Contract renegotiation opinion/input

[clausewitz2]

Working with a specialized psychotherapy practice on a 1099 basis. Currently getting admin assistance in screening and getting paperwork done for new clients, scheduling new appointments, and generation of some kinds of paperwork (ROIs etc). Got assistance with credentialling and they handle billing the one insurance I take. Doing prior auths myself. No benefits otherwise. Currently on a 70/30 split. I've posted revenue numbers before, but so far working three days a week generating revenue consistently between 15k and 20k per month gross.

I proposed to owner of practice that when contract is up in August we move to 80/20 split based on market research and talking to some other people in similar situations. For what it's worth, there is a therapy group in town that will pay a flat $160 per scheduled hour regardless of no-shows on a similar 1099 basis with a large enough demand that filling quickly would not be a problem. Similarly, agency work around here pays $180 per hour with nursing support, (crappy) EMR provided, help with credentialing etc, handle all billing and triaging phone calls, etc on a 1099 basis. I also started working with these folks expecting to be in a pretty conveniently located office they'd pay for but I haven't set foot in it yet since I started working with them and they are planning to give up the lease and stick with a much more distant location that would turn my commute into a bit of a schlep.

He came back with a change in the split, effectively immediately, that looks like this:

If monthly revenue from 0-18999, I get 75% of gross
If monthly revenue 19000-21999, I get 77% of gross
if monthly revenue 22000+, I get 80% of gross

Still not talking about providing any CME, prior auth assistance, malpractice, or any other kind of benefit. The kicker is he wants a two year contract commitment for this (instead of the current contract, in which I can basically bail any time with 60 days notice and no meaningful non-compete).

For personal reasons I can't really swing a long period of time with a big drop in income right at this moment, probably the inevitable result if I bailed for my own solo practice. If I just took my cash patients along with me I could fill like 1 day a week instead of 3 days a week, and while the vast majority of my insurance folks would probably come with me credentialing takes time. If I went to doing this practice four days a week I would have no trouble hitting 22k monthly which I am inclined to do when one of my side gigs' contract is up in August. My inclination is to push back on the length of the commitment he wants and say I'll commit to a year. If he wants 2 I think I'll insist they pick up malpractice. If he won't go for either I think a flat 80% is my line in the sand.

He talks about trying to buy into a group health insurance policy at some point but hasn't set it up yet and I'm not going to rely on that.

What does the hivemind think? Any suggestions about things to haggle for in case he won't budge on these things that might still make it worth it for me?

All inputs and suggestions welcome. I like the patient population and the clinical work is great, but I do have bills to pay.

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[psychacad]

Is the new offer W2 or 1099? A 2 year commitment on 1099 is playing it dangerously on his part. If he's audited they might determine that the contract is illegal, as you're supposed to set your own hours, own rates..etc as an independent contractor.

Personally I would stay with him with the least restrictive contract available while building my practice on the side, if this is an option. I'd prioritize that over 80/20 vs 70/30. This is why it's difficult to stay in this kind of arrangement for a long term.

 

[Merovinge]

If I'm doing the math right and you average 17.5k/month gross, x 12 months/year, x 5/3 (for full-time vs 3 days/week as you are now) x 0.8 (for his 20%), you come out to 280k/year on 1099 income, which is about 250k/month ish on W2. That is to say the position pays pretty poorly, so there needs to be something for you either in flexibility, hours, potential to shift to own practice or something that makes it worthwhile.

If you are planning to start your own practice but need more time with stable income, I would definitely push back on contract length and hold steady at 1 year. You're worst case scenario of doing work at $160/180/hour will pay similarly to your current position and then you can jump back out whenever you are ready in your life for the practice.

 

[Sushirolls]

1099 is on the way out. Very, very rarely, can 1099 pass the muster as 1099. The majority, especially in health care is really W2 work and I've seen docs sue, after the fact and had settlements for the mislabeling as a 1099.

In summary for my little practice if I ever hire, it will never be a 1099 offer. Despite the many positives of what 1099 work is.

