Wanting to make 1M+ per year on first year out of residency

[dl2dp2]

I feel like we're being trolled.

You are not. The number of psychiatrists who make between 500k - 750k in the flyover (or in general, even) is not small. Over and above that number is unusual. Typically you are looking for: 1) male sole wage earner with a SAHW, sometimes gay; 2) very quiet about money, mid-level clinician, non-academic, non-administrative 3) never around, works a lot of nights/weekends. These types exist at almost every institution. This seems weird mostly because most psychiatrists, especially younger ones are 1) female; 2) lifestyle oriented; 3) often married to another doc or high income person.

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[deleted480308]

You sure about that?

 

[Candidate2017]

It was basically all Medicaid patients. 5 mins appointments, if not less. One doc would just line the patients outside of his door and wouldn’t even chart much of anything beyond copying the past notes over and over. I’m not sure if they kept all of the collections as they were employed by a facility in Florida. I guess government is too busy going after pill mills, to pay attention to anything else

Perfectly legit to bill for low complexity visits, at 5 or 10 minutes. But Medicaid rates for those codes would bankrupt a facility. I'm guessing the facility gets additional fed/state funding to keep the lights on and pay the psychiatrist a flat salary.

These Medicaid patients need to be seen, despite the financial penalty to do so (2-4 patients per hour on private insurance pays much better), and someone has to do it. And no, Medicaid PCPs barely staying afloat dont' have the time. I wouldn't want to practice that way but you have to understand the rigged game before judging the players harshly.

 

[Candidate2017]

There was a guy on whitecoatinvestor I was just reading about who made over 1M in his first year out of psychiatry residency. But of course, he was hustling like crazy. Personally, I've never heard of being to do that in any other specialty. Even the competitive ones.

In medium to small towns, upper $700k to one million is very obtainable for surgical subspecialties and GI, cardiology. And probably less work than a psychiatrist with the same clinical income.

 

[Candidate2017]

so if one makes 500k, you’re saying they can pay themselves 100k and only pay taxes on that, then use the 400k to buy real estate with no taxes as a 1099?

$100k is not a reasonable salary if you're netting $500k. Pay yourself at least the average $300k salary, and the remaining $200k can get a lower tax rate (0-15%) as some combo of deferred bonus, capital reinvestment, SEP, whole life insurance etc.

 

[Psychdoc4755]

Candidate 2017,

You say GI, cards, surg can easily pull 700k to 1 million with less work than a psychiatrist? Name me one part time surgical specialist or cardiologist? I mean seriously you don’t go into these fields to “lay back” and enjoy a festive work life balance. They all work long, grueling hours so their compensation is appropriate in that range. Alternatively, there’s plenty of low key, part time psych docs but if they choose to work like the specialists, they can make the same if not more salary per unit of effort/time if they are creative, smart

As for your analogy regarding Medicaid psychiatrists needing government stipends to “keep the lights on”. Lol. That is seriously ridiculous. I don’t want to flame you but please it’s not helpful when people make blanket statements with no basis in reality. Bro, check my previous post on the last page. I cited an OB/Gyn doc who sold his Medicaid practice in Detroit which he built over 20 years for 3 BILLION DOLLARS. Clearly, there is money to be made for the strong-willed and determined regardless of what naysayers say that “you’ll never make more than xx amount”

 

[finalpsychyear]

You are not. The number of psychiatrists who make between 500k - 750k in the flyover (or in general, even) is not small. Over and above that number is unusual. Typically you are looking for: 1) male sole wage earner with a SAHW, sometimes gay; 2) very quiet about money, mid-level clinician, non-academic, non-administrative 3) never around, works a lot of nights/weekends. These types exist at almost every institution. This seems weird mostly because most psychiatrists, especially younger ones are 1) female; 2) lifestyle oriented; 3) often married to another doc or high income person.

Once in PP the trick isn't to make that but work sub 35 hours while doing such. Also, with NP's and extenders in my area you can have 5 at full time under you or you can do the newer tech stuff. I have 0 desire to have 5 NPs to break into the upper end. I am much happier with my Sub 35 hour week, no wknd, no holiday, no nights, no call and hitting the numbers i want.

Ultimately, i always would prefer to be the kid who studied the night before the test and got the 90 percent than the guy who studies for weeks to get the 99. You can't buy time. Fools will eventually learn.

 

[calvnandhobbs68]

Perfectly legit to bill for low complexity visits, at 5 or 10 minutes. But Medicaid rates for those codes would bankrupt a facility. I'm guessing the facility gets additional fed/state funding to keep the lights on and pay the psychiatrist a flat salary.

