Outpatient Job Offer, Independent Contractor?

[theusual]

I'm hoping for some feedback regarding a job offer I've received, current PGY4 in a large city.

I would be working as an independent contractor/1099 in a physician owned outpatient private practice. The practice has 3 MDs and a few PAs. They are offering a 75/25 split. The practice only takes 1 insurance or cash pay. They estimate billing about 80% 99214 +90833 which is reimbursed at ~240 for a 30 min appointment, similar for cash pay (however most pts have insurance). Staff helps with billing. Estimate my schedule will be filled in about 3 months. They offer TMS and ketamine. There is no non-compete. I can choose my own hours. I'm not concerned about health insurance as I can join my partner's plan.

Overall, if my schedule is filled within a few months (I recognize I would be taking a financial hit for a while, but could manage that given my partner's job), I think this sounds like it has the potential to be a lucrative position, offering some stuff I'm interested in (they see a specific subset of patients I'm interested in, TMS, ketamine) and good mentorship within the practice.

Thoughts?

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[littlefred]

Good spot to learn the ropes and then eventually you can spread your wings by yourself.
It looks like you got a good gut feeling, I say go for it.

 

[clausewitz2]

I'm hoping for some feedback regarding a job offer I've received, current PGY4 in a large city.

I would be working as an independent contractor/1099 in a physician owned outpatient private practice. The practice has 3 MDs and a few PAs. They are offering a 75/25 split. The practice only takes 1 insurance or cash pay. They estimate billing about 80% 99214 +90833 which is reimbursed at ~240 for a 30 min appointment, similar for cash pay (however most pts have insurance). Staff helps with billing. Estimate my schedule will be filled in about 3 months. They offer TMS and ketamine. There is no non-compete. I can choose my own hours. I'm not concerned about health insurance as I can join my partner's plan.

Overall, if my schedule is filled within a few months (I recognize I would be taking a financial hit for a while, but could manage that given my partner's job), I think this sounds like it has the potential to be a lucrative position, offering some stuff I'm interested in (they see a specific subset of patients I'm interested in, TMS, ketamine) and good mentorship within the practice.

Thoughts?

Unless they strike you as sharks this seems like a reasonable deal. Only thing to do is ask to see what their reimbursement schedule for E&M codes is like with insurance they take. Are they good with you doing psychotherapy cases (in case you care about that) or deciding how long your appointments will be PRN for intakes/special circumstances/etc?

 

[Merovinge]

Seems very reasonable. The one point to potentially work on is a decreasing split based on your revenue. For example you keep 75% of the first $200k in collections then 80% for anything thereafter (or any variant thereof). This lets them recoup some fixed costs at a higher cut while incentivizing you to see more patients to some degree.

 

[dl2dp2]

This seems reasonable. The only question is whether they'd consider an associate to partner bridge. If you become a partner for this sort of practice you probably wouldn't leave. Sometimes they resist it, which means that they expect you to leave after a few years.

 

[calvnandhobbs68]

Seems very reasonable. The one point to potentially work on is a decreasing split based on your revenue. For example you keep 75% of the first $200k in collections then 80% for anything thereafter (or any variant thereof). This lets them recoup some fixed costs at a higher cut while incentivizing you to see more patients to some degree.

I was going to say the same thing. Realistically once you have several people in a practice and you're working off a straight split 1099 (no income guarantee), they're taking fairly minimal risk bringing you on board and you're actually adding very little to their overhead. They already have to rent out the office space you're using, they already have to employ the biller and front desk staff you're utilizing, they're already paying for the EMR, etc etc. So unless you're actually adding to the overhead somehow (ex. they have to hire another front desk person because you're seeing so many more patients), you're just splitting their existing overhead among more people.

 

[Merovinge]

This seems reasonable. The only question is whether they'd consider an associate to partner bridge. If you become a partner for this sort of practice you probably wouldn't leave. Sometimes they resist it, which means that they expect you to leave after a few years.

I think it's pretty rare for the owning psychiatrist to offer you partnership, it tends to not bring them much financial benefit (other than economy of scale which is certainly relevant for ketamine or TMS). If that was an option or something to consider I would certainly do it up front. If you just want to learn for a few years and start your own practice, these types of setups make sense, particularly with no non-compete and mentorship. What that is offering you is worth a significant amount of money.