If you try to venture off, you'll want to consider offering those insured patients free care until the insurance panel kicks in. Not worth having to try and re-learn that many patients nor give up that many higher paying insured patients when going out solo.

I have no vote on what you should do. Too much gray, and not enough knowledge about your circumstances to guide you in any direction. With the excpetion that if you are going to open your own place, best to have less strings attached, less time based contracts to facilitate a quick pivot.

 

[Stagg737]

Sounds like you know what you're doing, questions I'd have though are how much of your time do prior auths currently take up? Also, would the new contract have a non-compete included? There are better responses above, but I'd like to know what the full limitations of the contract are as well as how much work you'll actually be putting in.

 

[clausewitz2]

Is the new offer W2 or 1099? A 2 year commitment on 1099 is playing it dangerously on his part. If he's audited they might determine that the contract is illegal, as you're supposed to set your own hours, own rates..etc as an independent contractor.

Personally I would stay with him with the least restrictive contract available while building my practice on the side, if this is an option. I'd prioritize that over 80/20 vs 70/30. This is why it's difficult to stay in this kind of arrangement for a long term.

I definitely do set my own hours and own rates. Scheduling intakes (usually people coming from my PT today profile directly to me) involves me telling the admin person "here are the hours I want to work", and then if there are any new folks she tries to fit them in available 60 minute gaps. I schedule all follow-ups myself. I do also decide my own rates, though obviously for insurance folks the insurer decides what I actually get paid. Cash patients pay full freight for what I have determined I will charge. I will retain that power regardless. I am very confident of my ability to justify my status as a contractor, I don't really resemble an employee, much in the same way that hiring a yard service on a yearly contract does not make them your employee.

If I'm doing the math right and you average 17.5k/month gross, x 12 months/year, x 5/3 (for full-time vs 3 days/week as you are now) x 0.8 (for his 20%), you come out to 280k/year on 1099 income, which is about 250k/month ish on W2. That is to say the position pays pretty poorly, so there needs to be something for you either in flexibility, hours, potential to shift to own practice or something that makes it worthwhile.

If you are planning to start your own practice but need more time with stable income, I would definitely push back on contract length and hold steady at 1 year. You're worst case scenario of doing work at $160/180/hour will pay similarly to your current position and then you can jump back out whenever you are ready in your life for the practice.

Full-time at one of the big agencies in town is 237k as of last year on a W2. The math is wrong, I think; those numbers

1099 is on the way out. Very, very rarely, can 1099 pass the muster as 1099. The majority, especially in health care is really W2 work and I've seen docs sue, after the fact and had settlements for the mislabeling as a 1099.

In summary for my little practice if I ever hire, it will never be a 1099 offer. Despite the many positives of what 1099 work is.

If you try to venture off, you'll want to consider offering those insured patients free care until the insurance panel kicks in. Not worth having to try and re-learn that many patients nor give up that many higher paying insured patients when going out solo.

I have no vote on what you should do. Too much gray, and not enough knowledge about your circumstances to guide you in any direction. With the excpetion that if you are going to open your own place, best to have strings attached, less time based contracts to facilitate a quick pivot.

If I am going to do private practice for real I think I am going to stick to self-pay exclusively. So much overhead vanishes without insurance and there is a more robust market for this than I anticipated before starting this gig. As i said, if I bailed today and brought my self-pay folks with me, I would fill a day a week off the bat. I don't know why they'd stay (they almost universally made inquiries directly to me about becoming patients, generally don't see therapists from the practice, and have never actually physically been to any of those offices so I can't imagine they're especially sentimental about it).

I always hate agreeing with @sluox but they are 100% correct about there being a lot of demand for really high quality and thoughtful pharmacotherapy +/- evidence-based therapies.

DoL has issued opinions saying that 1099 contractors can be offered group health insurance benefits without endangering their contractor status, though it seems a lot of insurers aren't so keen.

Sounds like you know what you're doing, questions I'd have though are how much of your time do prior auths currently take up? Also, would the new contract have a non-compete included? There are better responses above, but I'd like to know what the full limitations of the contract are as well as how much work you'll actually be putting in.