These Medicaid patients need to be seen, despite the financial penalty to do so (2-4 patients per hour on private insurance pays much better), and someone has to do it. And no, Medicaid PCPs barely staying afloat dont' have the time. I wouldn't want to practice that way but you have to understand the rigged game before judging the players harshly.

PCPs bill for 99212s all the time because they can actually have someone with a URI in and out in 5 minutes. I've almost never had a psych patient that would bill as a 99212. Literally the primary care examples of 99212 are "cold, insect bite, tinea corporis". It would be tough to do a 99213s in under a 15 min visit unless they're a very well established patient and honestly the vast majority of my Medicaid psych patients are 99214s (ex. MDD, GAD, nicotine use d/o bam you've hit 3 chronic conditions even with no exacerbation for med complexity for 99214).

I doubt this guy had 100 99212/99213 Medicaid patients lined up outside his door.

 

[TexasPhysician]

Candidate 2017,

You say GI, cards, surg can easily pull 700k to 1 million with less work than a psychiatrist? Name me one part time surgical specialist or cardiologist? I mean seriously you don’t go into these fields to “lay back” and enjoy a festive work life balance. They all work long, grueling hours so their compensation is appropriate in that range. Alternatively, there’s plenty of low key, part time psych docs but if they choose to work like the specialists, they can make the same if not more salary per unit of effort/time if they are creative, smart

As for your analogy regarding Medicaid psychiatrists needing government stipends to “keep the lights on”. Lol. That is seriously ridiculous. I don’t want to flame you but please it’s not helpful when people make blanket statements with no basis in reality. Bro, check my previous post on the last page. I cited an OB/Gyn doc who sold his Medicaid practice in Detroit which he built over 20 years for 3 BILLION DOLLARS. Clearly, there is money to be made for the strong-willed and determined regardless of what naysayers say that “you’ll never make more than xx amount”

I have concerns about anyone that would buy a single specialty practice of Medicaid only patients. What’s the real reason for the valuation? Bad deals happen. Look at Oxy buying Anadarko which may prompt bankruptcy this year.
Starting a Medicaid clinic and filling it is easy. Making good money on it - Very hard.

Just to give you an idea. A friend of mine worked with Medicaid. He would schedule 4 evals per hour. Usually 3 would show. He hired counselors to obtain background information. He would then spend 20 min with them and treat. At the time, I’d see 1 commercial new eval in an hour and be compensated more.

 

[VA Hopeful Dr]

PCPs bill for 99212s all the time because they can actually have someone with a URI in and out in 5 minutes. I've almost never had a psych patient that would bill as a 99212. Literally the primary care examples of 99212 are "cold, insect bite, tinea corporis". It would be tough to do a 99213s in under a 15 min visit unless they're a very well established patient and honestly the vast majority of my Medicaid psych patients are 99214s (ex. MDD, GAD, nicotine use d/o bam you've hit 3 chronic conditions even with no exacerbation for med complexity for 99214).

I doubt this guy had 100 99212/99213 Medicaid patients lined up outside his door.

We absolutely do not. Across all of Epic, FM bills 99212s 2% of the time.

My personal rate is .23%, the FPs in my hospital system are at 1.3%.

 

[Mass Effect]

Remember, units typically have the main staff working during the day. That means the unit secretary, social workers, and higher nursing ratios are all for the day time, and they are there to help facilitate the discharge process. Patients are also awake during the day. If you are looking to round extra early or extra late, there is less staff to facilitate the actual discharge, or well the patients are asleep.

So other external factors may limit the big rounding plans.

He wants to see 100+ patients a day. I think he's going to have bigger problems than patients being asleep.

 

[Mass Effect]

Doesn't shufflin work multiple units and pull in big (albeit not 1M a year) income? From what I recall he has a pretty great set up. In residency we round on the inpatient unit starting at 630 some mornings. Rounds are done by 11ish. If I were an attending, it doesn't seem unrealistic to eat lunch then drive across town and round from 1-530ish at another unit. Is this really not doable as some are implying?

You can work in academics and do this because you've got a resident to do the notes, answer pages, finalize discharges. Doing this in the community is much more difficult and if you actually remember the thread with that poster, he took a hell of a lot of flak for this.

Jesus. How

Emphasis was on crook

 

[Psychresy]

Once in PP the trick isn't to make that but work sub 35 hours while doing such. Also, with NP's and extenders in my area you can have 5 at full time under you or you can do the newer tech stuff. I have 0 desire to have 5 NPs to break into the upper end. I am much happier with my Sub 35 hour week, no wknd, no holiday, no nights, no call and hitting the numbers i want.

