How does this inpatient job sound?

[surfguy84]

Community hospital. Set your own cap, do your own Billings. The hospital is majority Tricare with about 35% private insurers. I've been told my average billings will work out to 85ish an encounter, which seems low. So a patient cap of 15 should generate about 1300 dollars a day. Again seems very low but maybe this is because of Tricare making up a large part of their mix? Also, this is in Socal mind you.

The other thing which seems odd, but maybe it's normal, is the fact you're responsible for your patients 24/7. Floor calls overnight go to you. You're also responsible for covering weekends but seems like most docs will either have a resident cover or form separate call pools and end up covering q3weekends or so.

The doctors working here seem of good quality, following evidence based medicine, collegial atmosphere. It's just that the billings seem low and I don't know about the hospital not having a weekend or overnight call person.

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[clozareal]

Sounds terrible! In the insurance based community inpatient practices in my area that take most insurances, they were paying at least $125 per encounter and you don't have to do your own billing other than what's in the documentation (Do you have to pay your own biller? That can be 5-12% off of that total. Some inpatient jobs are like that.), you don't have to take call (you get paid extra if you do) although are responsible for that patient up until I think 5pm and then someone takes over overnight and on the weekends.

But the reason why it sounds terrible is because the call is HORRIBLE. I mean being on call EVERY weeknight? And doing one weekend month or more of call if no one else is gracious enough to take your weekends? When do you have time off? What about holidays and vacations? That sounds worse than residency.

Just as reference, the resident moonlighters on the weekends on the inpatient community unit in my area which may be similar to yours were getting ~$138/encounter.

 

[Bartelby]

That's close to $300k ($1300/day x5 days/wk x 46 weeks = $299,000) for 15 inpatients a day and 24/7 call (or rotating a frequent call coverage for multiple inpatient teams). That sounds pretty bad to me. And if you mean in-person weekend coverage is always up to you that sounds terrible.

 

[surfguy84]

Sounds terrible! In the insurance based community inpatient practices in my area that take most insurances, they were paying at least $125 per encounter and you don't have to do your own billing other than what's in the documentation (Do you have to pay your own biller? That can be 5-12% off of that total. Some inpatient jobs are like that.), you don't have to take call (you get paid extra if you do) although are responsible for that patient up until I think 5pm and then someone takes over overnight and on the weekends.

The resident moonlighters on the weekends on the inpatient community unit were getting ~$138/encounter.

So the 85 is after a biller takes 7 percent. Why in the world are billings so low, particularly in this VHCOL area? Is Tricare just that horrible?

Do you know if the average encounter reimbursements you described are for a 99232 plus add on therapy or just the 232?

 

[smalltownpsych]

Community hospital. Set your own cap, do your own Billings. The hospital is majority Tricare with about 35% private insurers. I've been told my average billings will work out to 85ish an encounter, which seems low. So a patient cap of 15 should generate about 1300 dollars a day. Again seems very low but maybe this is because of Tricare making up a large part of their mix? Also, this is in Socal mind you.

The other thing which seems odd, but maybe it's normal, is the fact you're responsible for your patients 24/7. Floor calls overnight go to you. You're also responsible for covering weekends but seems like most docs will either have a resident cover or form separate call pools and end up covering q3weekends or so.

The doctors working here seem of good quality, following evidence based medicine, collegial atmosphere. It's just that the billings seem low and I don't know about the hospital not having a weekend or overnight call person.

24/7 call? I wouldn’t take that job no matter what the pay. That is a bizarre expectation. I used to do a rotation of call coverage at a community hospital with four of us getting a week at a time and that was tough enough to do and I was getting three weeks off from call in a row.

 

[clozareal]

So the 85 is after a biller takes 7 percent. Why in the world are billings so low, particularly in this VHCOL area? Is Tricare just that horrible?

Do you know if the average encounter reimbursements you described are for a 99232 plus add on therapy or just the 232?