Because of the population I work with about 60% of my prior auths I simply don't fill out because they are never successful for this particular treatment but it is well-established and goodrx makes it super cheap so patients usually don't mind paying out of pocket. I would say I spent maybe 30 minutes or less a week with prior auths.

My current non-compete is extremely anemic; basically, when i terminate with them for the next 60 days I can't open or work for a practice within 10 miles that advertises a specific specialization or special focus on a particular set of disorders. This basically blocks me from working with the other specialty clinic that does this work in town but nobody else. I don't anticipate this being an issue and am certainly not going to stand for it being strengthened.

 

[Sushirolls]

Let's flip the question. What's keeping you from opening your cash practice today?

 

[clausewitz2]

Let's flip the question. What's keeping you from opening your cash practice today?

Fair.

1) Hours in the day. I am working five days a week at present. I can't reliably commit to regular weekends due to other obligations; same is true with evenings. To migrate to cash practice I need to cut back somewhere, which means problems with

2) Money. Significant income hit for more than a month would be unsustainable at present. I hope to be able to change that in the near-to-medium term but certainly in the next, say, 3 months, no way.

3) Marketing. I don't have much of an internet presence beyond PT and their website. I know I can build such a thing, and probably will in the near term, but it won't happen overnight.

I do have a major advantage, though, come to think; I use Luminello under an account I control and no one else in the practice does; I also am the one whose name is on the BAA (or rather my LLC is). This means I could migrate my patient records effortlessly (just remove admin access for the administrator, bam, done).

To people asking what advantages this gig has: flexibility is huge - I don't want to or can't work some particular hours, bam, done, I just block myself off at those times and I'm set. I also get to entirely determine my appointment lengths (I want to see someone for a second one hour appointment after a particularly complex initial consultation to clarify things more, I just put it on the schedule so long as I am good losing the money I would have earned by fitting another appointment in). Also, if I want to see someone for therapy primarily, I just do it. I think I have reached the point where I am only going to be offering full-fat hour-long psychotherapy to cash pay clients, though.

 

[Sushirolls]

I do have a major advantage, though, come to think; I use Luminello under an account I control and no one else in the practice does; I also am the one whose name is on the BAA (or rather my LLC is). This means I could migrate my patient records effortlessly (just remove admin access for the administrator, bam, done).

Just beautiful.

Seems to me, pushing on the negotiations may not be worth it. Just keep doing what you are doing and then flip the switch when the timing is right?

 

[clausewitz2]

Seems to me, pushing on the negotiations may not be worth it. Just keep doing what you are doing and then flip the switch when the timing is right?

This is probably my BATNA.

 

[finalpsychyear]

I wouldn't commit to 2 years for 10 percent more. There is a very simple solution of what one of my colleagues did since he has a similar set up and no non compete. He started all the prep work and credentialing for his own PP several months before he called it quits. He increased his hours at the current job 6 mo prior to quitting and gobbled up a full 4 day a week practice. He then funneled everyone carefully into his own PP and went from collecting 70/30 to 100%. Good luck..

 

[Stagg737]

I wouldn't commit to 2 years for 10 percent more. There is a very simple solution of what one of my colleagues did since he has a similar set up and no non compete. He started all the prep work and credentialing for his own PP several months before he called it quits. He increased his hours at the current job 6 mo prior to quitting and gobbled up a full 4 day a week practice. He then funneled everyone carefully into his own PP and went from collecting 70/30 to 100%. Good luck..

Wouldn't the 60 day non-compete be a problem if he's siphoning patients from that clinic to his? Idk the legality or how enforceable it would actually be, but poaching seems a little shady even if it's your own patients.

 

[clausewitz2]

Wouldn't the 60 day non-compete be a problem if he's siphoning patients from that clinic to his? Idk the legality or how enforceable it would actually be, but poaching seems a little shady even if it's your own patients.