Ultimately, i always would prefer to be the kid who studied the night before the test and got the 90 percent than the guy who studies for weeks to get the 99. You can't buy time. Fools will eventually learn.

How much are you typically able to make off an NP, seeing mix of private insurances?

 

[Mass Effect]

Candidate 2017,

You say GI, cards, surg can easily pull 700k to 1 million with less work than a psychiatrist? Name me one part time surgical specialist or cardiologist?

Pretty sure that poster is saying that in order for a psychiatrist to pull in 700 K - 1 million dollars a year, they'd have to work more than GI, cards, surg. In other words, if you want to make what they make, you need to put in more hours.

 

[myPsychAlt]

I’ve seen multiple crooks see over 100 patients a day in outpatient setting

There have been a couple guys in my area who did the same with inpt + nursing homes. Needless to say they had a reputation for their quality of care long before the feds eventually knocked on their door.

 

[calvnandhobbs68]

We absolutely do not. Across all of Epic, FM bills 99212s 2% of the time.

My personal rate is .23%, the FPs in my hospital system are at 1.3%.

Sure fine correct nobody wants to bill for a 99212 because that would basically require an otherwise healthy person coming in with one minor complaint, so most patients will hit a 99213 as a bare minimum. My point is that in psychiatry most of our patients are on the upper end of a more complicated 99213 vs 99214s for the vast majority of them and the amount of information gathering required to get to those complexity levels is quite a bit longer than 5 minutes. I think I've billed a 99213 like a handful of times in my community clinic which is all uninsured or medicaid patients.

I realize complexity based codes aren't equivalent to time based codes but they're what most people use. So I'd say 5-10 minutes is really not acceptable for any patient seeing a psychiatrist.

 

[BiscoDisco]

So grand take away here is do full time corrections locums plus weekend coverage once or twice a month to get close to there quarter mil which is more than anyone probably actually needs anyways.

Glad this is all clear now.

 

[Psychdoc4755]

Mass Effect,

That’s a broad generalization. I’m not sure how valid of a conclusion that is when there are so many factors to consider (demand in the area, negotiation capabilities)

myPsychAlt,

You mean to tell me that feds are wasting their time taking down psychiatrists who don’t spend enough time with their patients? Don’t you think they have better things to do? Lol I know plenty of doctors who practice like this and have no problems in their day to day lives. People here seem to make it seem as if one deviation from the accepted norm and everything in your life/reputation will come crashing down and you’ll lose everything..

 

[Mass Effect]

Mass Effect,

That’s a broad generalization. I’m not sure how valid of a conclusion that is when there are so many factors to consider (demand in the area, negotiation capabilities)

What was a broad generalization? I've made like 4 comments in this thread. Which one are you objecting to?

myPsychAlt,

You mean to tell me that feds are wasting their time taking down psychiatrists who don’t spend enough time with their patients? Don’t you think they have better things to do?

Yes, they do take down psychiatrists who don't spend enough time with patients because 99% of those folks doing 5 - 10 minutes are practicing bad medicine. Have you not seen it?

Example:
Patient: Doc, I can't concentrate. I think I might have ADHD.
Doc: Here's some Adderall.

6 months later:
Patient: Doc, I still can't concentrate.
Doc: Let's increase dose and add IR to XR to help you out there, sport.

3 months later:
Patient: Doc, I can't sleep. I don't know what to do.
Doc: Let's add some Ambien.

3 months later:
Patient: Doc, I'm jittery and nervous all the time.
Doc: Xanax works wonders. If you like, I'll give you Klonopin tid since it's longer acting and we'll give you Xanax tid for breakthrough.

Feds come knocking and after the clinic is closed for this and multiple other similar cases, the patient has an evaluation done by a competent psychiatrist who determines the only diagnosis is GAD. Patient is started on an SSRI, up-titrated to therapeutic dose. The patient is doing well in his job, sleeping at night, and only sees the psychiatrist once a year.

FYI, the above is a true story.

 

[Psychdoc4755]

Mass Effect,

I'm talking about the post you made today at 8:41 AM

Regarding your example of feds arresting that doctor, you just proved my point. The doctor was arrested for prescribing controlled substances excessively when not needed. I really doubt you will be flagged/harassed by these people if you are spending slightly less time than an average psychiatrist, but still not prescribing the addictive medications. DEA has better things do to then go after doctors who don't take the time each day to talk to each patient extensively about their "feelings" lol

 

[finalpsychyear]

What was a broad generalization? I've made like 4 comments in this thread. Which one are you objecting to?