 

[Stagg737]

Basic math this looks like a solid opportunity. Doing 20 hours of 99214 +90833 per week comes out to $9600 per week, or about $440k for 46 weeks a year. After the 75/25 split you take home about $330k for 20 hrs of work per week. Expand the math to 30-40 clinical hours per week and this has potential to be a very nicely compensated position.

Further questions, are you going to be paid based on what is billed or collected? If based on collections, how quickly will you see that money in your paycheck? No show rates?

 

[BiscoDisco]

How frequently are those in PP seeing these kind of reimbursements for 214 + add on? Lets say in a HCOL metro.

 

[TexasPhysician]

This seems reasonable. The only question is whether they'd consider an associate to partner bridge. If you become a partner for this sort of practice you probably wouldn't leave. Sometimes they resist it, which means that they expect you to leave after a few years.

If the OP is willing to help supervise multiple midlevels in the practice, this is a reasonable request. If not, it isn’t. There are no significant ancillary services that OP is contributing to like other fields.

This is a really good gig if all is true. Bordering on fantastic.

 

[liquidshadow22]

I think it will take forever to fill your panel probably will get 1-2 days of work max

 

[clausewitz2]

How frequently are those in PP seeing these kind of reimbursements for 214 + add on? Lets say in a HCOL metro.

Varies from weekly to Q8 weeks, mode is 4-6

 

[forchinet121]

Seems solid..we’ve been getting better job offers on this forum lately as they’re realizing we’re wising up to their antics

 

[hamstergang]

Varies from weekly to Q8 weeks, mode is 4-6

I think the question was not how frequently do you see the patients, but how frequently do you see that level of reimbursement. 'Frequent' was probably not the best word for the situation, and I would have used 'commonly' instead.

 

[ObsequiousAplomb]

Varies from weekly to Q8 weeks, mode is 4-6

So you are not having any trouble with reimbursement/auditing for weekly 99214+90833? I ask because I have been intermittently under coding with 90834 or the occasional 99213+90833 to avoid scrutiny despite providing what I consider 99214+90833 each visit with my weekly 30 minute appointments or 90837 / 99213+90836 for my hourly patients where I am really doing a 99214+90836 (but only billing that once or twice a month)

 

[clausewitz2]

So you are not having any trouble with reimbursement/auditing for weekly 99214+90833? I ask because I have been intermittently under coding with 90834 or the occasional 99213+90833 to avoid scrutiny despite providing what I consider 99214+90833 each visit with my weekly 30 minute appointments or 90837 / 99213+90836 for my hourly patients where I am really doing a 99214+90836 (but only billing that once or twice a month)

Never been an issue, but admittedly weekly 99214+90833 is only a handful for me at any given time. I do have a couple of people I do weekly 99214+90838 with because I am properly doing hour-long therapy with them and they are on meds that are no joke (think MAOIs or lithium). Occasionally one of those people will in fact be a 99215+90836 but obviously this involves a lot of labwork being ordered/getting collateral etc.

If you get familiar with the insurance requirements for billing for the codes and know the criteria back and forth no reason, just make sure you document accordingly. Audits suck but nothing to fear if your notes support your billing.

 

[calvnandhobbs68]

So you are not having any trouble with reimbursement/auditing for weekly 99214+90833? I ask because I have been intermittently under coding with 90834 or the occasional 99213+90833 to avoid scrutiny despite providing what I consider 99214+90833 each visit with my weekly 30 minute appointments or 90837 / 99213+90836 for my hourly patients where I am really doing a 99214+90836 (but only billing that once or twice a month)

I never code with just psychotherapy only codes, even for the couple patients I have seen weekly historically. If you document literally anything about their meds, it's a 99213 even like "taking medication daily, compliant, no significant side effects".

 

[hdeng]

I think it will take forever to fill your panel probably will get 1-2 days of work max

I'm curious why you think this and if anyone else has any thoughts about time to fill a panel at this type of job?