The current non-compete does not contain any language prohibiting solicitation of employees or clients/patients. It also makes it clear I am responsible for providing and maintaining EMR, which I did, so they can't argue they get to keep the records for contractual reasons. I might feel bad about poaching if there was another psychiatrist there who could conceivably pick some of these folks up but if I leave and they didn't come with me they'd sort of be SOL and have to find a new psychiatrist somewhere else regardless.

 

[clausewitz2]

Update:

I told practice owner I would not be accepting his offer, laid out my reasons why I thought 80 percent was fair. He agreed to immediately increase my cut to 80% effective next paycheck and extending for one year period from today. I conceded nothing, essentially.

Don't undervalue yourselves out there on the job market, folks. Thanks to all y'all who replied in public and in private, very helpful.

 

[calvnandhobbs68]

Update:

I told practice owner I would not be accepting his offer, laid out my reasons why I thought 80 percent was fair. He agreed to immediately increase my cut to 80% effective next paycheck and extending for one year period from today. I conceded nothing, essentially.

Don't undervalue yourselves out there on the job market, folks. Thanks to all y'all who replied in public and in private, very helpful.

Very solid. Good example of him coming back with something that seems like a concession but was actually willing to go all the way to that 80%.

 

[clausewitz2]

Very solid. Good example of him coming back with something that seems like a concession but was actually willing to go all the way to that 80%.

For me it also highlights the importance of having other options. I was able to say 'i will walk in August if we can't work this out' as a simple statement of fact about a situation I wanted to figure out a solution to, rather than empty bluster.

 

[Merovinge]

For me it also highlights the importance of having other options. I was able to say 'i will walk in August if we can't work this out' as a simple statement of fact about a situation I wanted to figure out a solution to, rather than empty bluster.

It's very helpful to read this, I am looking at a position that would be a roughly 75/25 split with similar infrastructure for my 25% (i.e. office space, limited use of secretary to collect payment, EMR, HIPAA secure online video session app), however this would be with a senior clinician with decades of experience running a cash practice who would assist with clinical and business supervision as well as help with referrals. Definitely makes me feel better about the setup comparing to what others are seeing.

 

[Stagg737]

Update:

I told practice owner I would not be accepting his offer, laid out my reasons why I thought 80 percent was fair. He agreed to immediately increase my cut to 80% effective next paycheck and extending for one year period from today. I conceded nothing, essentially.

Don't undervalue yourselves out there on the job market, folks. Thanks to all y'all who replied in public and in private, very helpful.

Congrats! Glad things worked out and thanks for starting this thread. It's always good to get some insight into the real world and how to navigate it.

 

[FlowRate]

I might feel bad about poaching if there was another psychiatrist there who could conceivably pick some of these folks up but if I leave and they didn't come with me they'd sort of be SOL and have to find a new psychiatrist somewhere else regardless.

Don't undervalue yourselves out there on the job market, folks. Thanks to all y'all who replied in public and in private, very helpful.

I was about to say that it sounds like you have no competition and, rather, would potentially have a built-in referral stream from that psychotherapy practice since they know you do good work with specialized patients. Is there a compelling reason they'd try to pick up an internal 1099 psychiatrist again, rather than refer out to you?

 

[Sushirolls]

I was about to say that it sounds like you have no competition and, rather, would potentially have a built-in referral stream from that psychotherapy practice since they know you do good work with specialized patients. Is there a compelling reason they'd try to pick up an internal 1099 psychiatrist again, rather than refer out to you?

Spite. If separation or renegotiations left a sour taste in their mouth is my guess.

 

[clausewitz2]

Update:

First month of 80/20 split. I was paid for a total of 56.5 patient contact hours.

18 hours of new evals:
99204 - 15
99205 - 3

38.5 hours of follow-ups:
99213 - 5
99214 - 70
99215 - 2


Vast majority had psychotherapy add-on codes, typically 90833. This month, two new cash pay evals and 12 cash pay follow ups.

This month my share of the gross was a smidge higher than 15k.