Yes, they do take down psychiatrists who don't spend enough time with patients because 99% of those folks doing 5 - 10 minutes are practicing bad medicine. Have you not seen it?

Example:
Patient: Doc, I can't concentrate. I think I might have ADHD.
Doc: Here's some Adderall.

6 months later:
Patient: Doc, I still can't concentrate.
Doc: Let's increase dose and add IR to XR to help you out there, sport.

3 months later:
Patient: Doc, I can't sleep. I don't know what to do.
Doc: Let's add some Ambien.

3 months later:
Patient: Doc, I'm jittery and nervous all the time.
Doc: Xanax works wonders. If you like, I'll give you Klonopin tid since it's longer acting and we'll give you Xanax tid for breakthrough.

Feds come knocking and after the clinic is closed for this and multiple other similar cases, the patient has an evaluation done by a competent psychiatrist who determines the only diagnosis is GAD. Patient is started on an SSRI, up-titrated to therapeutic dose. The patient is doing well in his job, sleeping at night, and only sees the psychiatrist once a year.

FYI, the above is a true story.

If there is some basis for using multiple controlled meds, their is no diversion, and urine drug screens are being used their is no basis for what the doctor can do. Fed's come due to diversion issues or docs selling these type of meds if they see a pattern of scripts being sold on the streets from the street. There is a strong reason to give monthly only scripts and document monthly encounters rather than giving 12 months of adderall via multple scripts and 6 mo of xanax via a single script.

 

[Mass Effect]

Mass Effect,

I'm talking about the post you made today at 8:41 AM

Regarding your example of feds arresting that doctor, you just proved my point. The doctor was arrested for prescribing controlled substances excessively when not needed. I really doubt you will be flagged/harassed by these people if you are spending slightly less time than an average psychiatrist, but still not prescribing the addictive medications. DEA has better things do to then go after doctors who don't take the time each day to talk to each patient extensively about their "feelings" lol

Who do you think the feds are? We're talking about the DEA. Of course they're dealing with controlled substances. That's what they do.

Psychiatrists who spend 5 - 10 minutes with their patients send up every red flag imaginable because no, you cannot practice good psychiatry this way in 99% of cases. So yes, if there's a red flag, you're under scrutiny. You don't have to believe me. You're welcome to try it out.

 

[Mass Effect]

Mass Effect,

I'm talking about the post you made today at 8:41 AM

I still don't understand where the generalization was? What am I generalizing? I I said that you want to see 100+ patients a day. You'll have bigger problems than patients being asleep. That's not a generalization.

 

[Mass Effect]

If there is some basis for using multiple controlled meds, their is no diversion, and urine drug screens are being used their is no basis for what the doctor can do. Fed's come due to diversion issues or docs selling these type of meds if they see a pattern of scripts being sold on the streets from the street. There is a strong reason to give monthly only scripts and document monthly encounters rather than giving 12 months of adderall via multple scripts and 6 mo of xanax via a single script.

Feds come for suspicious activity. You have no idea what your patients do when they leave your clinic and if you're prescribing like the doc I noted, you will eventually get that knock on your door.

 

[Psychdoc4755]

Jeeze Mass Effect no need to get upset. I was just pointing out a flaw in your logic that any doctor who likes to spend less time with their patients will get arrested and lose their license due to feds coming knocking lol. Dude, it almost seems like you're arguing that any doctor that doesn't take the time to psychotherapize each patient of theirs for 30 minutes minimum each will have FEDERAL AUTHORITIES coming after them. Dude, that's ridiculous. You are entitled to practice medicine how you see fit with some limitations of course, but your example is far-fetched and unbelievable ESPECIALLY since where I work I see doctors doing it ALL THE TIME with 50+ patient census rounding on inpatients and THERE'S NO FEDERAL INVESTIGATIONS ON THEM. Lol

 

[Psychdoc4755]

Yes God forbid I ever tried to do something ambitious, bold, and significant with my life. I'll send up every "red flag imaginable". Take it from here folks! Don't go chasing dreams because if you do, you'll be arrested by DEA! Ha!

 

[allantois]

Mass Effect,

That’s a broad generalization. I’m not sure how valid of a conclusion that is when there are so many factors to consider (demand in the area, negotiation capabilities)

myPsychAlt,

You mean to tell me that feds are wasting their time taking down psychiatrists who don’t spend enough time with their patients? Don’t you think they have better things to do? Lol I know plenty of doctors who practice like this and have no problems in their day to day lives. People here seem to make it seem as if one deviation from the accepted norm and everything in your life/reputation will come crashing down and you’ll lose everything..