It's a mix. It gets averaged out and then given based on a point system per patient encounter to make it fair.

 

[forchinet121]

Extremely bad

 

[splik]

So the 85 is after a biller takes 7 percent. Why in the world are billings so low, particularly in this VHCOL area? Is Tricare just that horrible?

Do you know if the average encounter reimbursements you described are for a 99232 plus add on therapy or just the 232?

tricare pays medicare rates. you can look up the rates online they are publically available

 

[michaelrack]

what the op is describing is not a job. It's staff privileges at a private hospital. Hard to do as a solo doc, even with cross-coverage arrangements.

Nothing wrong with the arrangement OP is describing, but it's not a job, it would be part of a private practice. Hard to do as a solo doc, especially if he is not already credentialed with insurance in the area, and not working with an experienced biller.

 

[surfguy84]

what the op is describing is not a job. It's staff privileges at a private hospital. Hard to do as a solo doc, even with cross-coverage arrangements.

Nothing wrong with the arrangement OP is describing, but it's not a job, it would be part of a private practice. Hard to do as a solo doc, especially if he is not already credentialed with insurance in the area, and not working with an experienced biller.

I'll say there are several docs working here who are solo and have been here for years.

There is a very experienced biller who works with many of the docs here. So I would at least have that. He helps with all credentialing, etc.

 

[surfguy84]

It's a mix. It gets averaged out and then given based on a point system per patient encounter to make it fair.

Gotcha. So the other thing I noticed is no one is using any add on therapy codes here. Where I currently moonlight this happens all the time. Is it not common to use a 90833 while inpatient?

 

[annoyedpsychiatrist]

Ive personally never seen add on therapy codes on an inpatient unit. 16 mins of therapy for each rounding patient not counting med management, given the setting, may not be ideal. Also most of these people are in crisis- psychotic, acutely suicidal, manic or even malingering so probably brief therapy wouldnt be as indicated for a lot of these patients because they have acutely decompensated likely are less receptive to it.

Also i would never do a job that had 24/7 call and they could call you whenever. That sounds terrible. If you're on 24/7 call you're still working in my mind, and you should be getting some kind of bonus compensation for your availability. You start getting personality disorder patients on the unit, your life might really suck with that 24/7 call. "Patient would like to talk to you, they feel stable for discharge and have to go back and see their kids" "Patient changed his mind and would like to stay there because he feels safe" "Now patient states he intends to commit suicide on unit by going on a hunger strike, he decided this after he ate dinner"

 

[nexus73]

I'll say there are several docs working here who are solo and have been here for years.

There is a very experienced biller who works with many of the docs here. So I would at least have that. He helps with all credentialing, etc.

it’s possible these more experienced docs don’t realize they’re getting a bum deal. If they’re covering call and have majority poor paying insurance, the hospital should be giving them a supplemental stipend either per day or annually to offset the lower pay. IMO. I’ve seen older docs get complacent because their first job 30 years ago paid 95k or something really low and they’re bad at advocating for themselves.

 

[Psych19]

Some docs will take a gig like this because they can round on their inpatients in the morning and do private practice in the afternoon. It can be very lucrative, albeit hard work.

24/7 call on an inpatient unit is a lousy situation, but it may not be as bad as you expect. I did a brief stint (several months) of 24/7 call for an inpatient unit before we reorganized our call coverage at a community hospital. I got far fewer calls than I expected. Nursing was good and they rarely called after 10 or 11pm with any issues. Having PRN orders in place already was helpful to prevent calls.

That said, I wouldn't do that call arrangement again. You should also get a stipend for call coverage and it shouldn't be every night.

 

[surfguy84]

it’s possible these more experienced docs don’t realize they’re getting a bum deal. If they’re covering call and have majority poor paying insurance, the hospital should be giving them a supplemental stipend either per day or annually to offset the lower pay. IMO. I’ve seen older docs get complacent because their first job 30 years ago paid 95k or something really low and they’re bad at advocating for themselves.