I worked 9 days at this job last month from 8 to 4 PM, typically with a half hour lunch break. I have two regular therapy clients who I see outside of those hours (gotta love tele). I also took an entire week off from this job last month and the insurance billings had only caught up through mid-February but did include about half of the encounters in the last two weeks of January. Thus I expect to dip a bit next month but not sure how much yet; I have already had 37 patient contacts in March so far so am busier than I was at the beginning of last month.

I am confirmed in my decision to stop seeing insurance clients for therapy; I will keep the few l have moving forward but for anyone new therapy is for private pay at $300 an hour. When my take of the average half hour encounter is ~150 and my take of 99214+90838 from insurance is ~215, it is hard to justify not splitting the hour between two different patients encounters.

My next new patient slot is available March 29th and even if I really wanted to squeeze someone in during regular hours it wouldn't be possible until the 22nd.

Conclusions:

When lowest-paying CMHC side job comes up for renewal in the summer, they are going to go to $180 an hour or I'm Audi 5000. I would make as much before lunch sitting in my home office as they are paying me now for a full day + 30 minute each way commute.

I could live pretty comfortably if I just quit all my side jobs if this keeps up.

Will keep working the specialty grant-funded side job but it is way less urgent that they bump me up from 6 hours per week.

Making my regular lunch break 60 minutes instead of a half-hour is a major improvement for my own mental health and makes me feel way less crispy at the end of the day.

Private practice is the best.

 

[Old&InTheWay]

Making my regular lunch break 60 minutes instead of an hour is a major improvement for my own mental health and makes me feel way less crispy at the end of the day.

Even though it does sound like more, 60 minutes actually is the same as 1 hour. But good on you if this reframe makes you feel better.

 

[clausewitz2]

Even though it does sound like more, 60 minutes actually is the same as 1 hour. But good on you if this reframe makes you feel better.

I am going to edit it above, but meant I was originally taking half an hour.

 

[Merovinge]

I could live pretty comfortably if I just quit all my side jobs if this keeps up.

Will keep working the specialty grant-funded side job but it is way less urgent that they bump me up from 6 hours per week.

Making my regular lunch break 60 minutes instead of a half-hour is a major improvement for my own mental health and makes me feel way less crispy at the end of the day.

Private practice is the best.

Do you prefer working at the mix of practices you have right now or would you ideally be 100% PP if the patient population was there? I'm trying to decide splitting my time with a PHP/IOP and PP versus going all into PP, seems like a lot of things to consider when deciding how to fill the week.

 

[finalpsychyear]

Do you prefer working at the mix of practices you have right now or would you ideally be 100% PP if the patient population was there? I'm trying to decide splitting my time with a PHP/IOP and PP versus going all into PP, seems like a lot of things to consider when deciding how to fill the week.

If you have the volume I wouldn't even blink at going full time PP. Now some who want to work even more will do the PHP/IOP outside of their PP hours. Not for me but to each their own. For me the flexibility is priceless but the other part is a definite plus.

 

[hebel]

Awesome work. Am I correct in that if you extrapolate this out, you could gross 40-45k per month if you did this full time?

Why are you doing E/M codes for initial evals instead of the 90792? I assume it's because you are doing psychotherapy add-on codes with the 99204/05's?

Ever think of doing a hybrid billing scheme for therapy patients? Bill the insurance and just have them pay cash for the difference from $300/hr?

 

[AD04]

@clausewitz2

Excellent update. What do you do for marketing and what is your best source of referral? And what is your no-show rate and how do you keep that down?

 

[clausewitz2]

Do you prefer working at the mix of practices you have right now or would you ideally be 100% PP if the patient population was there? I'm trying to decide splitting my time with a PHP/IOP and PP versus going all into PP, seems like a lot of things to consider when deciding how to fill the week.

I would like ideally to be doing PP and one to one and a half days a week doing my more specialized side gig because I really like the population and the treatment model. It scratches that multidisciplinary treatment team itch for me and I'm not even sure I'd walk if the pay decreased slightly. It helps that in that position I have multiple other clinicians running interference for me so rarely ever have to deal with anything outside of my working hours. They also pay for me to attending relevant trainings and supervision with national experts in the area so it's pretty great.