You don’t think defrauding the government is worthy of investigation? It’s not just spending enough time, it’s over-billing, not following CMS documentation guidance, making up patients’ vitals, having every patient follow up every month with no good reason whatsoever, and in some cases improperly prescribing controlled substances without performing an adequate assessment. The place I had in mind never billed for level 2 visit, they most commonly billed for level 4 visits as well as for counseling on every patient because they would check off a few boxes in the EMR without providing any counseling.

 

[VA Hopeful Dr]

Yes God forbid I ever tried to do something ambitious, bold, and significant with my life. I'll send up every "red flag imaginable". Take it from here folks! Don't go chasing dreams because if you do, you'll be arrested by DEA! Ha!

I think you're completely midreading all of this. No one is saying you can't do this. But, if making that much money as a psychiatrist was easy, everyone would do it.

Yes its possible to do, but it either requires shady practice (overbilling), taking no time off ever (see calculations below), or finding a non-clinical something that pays really well. One of these will get you in trouble with the Feds. One will likely burn you out pretty fast. And one is pretty rare.

For instance, let's say you want to make an even million per year. Let's say you can find a gig that pays $250/hr with as many hours as you want. To make 1 million you'll have to work 4,000 hours in a year. If we assume you take no vacations whatsoever, that's 77 hours/week to pull that off.

 

[Psychresy]

Jeeze Mass Effect no need to get upset. I was just pointing out a flaw in your logic that any doctor who likes to spend less time with their patients will get arrested and lose their license due to feds coming knocking lol. Dude, it almost seems like you're arguing that any doctor that doesn't take the time to psychotherapize each patient of theirs for 30 minutes minimum each will have FEDERAL AUTHORITIES coming after them. Dude, that's ridiculous. You are entitled to practice medicine how you see fit with some limitations of course, but your example is far-fetched and unbelievable ESPECIALLY since where I work I see doctors doing it ALL THE TIME with 50+ patient census rounding on inpatients and THERE'S NO FEDERAL INVESTIGATIONS ON THEM. Lol

As an independent observer, you seem far more upset than Mass Effect. I think there is some projecting going on here. Chill brah.

 

[CalmAndCollected]

What was a broad generalization? I've made like 4 comments in this thread. Which one are you objecting to?



Yes, they do take down psychiatrists who don't spend enough time with patients because 99% of those folks doing 5 - 10 minutes are practicing bad medicine. Have you not seen it?

Example:
Patient: Doc, I can't concentrate. I think I might have ADHD.
Doc: Here's some Adderall.

6 months later:
Patient: Doc, I still can't concentrate.
Doc: Let's increase dose and add IR to XR to help you out there, sport.

3 months later:
Patient: Doc, I can't sleep. I don't know what to do.
Doc: Let's add some Ambien.

3 months later:
Patient: Doc, I'm jittery and nervous all the time.
Doc: Xanax works wonders. If you like, I'll give you Klonopin tid since it's longer acting and we'll give you Xanax tid for breakthrough.

Feds come knocking and after the clinic is closed for this and multiple other similar cases, the patient has an evaluation done by a competent psychiatrist who determines the only diagnosis is GAD. Patient is started on an SSRI, up-titrated to therapeutic dose. The patient is doing well in his job, sleeping at night, and only sees the psychiatrist once a year.

FYI, the above is a true story.

Pill mills and insurance fraud in medicine is rampant in many states across the US. I think the other posters are not specifically saying that it can't happen, but that is unlikely to happen generally across the board. Obviously this is location dependent, as places like Miami and NYC have more practices like this that get away with it, but smaller, more tight-nit communities are less likely to put up with it.

In general, I don't think the feds are going to be very interested in bringing down a practice unless there is significant diversion.

 

[Candidate2017]

I doubt this guy had 100 99212/99213 Medicaid patients lined up outside his door.

I doubt that too, though theoretically possible.

As you say, most are going to be of moderate complexity so it makes no sense to down code them and rip through twelve 99212s an hour. Two moderately complex patients an hour also reimburses better than twelve simple patients an hour.

 

[Candidate2017]

You don’t think defrauding the government is worthy of investigation? It’s not just spending enough time, it’s over-billing, not following CMS documentation guidance, making up patients’ vitals, having every patient follow up every month with no good reason whatsoever, and in some cases improperly prescribing controlled substances without performing an adequate assessment. The place I had in mind never billed for level 2 visit, they most commonly billed for level 4 visits as well as for counseling on every patient because they would check off a few boxes in the EMR without providing any counseling.

If you think there was fraud, why don't you contact the authorities instead of posting on an internet board? The amount of fraud you're alleging would surely leave incontrovertible evidence. I hear whistleblowers get rewarded with an amount equal to 10% of the fraud.