 

[TexasPhysician]

I'm curious why you think this and if anyone else has any thoughts about time to fill a panel at this type of job?

Highly variable on fill time. I’ve seen a solo psychiatrist take years to fill an insurance practice, and cash only psychiatrists fill fast at high rates. Competition and marketing skills have a big range in medicine.

 

[ObsequiousAplomb]

I never code with just psychotherapy only codes, even for the couple patients I have seen weekly historically. If you document literally anything about their meds, it's a 99213 even like "taking medication daily, compliant, no significant side effects".

That's really good to hear. Do the insurances you take only require one copay for the 9921x+9083x? I suppose if I had my patients get used to paying the double copay it wouldn't be as big a deal as I feel it is.

 

[splik]

That's really good to hear. Do the insurances you take only require one copay for the 9921x+9083x? I suppose if I had my patients get used to paying the double copay it wouldn't be as big a deal as I feel it is.

If the patient has a copay then it is per visit, regardless of how many CPT codes you use. If they have a coinsurance, then they wil pay a lot more the more codes you use since they are payinf a % of the bill.

 

[Ironspy]

I never code with just psychotherapy only codes, even for the couple patients I have seen weekly historically. If you document literally anything about their meds, it's a 99213 even like "taking medication daily, compliant, no significant side effects".

You don’t have to prescribe at all to have an E&M visit. You just have to to be evaluating for meds. I have weekly therapy patients who are not on meds and I bill E&M plus therapy add on.

 

[surfguy84]

So 1 minute of E&M might not actually be "fraudulent" if someone is stable on a single med and it's a quick check in about efficacy and side effects.

@Ironspy what type of language do you put in notes when you're doing a 99213 in a therapy patient not on meds to validate that code?

 

[smalltownpsych]

You don’t have to prescribe at all to have an E&M visit. You just have to to be evaluating for meds. I have weekly therapy patients who are not on meds and I bill E&M plus therapy add on.

The first statement makes complete sense, but it does seem a little odd to have a longer term weekly psychotherapy patient that you are always considering medications for but never actually prescribe any medications and continue to bill using the medical code. On the other hand, not a big fan of CMS and the system they designed so I’m always on the side of practitioners against the insurance companies.

 

[Ironspy]

So 1 minute of E&M might not actually be "fraudulent" if someone is stable on a single med and it's a quick check in about efficacy and side effects.

@Ironspy what type of language do you put in notes when you're doing a 99213 in a therapy patient not on meds to validate that code?

GAD or MDD: continue with dynamic therapy or CBT focusing on xyz. Patient has improved/remained stable with therapy, behavioral modifications, lifestyle changes. They are hesitant about medications, have xyz complicating factors for medication use. Continuing to offer/explore trial of SSRI but patient declining/improving or stable and prefers to continue with current treatment plan. I write this once then tweak based on what we are currently working on and which interventions we are using.

@smalltownpsych I get what you are saying but I've worked with PCPs who would do monthly weight checks for adults trying to lose weight and code E&M for a <10 min visit and no meds. The weekly therapy patients I see are sufficiently medically complicated that I feel that I am offering value over a non psychiatrist therapist. I've had a number of cases where medical history informs their mental health and I have had to coordinate care with PCPs or specialists. Also, it's often the case that patients are hesitant about meds that they could clearly benefit from but agree to a trial once we develop trust.

Side note, I almost never bill 99213. Most patients I see have either 2 stable problems or one worsening problem and meet criteria for 99214.

 

[ObsequiousAplomb]

If the patient has a copay then it is per visit, regardless of how many CPT codes you use. If they have a coinsurance, then they wil pay a lot more the more codes you use since they are payinf a % of the bill.

That makes sense to me. That's how I understand it to be. I'm asking because despite that being my understanding, what I asked is how the insurance and the billing department had been handling it.

 

[clausewitz2]

That makes sense to me. That's how I understand it to be. I'm asking because despite that being my understanding, what I asked is how the insurance and the billing department had been handling it.

Just cause it's their job doesn't mean they're good at it.