I like IOP work and I could definitely see the appeal of splitting like that.

The patient population is definitely there should I want to go 100% PP. If I opened up another day this very week I think it would be reasonably full (i.e. seeing at least 8 patients per day) in perhaps two months at most, much sooner if I decided to open the new patient floodgates and was willing to see more than 2 new intakes per day or took on some more therapy clients with insurance.

 

[clausewitz2]

Awesome work. Am I correct in that if you extrapolate this out, you could gross 40-45k per month if you did this full time?

Why are you doing E/M codes for initial evals instead of the 90792? I assume it's because you are doing psychotherapy add-on codes with the 99204/05's?

Ever think of doing a hybrid billing scheme for therapy patients? Bill the insurance and just have them pay cash for the difference from $300/hr?

If I was doing 40 hours of patient encounters per week with 100% show rate and only 30 minute follow-ups, yes that is a reasonable estimate of what I would gross. I don't think any of those assumptions are sustainable for me but I also like to do things other than work.

Yes, I am using E/M codes for initial evals because I am doing add-on codes for virtually all of them. Definitely better reimbursed than 90792 from my payer and with new MDM standards I can't imagine ever billing a 99203 for someone who actually wants to see a psychiatrist for a legitimate reason.

I hadn't thought about doing a billing scheme like that. I would have to make sure my contract with the payer doesn't forbid that. It also doesn't sit quite right with me and feels somewhat sleazy somehow. I think to make that work I would need to be putting more effort into marketing/advertising to build a brand and omg I get nauseous even typing that.

 

[clausewitz2]

@clausewitz2

Excellent update. What do you do for marketing and what is your best source of referral? And what is your no-show rate and how do you keep that down?

Marketing is a) profile on practice website b) Psychology Today profile and c) listed business on google maps with address of notional office that I have still never set foot in. That is the sum total. PT is my greatest referral source as such. I have a smattering of referrals from random therapists I have never heard of who I assume just found me looking in an insurance database. Maybe 5% of my caseload is people referred from the group practice. I get maybe one a month referred from IOP/PHP where I trained and in at least one memorable instance someone was referred to me from inpatient as their discharge plan without notifying me of this fact.

No-show rate is on average perhaps 10%, 15% in a bad week? We charge $100 for people who cancel with less than 24 hours notice and full freight for a no-show appointment. I typically will waive this the first time it happens if people are willing to reschedule or in a couple of unusual cases of extremely exigent circumstances but we enforce it otherwise. This tends to curtail this problem nicely. This works because we have CC on file before first appointment. This does mean that I will charge someone my full hour fee who arranged an initial consultation, no-showed, and doesn't respond to attempts to reschedule them. I am sure I could be fuller faster if I didn't have this policy but my no-show rate would also be higher. Most of my patients who have been charged don't seem especially upset about it and I have only lost one person because they had strong feelings about this policy, but they were not terribly invested in treatment to begin with.

 

[capsychiatrist]

Update:

First month of 80/20 split. I was paid for a total of 56.5 patient contact hours.

18 hours of new evals:
99204 - 15
99205 - 3

38.5 hours of follow-ups:
99213 - 5
99214 - 70
99215 - 2


Vast majority had psychotherapy add-on codes, typically 90833. This month, two new cash pay evals and 12 cash pay follow ups.

This month my share of the gross was a smidge higher than 15k.

I worked 9 days at this job last month from 8 to 4 PM, typically with a half hour lunch break. I have two regular therapy clients who I see outside of those hours (gotta love tele). I also took an entire week off from this job last month and the insurance billings had only caught up through mid-February but did include about half of the encounters in the last two weeks of January. Thus I expect to dip a bit next month but not sure how much yet; I have already had 37 patient contacts in March so far so am busier than I was at the beginning of last month.