 

[allantois]

If you think there was fraud, why don't you contact the authorities instead of posting on an internet board? The amount of fraud you're alleging would surely leave incontrovertible evidence. I hear whistleblowers get rewarded with an amount equal to 10% of the fraud.

I was just a student on rotation. Other students have been complaining to the school for years about that particular rotation. Personally, I’m just trying to graduate without causing anyone any issues. I’ve looked into FBI tip, but it’s not anonymous.

 

[Psychdoc4755]

There’s obviously a preset amount of time you are expected to spend with each patient when you bill for services. I believe for inpatient psychiatry it’s 15 minutes for progress note encounter. Let’s say you worked for 14 hours per day, 7 days a week. That’s 14 x 7 x (4 Billings per hour) = about 400 billing encounters per week. Let’s say you get 50 dollars for every billing (which is around or possibly below average). This comes out to a weekly salary of 20000$ and slightly over 1 million yearly salary. So yes, this is within insurance guidelines and completely legal.

 

[Psychdoc4755]

Hm now that I think about that. That’s kinda low only $200 an hour. There’s definitely better offers out there. I’m sure there’s a way to negotiate/leverage the hospital into compensating you more appropriately for each billing on top of insurance reimbursement or just threaten to leave and force their hand..

 

[calvnandhobbs68]

I doubt that too, though theoretically possible.

As you say, most are going to be of moderate complexity so it makes no sense to down code them and rip through twelve 99212s an hour. Two moderately complex patients an hour also reimburses better than twelve simple patients an hour.

In psychiatry you'd be hard pressed to provide quality care with 10 minute 99214 visits. You can also do 20 minute 99214 followups and still stay viable, given that many psychiatry offices that take Medicaid are community mental health agencies who get additional reimbursement or financial support from the state government.

That's also not true. For instance, primary care survey in my state in 2010-2011 showed Medicaid reimbursed average of $40.38 for a 99213 and $61.24 for a 99214. So if you "downcode" to 99213s and bill for 10 minute f/u 6x 99213 (40.38 *6= $242.28) vs 20 minute f/u 3x 99214 (61.24*3=183.72), you're making more by saying you're seeing twice as many low complexity patients an hour than moderate complexity patients (or throw a moderate code or two in there every hour since that's unlikely to raise any eyebrows).

Also to re-emphasize, moderate complexity in psychiatry tends to just require more discussion than moderate complexity in other specialities. Not to get too far into this but you can easily hit a 10 minute 99214 visit in medicine for seeing someone with 1) Asthma- Mild exacerbation, start albuterol PRN, continue Flovent as ordered, f/u in 2-3 days if no improvement and 2) HTN- BP today 126/76, on lisinopril, no changes today. Bam, two chronic conditions, one with mild exacerbation, moderate decision making and you just have to hit criteria in the history or physical exam section to bill for a 99214.

There was actually just a discussion about this in a psychiatry facebook group I'm in talking about if 15 minute followups are legit in psychiatry and the majority of people felt this was not adequate care except for the absolute most stable patients.

So yes, as has been stated many times on here already, if someone is planning to try to make buttloads of money in psych by just churning through as many patients as possible, they're 99.99% of the time being a crappy doctor. Inpatient side too, we've had this discussion before on here about covering 3 different inpatient units. We all know those guys who come in and round for 5 minutes each on a 30-40 patient unit and start everyone on 3 different meds by the time they're d/c'd with no real reasoning behind it. I've cleaned up those messes on the outpatient side more than once too.

 

[calvnandhobbs68]

There’s obviously a preset amount of time you are expected to spend with each patient when you bill for services. I believe for inpatient psychiatry it’s 15 minutes for progress note encounter. Let’s say you worked for 14 hours per day, 7 days a week. That’s 14 x 7 x (4 Billings per hour) = about 400 billing encounters per week. Let’s say you get 50 dollars for every billing (which is around or possibly below average). This comes out to a weekly salary of 20000$ and slightly over 1 million yearly salary. So yes, this is within insurance guidelines and completely legal.

You gonna round on 56 patients a day and expect to have your notes and everything else completely wrapped up after 14 hours? Anyway, I'm not aware of any pre-specified amount of time people are required to have face to face time with patients on the inpatient side. On the weekends, a lot of those encounters are less than 15 minutes given that you're just making sure the existing patients stay stable.

