. Nevertheless I didn't suggest running a "mill" but I don't see anything wrong on running a decent, honest business and adding income to one's practice that way.

 

[OldPsychDoc]

He meant passive income from not practicing medicine. Buy and manage a Krispy Kreme or thousands of other businesses. Once you set it up, get a trusted GM to run it.

Of course, the idea that he doesn't actually need to go to medical school to do this hasn't apparently occured to him...

Key pearl for PrideNeverDie (and everyone else): the only reason you should think about going into psychiatry is to treat mentally ill patients. If that's not on your agenda it will be a frustrating waste of your time and mine.

 

[notdeadyet]

the only reason you should think about going into psychiatry is to treat mentally ill patients. If that's not on your agenda it will be a frustrating waste of your time and mine.

Amen to that. I went in solely out of affinity for the mentally ill and fascination with mental illness and I STILL feel get the frustrated-waste-of-time feeling now and again.

This job would be intolerable if I was in it to raise capital for a Quizno's...

 

[PrideNeverDie]

Of course, the idea that he doesn't actually need to go to medical school to do this hasn't apparently occured to him...

Key pearl for PrideNeverDie (and everyone else): the only reason you should think about going into psychiatry is to treat mentally ill patients. If that's not on your agenda it will be a frustrating waste of your time and mine.

fortunately, i had the pleasure of the 9-5 corporate job after i graduated college. believe me when i say that for all the doom and gloom surrounding medicine it is a hundred times better than climbing the corporate ladder. i also started a small business, but it didn't have the satisfaction you get helping patients firsthand. i see medicine as my career, while everything else is just ways to pad the bank account.

i want it all. the great job satisfaction that comes with being a psychiatrist and still be able to invest and generate passive income. if you are going to dream, dream big right?

 

[Ibid]

i want it all. the great job satisfaction that comes with being a psychiatrist and still be able to invest and generate passive income. if you are going to dream, dream big right?

Put it another way. You want to find a way to live at the expense of other people and salve your conscience at the same time. Particularly greedy imo. Getting rich even honestly usually involves being a rsole. Just live with it.

p.s. You have confused generating wealth with just getting rich for yourself.

 

[makshim]

fortunately, i had the pleasure of the 9-5 corporate job after i graduated college. believe me when i say that for all the doom and gloom surrounding medicine it is a hundred times better than climbing the corporate ladder. i also started a small business, but it didn't have the satisfaction you get helping patients firsthand. i see medicine as my career, while everything else is just ways to pad the bank account.

i want it all. the great job satisfaction that comes with being a psychiatrist and still be able to invest and generate passive income. if you are going to dream, dream big right?

zyzz/10

 

[birchswing]

http://www.bloomberg.com/news/2012-...hiatrists-paid-400-000-shows-bidding-war.html

 

[PrideNeverDie]

Put it another way. You want to find a way to live at the expense of other people and salve your conscience at the same time. Particularly greedy imo. Getting rich even honestly usually involves being a rsole. Just live with it.

p.s. You have confused generating wealth with just getting rich for yourself.

a lot of people would consider you a greedy "rsole" just because you are pursuing medicine. you should be making decisions based on your beliefs instead of popular opinion.

everyone makes money at the expense of other people. there are people who believe that doctors overcharge all their patients. they show how much more doctors charge for procedures here compared to other countries and how much doctors make.

it is all about perspective.

i think you need to take a closer look at your views on money and generating wealth. why do you think that anyone rich is an "rsole" and living at the expense of other people? does this include doctors or are they exempt? what other jobs do you believe can be rich without being an "rsole?"

what about a small business owner than opens up 6 locations and makes over a million a year after 20 years in business? is he living at the expense of other people and being an "rsole?" what if he happened to be a doctor and 6 medical clinics? do you still feel the same way?

 

[Ibid]

it is all about perspective.

Indeed. An eminent economist asked me the other day how I would decide how much should be spent on health. I replied that I wanted spending on health to be related to how sick I was just like I want my food spend to be related to how hungry I am.

He started going on about GDP and how if we could get GDP up we could afford more as a nation. So I asked him "what if the same things that push up GDP also cause me to get sick?" So then he told me that productivity and efficiency were the key. You mean work until i'm dead with no holidays in between?

At that point he showed me a before and after shot of his mustache.

Have fun trying to get rich.

 

[toothless rufus]

Indeed. An eminent economist asked me the other day how I would decide how much should be spent on health. I replied that I wanted spending on health to be related to how sick I was just like I want my food spend to be related to how hungry I am.

He started going on about GDP and how if we could get GDP up we could afford more as a nation. So I asked him "what if the same things that push up GDP also cause me to get sick?" So then he told me that productivity and efficiency were the key. You mean work until i'm dead with no holidays in between?

At that point he showed me a before and after shot of his mustache.

Have fun trying to get rich.

I was with you, then huh!?...mustache...