 

[clausewitz2]

GAD or MDD: continue with dynamic therapy or CBT focusing on xyz. Patient has improved/remained stable with therapy, behavioral modifications, lifestyle changes. They are hesitant about medications, have xyz complicating factors for medication use. Continuing to offer/explore trial of SSRI but patient declining/improving or stable and prefers to continue with current treatment plan. I write this once then tweak based on what we are currently working on and which interventions we are using.

@smalltownpsych I get what you are saying but I've worked with PCPs who would do monthly weight checks for adults trying to lose weight and code E&M for a <10 min visit and no meds. The weekly therapy patients I see are sufficiently medically complicated that I feel that I am offering value over a non psychiatrist therapist. I've had a number of cases where medical history informs their mental health and I have had to coordinate care with PCPs or specialists. Also, it's often the case that patients are hesitant about meds that they could clearly benefit from but agree to a trial once we develop trust.

Side note, I almost never bill 99213. Most patients I see have either 2 stable problems or one worsening problem and meet criteria for 99214.

This is one of the downsides of seeing a lot of people with OCD, there are a fair number of 99213s when treatment works. A surprisingly large clinical population of people who are healthy and high-functioning in every way except for this one particular mind cancer.

 

[surfguy84]

GAD or MDD: continue with dynamic therapy or CBT focusing on xyz. Patient has improved/remained stable with therapy, behavioral modifications, lifestyle changes. They are hesitant about medications, have xyz complicating factors for medication use. Continuing to offer/explore trial of SSRI but patient declining/improving or stable and prefers to continue with current treatment plan. I write this once then tweak based on what we are currently working on and which interventions we are using.

@smalltownpsych I get what you are saying but I've worked with PCPs who would do monthly weight checks for adults trying to lose weight and code E&M for a <10 min visit and no meds. The weekly therapy patients I see are sufficiently medically complicated that I feel that I am offering value over a non psychiatrist therapist. I've had a number of cases where medical history informs their mental health and I have had to coordinate care with PCPs or specialists. Also, it's often the case that patients are hesitant about meds that they could clearly benefit from but agree to a trial once we develop trust.

Side note, I almost never bill 99213. Most patients I see have either 2 stable problems or one worsening problem and meet criteria for 99214.

Thanks for spelling that out. Is it necessary to write a plan for each problem?

I do it like this.

Dx: X, Y
Plan
1.
2.
3.

 

[Ironspy]

Thanks for spelling that out. Is it necessary to write a plan for each problem?

I do it like this.

Dx: X, Y
Plan
1.
2.
3.

Probably doesn’t matter. Listing them separately helps me make sure I’m documenting plan for each diagnosis

 

[Ironspy]

This is one of the downsides of seeing a lot of people with OCD, there are a fair number of 99213s when treatment works. A surprisingly large clinical population of people who are healthy and high-functioning in every way except for this one particular mind cancer.

Sounds like you see a very different population than I do. I’ve never seen a high functioning patient with just ocd. OCD patients I see all have SUDS, insomnia and/or mood disorders or psychotic disorders as well.

 

[clausewitz2]

Sounds like you see a very different population than I do. I’ve never seen a high functioning patient with just ocd. OCD patients I see all have SUDS, insomnia and/or mood disorders or psychotic disorders as well.

Oh those people definitely exist too, but maybe it's a function of getting a lot of referrals directly from EX/RP specialists. The kind of people who hold high-powered jobs for years and only present for treatment when their contamination rituals at home get so bad that they no longer feel they can touch shoes long enough to tie laces. Or healthcare people who report themselves to their licensing board because they are afraid they broke the rule against reproducing exam material because they accidentally brought out a slip of paper from their exam with part of a question written on it.

 

[Candidate2017]

I'm curious why you think this and if anyone else has any thoughts about time to fill a panel at this type of job?

It depends on your professional and financial goals. You'll fill immediately if you are ok with taking everyone and/or diagnosing everyone with GAD and ADHD and wearing out the click button of your mouse due to smashing the refill button for controlled substances like a telepsych NP. You'll possibly never fill if you want a panel of patients who come daily for psychoanalysis.

OP, sounds decent in terms of numbers. The usual split is 70/30 to start, then 80/20 when full. Personally, I'd want to know if I have control over accepting or rejecting patients, and if I can craft my own panel.