 

[clausewitz2]

There’s obviously a preset amount of time you are expected to spend with each patient when you bill for services. I believe for inpatient psychiatry it’s 15 minutes for progress note encounter. Let’s say you worked for 14 hours per day, 7 days a week. That’s 14 x 7 x (4 Billings per hour) = about 400 billing encounters per week. Let’s say you get 50 dollars for every billing (which is around or possibly below average). This comes out to a weekly salary of 20000$ and slightly over 1 million yearly salary. So yes, this is within insurance guidelines and completely legal.

This is assuming that you work 14 hours per day 7 days per week with literally no days off for an entire year. Again, patients being asleep is not going to be your biggest problem.

 

[clausewitz2]

You gonna round on 56 patients a day and expect to have your notes and everything else completely wrapped up after 14 hours? Anyway, I'm not aware of any pre-specified amount of time people are required to have face to face time with patients on the inpatient side. On the weekends, a lot of those encounters are less than 15 minutes given that you're just making sure the existing patients stay stable.

Just have a computer on wheels with a webcam following you around connected to one of those virtual scribe services so all your notes can be written by a random person in Davao or Bangalore. You can afford it since you're making a million dollars a year after all. I'm sure there is never any other paperwork any inpatient doc has ever had to do. You're not here to "psychotherapize" patients so who cares if they refuse to engage with you? What could possibly go wrong?

 

[Bartelby]

There’s obviously a preset amount of time you are expected to spend with each patient when you bill for services. I believe for inpatient psychiatry it’s 15 minutes for progress note encounter. Let’s say you worked for 14 hours per day, 7 days a week. That’s 14 x 7 x (4 Billings per hour) = about 400 billing encounters per week. Let’s say you get 50 dollars for every billing (which is around or possibly below average). This comes out to a weekly salary of 20000$ and slightly over 1 million yearly salary. So yes, this is within insurance guidelines and completely legal.

But this presumes that you never do an intake assessment, never deal with emergencies or disruptive behaviors, never coordinate care with anyone, never participate in team discussions, basically never do anything aside from 5-10 mins face to face plus 5 mins to write your note and place orders. Having this many acute inpatients just isn't realistic. Making a high income is great, but remember your ethical obligation to do reasonable quality work. I don't believe you can, for instance, handle 100 acute inpatient beds daily while providing a minimally reasonable level of care.

 

[Marasmus1]

Why does prison offer a higher salary? I look at the market prison psychiatry ads start with minimum 300k base.

I think prison psychiatry is a pretty sh.tty gig considering the patient population you have to deal with, a lot of burocratic tasks, paper work etc. Is it the reason they offer higher salary as an incentive?

 

[Bartelby]

Many people do not want to work in prisons, whether because of safety concerns or because it is a demoralizing place. The patient population also tends to be difficult. Add to that that most prisons are located in remote locations and employers have to pay more than the average health care system would to attract physicians.

 

[Psychdoc4755]

Yes and ultimately this gets into a discussion of building an actual multi-physician practice around this model in the inpatient and outpatient sectors.

Obviously working these hours or whatever close to those hours in the long run and making over a million dollars a year is hard to sustain. But doing it for a few years while expanding your influence in your region seems more feasible.

With that large of a patient panel and referral base, I could bring other docs into the practice and assign them to specific hospitals to round on my patients and also begin to create an outpatient clinic side of things for follow ups. The more docs I bring in, the less actual work I do and the more of a practice owner/manager I am. This is the path to real, significant wealth that many smart physicians take. Why do all the work yourself when you can have other docs do the work and you take a cut for "employing" them.

 

[Mass Effect]

Jeeze Mass Effect no need to get upset. I was just pointing out a flaw in your logic that any doctor who likes to spend less time with their patients will get arrested and lose their license due to feds coming knocking lol. Dude, it almost seems like you're arguing that any doctor that doesn't take the time to psychotherapize each patient of theirs for 30 minutes minimum each will have FEDERAL AUTHORITIES coming after them. Dude, that's ridiculous. You are entitled to practice medicine how you see fit with some limitations of course, but your example is far-fetched and unbelievable ESPECIALLY since where I work I see doctors doing it ALL THE TIME with 50+ patient census rounding on inpatients and THERE'S NO FEDERAL INVESTIGATIONS ON THEM. Lol

Uh, I'm not the one upset. Seems you are given all the shouting in this post.

But just to clarify, not one person on this thread said that every psychiatrist practicing ****ty medicine has the feds knocking on their door. Two of us gave our experiences and in both cases that's what happened. To then extrapolate that we're saying this happens in every single case is faulty and ridiculous. To then turn it around into the rant above is even more ridiculous.

 

[calvnandhobbs68]

Yes and ultimately this gets into a discussion of building an actual multi-physician practice around this model in the inpatient and outpatient sectors.