These guys are all <6 years out from residency. I was so surprised to see that.

 

[clozareal]

Gotcha. So the other thing I noticed is no one is using any add on therapy codes here. Where I currently moonlight this happens all the time. Is it not common to use a 90833 while inpatient?

At one of the places I moonlighted, it's encouraged if you can spend an extra 16 minutes with an inpatient on this. If you have 15 patients a day, that's an extra 4 hours of work.

 

[Stagg737]

National average for a 99232 is just over $71 and 99233 is just under $103, so the encounter average isn't good but around average for the nation. If you were just doing straight 15 patients/day at $1300/day it's not good but I don't think it's awful. For a high CoL area like SoCal though I would ask for more. I agree with others though, add the 24/7 call and weekend coverage in and it's pretty terrible. Even if you only get 3 or 4 calls after 10pm per week, the stress of just being on 24/7 would be a non-starter for me.

Gotcha. So the other thing I noticed is no one is using any add on therapy codes here. Where I currently moonlight this happens all the time. Is it not common to use a 90833 while inpatient?

I've never seen it done. Technically you can and it's not bad to keep track of patients you spend more time doing support or some brief therapy with, but most of the time docs aren't going to take 20-25+ minutes with inpatient follow-ups which would probably be the minimum amount of time you'd need to add on 90833.

 

[calvnandhobbs68]

Some docs will take a gig like this because they can round on their inpatients in the morning and do private practice in the afternoon. It can be very lucrative, albeit hard work.

Yeah I’ll bet that’s what’s happening here. Round on the inpatients in the morning, do a few hours of private practice in the afternoon and suddenly you’re 400k+ pretty quickly. Especially in this situation where you’re 24/7 on for your own patients anyway, people probably think why bother being on the unit longer than possible.

 

[J ROD]

Everybody needs a break. Money not even close enough

 

[surfguy84]

National average for a 99232 is just over $71 and 99233 is just under $103, so the encounter average isn't good but around average for the nation. If you were just doing straight 15 patients/day at $1300/day it's not good but I don't think it's awful. For a high CoL area like SoCal though I would ask for more. I agree with others though, add the 24/7 call and weekend coverage in and it's pretty terrible. Even if you only get 3 or 4 calls after 10pm per week, the stress of just being on 24/7 would be a non-starter for me.



I've never seen it done. Technically you can and it's not bad to keep track of patients you spend more time doing support or some brief therapy with, but most of the time docs aren't going to take 20-25+ minutes with inpatient follow-ups which would probably be the minimum amount of time you'd need to add on 90833.

Wow, 71 average is pretty awful. How in the world does anyone make any money doing inpatient? I swear I've seen several posters here talking about making 120-150 per encounter.

 

[TheFuture_22]

If you build a follow up template that automatically meets criteria for a level 3, then you can bill a lot of level 3s and boost those numbers a bit. You would just need to make sure the level of medical decision making is high enough to qualify for a level 3 which would be quite a few (probably half or so) as it is an acute hospital after all. You can also bill therapy if you spend at least 16 minutes doing supportive therapy with the patient which can again boost your numbers some. On average, I find that I can bill about 50% level 3s and 50% level 2s as well as add on therapy codes in about 25% of the encounters. That makes a big difference in terms of compensation. I still think they need to find a better system for the call, however, as most hospitals that use a system like this pay extra for call and have a rotating call system, so you aren’t on call 24/7. You couldn’t pay me enough to be available 24/7, even if it is easy.