 

[HeyThereJude]

Crap, all I do all that now for "free". I have no appointment scheduled for less than 30 minutes. I do all my own phone and email and all are returned within 24 hours. I do next day appointments, etc. etc. And all I get for it is whatever people's insurance companies say I deserve for a 90805. And to be honest, it's not very appreciated by patients and gets taken for granted a lot. I have people who feel I need to be at their beck and call 24/7. Like on Thursday, I saw a patient who hadn't been seen for 6 months even though she was supposed to be seen in three. She refused to come in at the recommended interval because she said she was "doing fine." All of sudden last week, her boyfriend dumps her and she's not doing fine anymore and demands to be seen because her "meds aren't working." I schedule her quickly. I review what's been going on and it seems that she was having some relapse of symptoms prior to the boyfriend thing, but that it was tolerable. I recommend more frequent visits with her psychotherapist and given that she was already having some symptom relapse offer the choice of changing her SSRI, which she elects to do. I tell her very clearly that this is not the magic answer . . . she needs time and more consistent contact with her therapist.

Based on her insurance, I know that I am going to have to do a prior authorization. I tell her so. I show her the form. "Don't go to the pharmacy," I say. "Until I call you and let you know that it's gone through." She voices understanding. I submit the auth within 30 minutes of her leaving my office. The next day, she calls and says, "OMG! Did you know my insurance requires an auth for this? You need to call my insurance company!!' At about the same time I receive a fax from her insurer saying the medication has been denied. So I call her back and tell her that the medication has been denied and that we need to submit an appeal. It's now 4pm on a Friday afternoon and I tell her it's not going to happen over the weekend. I call in a supply of her old med so she doesn't go without. She voices understanding. So yesterday, she calls my cell phone (which is my emergency number since I am solo and can't afford an answering service) and leaves a message saying, "OMG! Have you talked to my insurance company! I need a new medication NOW! This one isn't working and I can't deal anymore." I don't return her call. She calls again. When I don't answer, she calls again. When I don't answer she calls again. She hung up and re-dialed at least three times in a row. How long that went on for I don't know because after the third time, I turned my cell phone off for 30 minutes. There were no additional messages when I turned it back on. And I still plan to get back to her tomorrow during normal business hours. And all of this for just what her insurance deigns to pay me for the 90805 I billed on Thursday.

I have two other patients, a married couple, who when they scheduled their initial evaluations with me actually asked if I employed an office staff. I told them I didn't and they were pleased. That's why they didn't like their former psychiatrist. "I hate it that when I call him it's always the nurse who gets back to me." At the time, I didn't think much of it, but now several months later I recognize the red flag. These people are calling and emailing all the time. They hiccough after drinking soda pop and they're on the phone with me wanting to know if it's a med side effect. They feel a little stressed one day and they're on the phone with me wanting to know if their antidepressant dose needs to be increased. If it does need to be increased, they are quick to point out that they don't need to come in. "We can just do it over the phone." This means, of course, that Dr. Lioness doesn't get paid. Which in fairness, I don't think they actually realize.

So yeah, if people can get concierge rates to do what I am doing anyway. I say, go for it. Me? I'm getting out of solo practice and going back to inpatient. I'll be making more than twice what I am making now and it will be deposited into my account at regular intervals and I won't have to argue with insurance companies and/or patients to get it. I will be on call one week out of every 1-2 months during which time other professionals will be calling me and not patients. And I can't wait.

Ouch Sun.

That sounds like pain but it also sounds like you would be a perfect person for a concierge service. Why not try it out before going to inpatient if you are going to leave the practice anyways.

Tell your patients that in January 2011, you will be going to a new model. 15 minute visits will be the norm and filling out forms, next day/same day visits costing 25 dollars extra. Phone calls/emails not regarding scheduling will be 50 dollars. Offer them a 50 dollar plan where all these will be free including 30 minute visits and add a 100 dollar plan where you will come see them with their PCP once as well as see them if they are every admitted to an inpatient hospital and coordinate their care with their physician.

PS. let me know how it goes, this is roughly how we are thinking of having ours set up.

These seem like some great ideas. Any word on how it is working?

I am wondering how people learn to set up a private practice? Did anyone read a book or anything? Have you found other community psychiatrists are open to talking to you about it, or do they see you as competition?

It seems like it is easy to be abused by patients in private practice, and I am imagine myself in the place of sunlioness

I am not replying to this post because of a main interest in making "big bucks" but for those interested in private practice, this thread seems to be one of the main ones discussing it a lot (after my search anyway). Some other questions I was wondering about for private practice, for anyone that has any experience/knowledge:

- Can you supplement a patient's insurance by asking for a higher copay, or do insurance companies not allow you to? Or, has anyone had success with "insurance coupons" patients get after they visit a private out of network provider at full price?
- For all the comments about the frustrations of not being paid for your services - why not ask to paid before seeing the patient?
- I have heard a big problem is cancellation - has anyone had success with cancellation fees? or any other policies? Like 2 cancellations per 6 months or something?
- What happens to a patient that is repeatedly not paying their bills after seeing you – can you stop seeing them as a patient?
- Can you tell a patient you will not see them anymore if they are abusing the office/calling you on your cell phone 5 times a day?
- How do you limit weekend/night calls from patients, or are you always carrying your cell phone/pager?
- How hard has it been for people who do not accept insurance to fill up their practices with patients?