Obviously working these hours or whatever close to those hours in the long run and making over a million dollars a year is hard to sustain. But doing it for a few years while expanding your influence in your region seems more feasible.

With that large of a patient panel and referral base, I could bring other docs into the practice and assign them to specific hospitals to round on my patients and also begin to create an outpatient clinic side of things for follow ups. The more docs I bring in, the less actual work I do and the more of a practice owner/manager I am. This is the path to real, significant wealth that many smart physicians take. Why do all the work yourself when you can have other docs do the work and you take a cut for "employing" them.

What? Why wouldn’t they just go work for a hospital themselves and cut out the middleman (you). The hospital also has a contract with you even if you’re a 1099 and it doesn’t include some other person coming in to round on your patients. By the time you have to onboard someone with a hospital, they’re asking why don’t they just directly contract with the hospital themselves.

You also don’t really have a “referral base” with inpatient psychiatry. You’d just have 3 inpatient units that you work for and you’d probably be known by the nurses as the crappy doctor who spends 5 minutes with each patient bc they know you have to get to your 2 other gigs. This path is not the path you take towards building a good reputation in an area.

 

[Mad Jack]

I think 40 hours of corrections + maybe one weekend a month wouldn't be that terrible. Definitely FAR FAR FAR better than the ibankers or big law lawyers who work 70-80 hours a week, every week.

Also worth considering...if living/practicing in a state with high income tax is the difference between 700k vs 1M really that big of a difference when accounting for taxes? Didn't crunch the numbers, but I'd venture to guess it's MAYBE an extra 7-9k a month after tax. Nothing to sneeze at, but when you're making that kind of money, I would think time off becomes more important than a couple extra thousand in the bank account each week.

You need a better accountant if that's all you're pulling total after taxes

 

[s109442]

Look up David Cotton. He is ~70 year old OB/Gyn doctor with net worth of about 3 billion. Started a medicaid only practice about 20 years ago in his 50s and sold to a larger healthcare organization a few years ago. I thought everyone on this forum was saying that medicaid practice is non-lucrative? This guy made 3 billion. What's to say a psychiatrist or other specialty can't do that as well?

I'm not trying to name names. But there seems to be a significant amount of misinformation on this forum regarding what you can and can't do and what you can and can't make as a practicing psychiatrist.

I see psych currently as the most underrated specialty in all of medicine. It's not nearly as competitive as it should be (should honestly be ROAD) for 2 reasons:
1. Med students perceive it as "lesser" specialty because it is "psych" and not a real doctor and there could be some family pressures there. So they don't even take the time to research it
2. Salary surveys are largely skewed. Totally unreliable. There's lots of room for significant payment in this field based on how you practice. And for only 4 years of residency with no real requirement to fellowship? It's not a bad deal - on par with derm. On that note, you gotta realize that the average psychiatrist is probably in his 50s/60s and at the end of his career and working part-time so that is what brings the income reports down.

There was a guy on whitecoatinvestor I was just reading about who made over 1M in his first year out of psychiatry residency. But of course, he was hustling like crazy. Personally, I've never heard of being to do that in any other specialty. Even the competitive ones.

It wasn’t a medical practice it was a health insurance company called Meridian Health.

 

[Mass Effect]

You need a better accountant if that's all you're pulling total after taxes

The poster is saying the difference between 700K and 1 million after taxes per month is 7K-9K.

 

[myPsychAlt]

You mean to tell me that feds are wasting their time taking down psychiatrists who don’t spend enough time with their patients?

If you are indeed wrapping up your training, I have concerns about how well you program has educated you on the realities of practice.

 

[Psychdoc4755]

No s109442, it was an HMO with many physicians working within the entity. Please do your homework before making false statements. Lol

And yea, you're right calvinandhobbs. All anyone can ever hope for (based on the presented-as-fact advice from our forums greatest contributors with, to be perfectly honest, way too much time on their hands making forum posts), is a meager 300-400k a year. Any deviation from that is either - you name it?
1. Unrealistic
2. Immoral
3. Unethical
4. Not practical
5. Unlikely
6. ???

Any other suggestions?

And anyone who does pull off reaching into the skies in regards to income/net worth is either - what?
1. Lucky
2. Cheated
3. Had connections
4. ???

Suggest a deviation from the norm and get flammed by a bunch on anons on an online forum even though the anons happen to "allegedly" be doctors. Kinda funny.

Anyways, in the end there will always be the highest earners in any profession and they didn't get there taking crappy, defeatist advice from a bunch of people who didn't pull it off themselves and are trying to externalize their inadequacies to the system at large. Ha