 

[forchinet121]

If you build a follow up template that automatically meets criteria for a level 3, then you can bill a lot of level 3s and boost those numbers a bit. You would just need to make sure the level of medical decision making is high enough to qualify for a level 3 which would be quite a few (probably half or so) as it is an acute hospital after all. You can also bill therapy if you spend at least 16 minutes doing supportive therapy with the patient which can again boost your numbers some. On average, I find that I can bill about 50% level 3s and 50% level 2s as well as add on therapy codes in about 25% of the encounters. That makes a big difference in terms of compensation. I still think they need to find a better system for the call, however, as most hospitals that use a system like this pay extra for call and have a rotating call system, so you aren’t on call 24/7. You couldn’t pay me enough to be available 24/7, even if it is easy.

How much are you getting for a level 3, level 2, and psychotherapy add on code?

 

[1edyfirel]

You don't need to confirm, but this sounds like a psych hospital in San Diego. The market in San Diego sucks, and honestly I think people take this crap b/c it's San Diego (though that doesn't make it work it imo). Even the residents started backing off of taking weekend moonlighting work here b/c there are other opportunities and the pay system was ridiculous. (Meaning you may be stuck with a lot of weekends, holidays, etc.) The people I do know who work here are, as you say, good doctors and many have been there over a decade. Most of them all have outpatient PP in the afternoon, do TMS/ketamine, etc.

 

[TheFuture_22]

How much are you getting for a level 3, level 2, and psychotherapy add on code?

It very much depends on the payer source. Medicaid is by far the worst payer as they only pay 50 for a level 2, 68 for a level 3, 58 for therapy add on code. Private insurance pays around 90 for level 2, 120 for level 3, and 90 for therapy code. Medicare is in the middle at 67 for level 2, 96 for level 3, and 61 for therapy code.

 

[forchinet121]

It very much depends on the payer source. Medicaid is by far the worst payer as they only pay 50 for a level 2, 68 for a level 3, 58 for therapy add on code. Private insurance pays around 90 for level 2, 120 for level 3, and 90 for therapy code. Medicare is in the middle at 67 for level 2, 96 for level 3, and 61 for therapy code.

Thanks for sharing! What percent of your patients are private insurance?

 

[TheFuture_22]

Thanks for sharing! What percent of your patients are private insurance?

At the hospital I work at it is about 60% Medicaid, 20% Medicare, and 20% private insurance. Many psych hospitals don’t take Medicaid in my area, so we end up with a high amount of Medicaid patients.

 

[forchinet121]

At the hospital I work at it is about 60% Medicaid, 20% Medicare, and 20% private insurance. Many psych hospitals don’t take Medicaid in my area, so we end up with a high amount of Medicaid patients.

Oh gosh that’s less than ideal pay then overall right?

 

[TheFuture_22]

Oh gosh that’s less than ideal pay then overall right?

Obviously, it could be higher if the payer mix was better, but I like treating SMI patients and most of them have Medicaid so I’m okay with it. It works out to be some decent money if you know how to bill properly.

 

[annoyedpsychiatrist]

One thing that SDN preaches on here that I agree with 100% "know your worth". My last job I think I was low balled because they knew I was young and didnt fully understand wrvus at the time and what to even ask for, so they had all the power for negotiations.

 

[comp1]

Ugh, these contract things sound horrible. Find your self a salaried job.

 

[Stagg737]

Wow, 71 average is pretty awful. How in the world does anyone make any money doing inpatient? I swear I've seen several posters here talking about making 120-150 per encounter.

Keep in mind that is CMS average, private insurance can pay much higher and there's a reason many private psych hospitals don't accept Medicaid (and sometimes medicare). Per FAIR Health, where I'm at an uninsured 99232 on average costs $175 and "in-network" cost will still cost someone over $100. So yes, it is not unrealistic to expect to make $120-150 per inpatient encounter (especially if you can bill 99233 which has a CMS national average at $102).

Additionally, this is why you see jobs where one psychiatrist is rounding on 25+ patients a day. When you're seeing 25 people a day at $70/encounter plus a couple of new patients each day which pay a lot more (CMS average for 90792 is $175), you can still make good money (>$400k/yr). Obviously, patient care will suffer as these are the places where docs are spending 5 minutes (or less) with each patient.