 

[vistaril]

- Can you supplement a patient's insurance by asking for a higher copay, or do insurance companies not allow you to? Or, has anyone had success with "insurance coupons" patients get after they visit a private out of network provider at full price?
- For all the comments about the frustrations of not being paid for your services - why not ask to paid before seeing the patient?
- I have heard a big problem is cancellation - has anyone had success with cancellation fees? or any other policies? Like 2 cancellations per 6 months or something?
- What happens to a patient that is repeatedly not paying their bills after seeing you – can you stop seeing them as a patient?
- Can you tell a patient you will not see them anymore if they are abusing the office/calling you on your cell phone 5 times a day?
- How do you limit weekend/night calls from patients, or are you always carrying your cell phone/pager?
- How hard has it been for people who do not accept insurance to fill up their practices with patients?

1)no, insurance companies are not going to let you charge their patients more than the agreed upon copay. It's take it as is or nothing.

2) cancellations can be a problem, but in a well run practice shouldn't be more than 10%. And yes, you can try to charge for noshows. You won't be able to get insurance to pay for these. You can try running a 50 dollar charge or whatever on the pt's credit card based on an agreement that they signed, but the pt is going to likely raise hell and the cc company may decline it and then go back and charge you fees after they remove the 50 dollars.

3) No pp psychiatrist can keep seeing a pt who is not paying their bills. In fact, it may be a good idea to get the pts copay and have their insurance on file before they go back.

4) Of course you can tell a pt you won't see them anymore if they are calling that frequently.

5) You limit weekend and night calls by not giving your pts your phone#.

6) it is highly dependent on area, what services you provide, your fees, what % of your practice is self pay, etc. In most areas it is *very* difficult to have a full time cash pay practice that is a lot of med mgt(and not regular dynamic therapy)....simply because of the massive number of cash pay patients you would need to make that happen. It is more feasible to have a regular job and then maybe devote a small number of hrs/week to cash pay patients if you build a repuation(or are also providing other services like suboxone and are in an area that isn't oversaturated with suboxone providers).

 

[HeyThereJude]

1)no, insurance companies are not going to let you charge their patients more than the agreed upon copay. It's take it as is or nothing.

2) cancellations can be a problem, but in a well run practice shouldn't be more than 10%. And yes, you can try to charge for noshows. You won't be able to get insurance to pay for these. You can try running a 50 dollar charge or whatever on the pt's credit card based on an agreement that they signed, but the pt is going to likely raise hell and the cc company may decline it and then go back and charge you fees after they remove the 50 dollars.

3) No pp psychiatrist can keep seeing a pt who is not paying their bills. In fact, it may be a good idea to get the pts copay and have their insurance on file before they go back.

4) Of course you can tell a pt you won't see them anymore if they are calling that frequently.

5) You limit weekend and night calls by not giving your pts your phone#.

6) it is highly dependent on area, what services you provide, your fees, what % of your practice is self pay, etc. In most areas it is *very* difficult to have a full time cash pay practice that is a lot of med mgt(and not regular dynamic therapy)....simply because of the massive number of cash pay patients you would need to make that happen. It is more feasible to have a regular job and then maybe devote a small number of hrs/week to cash pay patients if you build a repuation(or are also providing other services like suboxone and are in an area that isn't oversaturated with suboxone providers).

Thanks for these great responses. I had thought I'd heard there was an issue (and rules) with patient abandonment; that once you start seeing them, you can't just stop (or maybe I misunderstood).

So do people make rules about patients not being able to make new appointments until they have paid the balance of their last appointment or paid the balance from their canceled or missed appointment?

I am trying to understand how so many people could be losing their salaries on not collecting bills.

Why don't people just require the cost of the appointment to be paid at the time of the visit, or before, so the psychiatrist doesn't bill to the patient's house afterward and possibly never get paid?

I have heard from some people on this thread they lose about half of potential income on patient not paying for services, it seems there has to better an easier way to do things.

 

[vistaril]

Thanks for these great responses. I had thought I'd heard there was an issue (and rules) with patient abandonment; that once you start seeing them, you can't just stop (or maybe I misunderstood).

So do people make rules about patients not being able to make new appointments until they have paid the balance of their last appointment or paid the balance from their canceled or missed appointment?

I am trying to understand how so many people could be losing their salaries on not collecting bills.

Why don't people just require the cost of the appointment to be paid at the time of the visit, or before, so the psychiatrist doesn't bill to the patient's house afterward and possibly never get paid?

I have heard from some people on this thread they lose about half of potential income on patient not paying for services, it seems there has to better an easier way to do things.

oh there are rules with patient abandonment....basically you just have to notify them and tell them they will need to be getting another provider if they want services.

And many people do require the cost of the appt(or at least copay) be paid at time of visit. That's generally the way it works.

I don't know anyone n psych who loses 50% of their income from patients not paying. A bigger problem in most cases can be having claims denied or not authorized. And you have to remember that margins in psych are so small(because there are no procedures or ancillary income) that every little bit counts.