I am confirmed in my decision to stop seeing insurance clients for therapy; I will keep the few l have moving forward but for anyone new therapy is for private pay at $300 an hour. When my take of the average half hour encounter is ~150 and my take of 99214+90838 from insurance is ~215, it is hard to justify not splitting the hour between two different patients encounters.

My next new patient slot is available March 29th and even if I really wanted to squeeze someone in during regular hours it wouldn't be possible until the 22nd.

Conclusions:

When lowest-paying CMHC side job comes up for renewal in the summer, they are going to go to $180 an hour or I'm Audi 5000. I would make as much before lunch sitting in my home office as they are paying me now for a full day + 30 minute each way commute.

I could live pretty comfortably if I just quit all my side jobs if this keeps up.

Will keep working the specialty grant-funded side job but it is way less urgent that they bump me up from 6 hours per week.

Making my regular lunch break 60 minutes instead of a half-hour is a major improvement for my own mental health and makes me feel way less crispy at the end of the day.

Private practice is the best.

I am brand new to considering private practice and am wondering if someone can explain this. I was thinking that if you were credentialed with an insurance company that you were required to take their insurance for any patients who have that insurance and not able to see them for a cash pay rate. Or is this just for Medicare/Medicaid and not for private insurance?

For example, if I work at a CSU on certain days and am credentialed through Blue Cross and other types of insurance through a group practice, could I work 1 day a week at a cash pay solo practice?

 

[clausewitz2]

I am brand new to considering private practice and am wondering if someone can explain this. I was thinking that if you were credentialed with an insurance company that you were required to take their insurance for any patients who have that insurance and not able to see them for a cash pay rate. Or is this just for Medicare/Medicaid and not for private insurance?

For example, if I work at a CSU on certain days and am credentialed through Blue Cross and other types of insurance through a group practice, could I work 1 day a week at a cash pay solo practice?

You are credentialed with particular insurance companies at a (notional) particular address. If you see them someplace else, the insurance company will not pay you and obviously you needn't accept the policy. Medicare/Medicaid is unique in the 'all out or still in' requirement.

 

[Sushirolls]

Private insurance is linked to you by Tax ID # and location (+/- Type II NPI number).
If both don't match, you are not in network.

For instance I have my business tax ID number that is associated with my type II NPI and my type I NPI. If I go and open up another office in another location, my Tax ID number and my NPI will all be in network - but my new practice address won't be *CLAIM DENIED*.
Remedy: add that location to that contract

If I decide to moonlight at a for profit psych hospital, they will add my to all their private insurance contracts. They submit a claim with their type II NPI, my type I NPI and their Tax ID number *CLAIM ACCEPTED*

I go out of state to cover for a cash pay Pyschiatrist who is on vacation for a week, and I see a bunch of patients there that have private insurance I am network with my practice, doesn't matter. Different practice location, and if the patient submitted a master bill claim on their own *CLAIM ACCEPTED, but as out of network provider*

 

[capsychiatrist]

You are credentialed with particular insurance companies at a (notional) particular address. If you see them someplace else, the insurance company will not pay you and obviously you needn't accept the policy. Medicare/Medicaid is unique in the 'all out or still in' requirement.

Awesome, thank you!

 

[capsychiatrist]

Private insurance is linked to you by Tax ID # and location (+/- Type II NPI number).
If both don't match, you are not in network.

For instance I have my business tax ID number that is associated with my type II NPI and my type I NPI. If I go and open up another office in another location, my Tax ID number and my NPI will all be in network - but my new practice address won't be *CLAIM DENIED*.
Remedy: add that location to that contract

If I decide to moonlight at a for profit psych hospital, they will add my to all their private insurance contracts. They submit a claim with their type II NPI, my type I NPI and their Tax ID number *CLAIM ACCEPTED*

I go out of state to cover for a cash pay Pyschiatrist who is on vacation for a week, and I see a bunch of patients there that have private insurance I am network with my practice, doesn't matter. Different practice location, and if the patient submitted a master bill claim on their own *CLAIM ACCEPTED, but as out of network provider*

Thank you, this is very helpful!

 

[TexasPhysician]

Update:

I told practice owner I would not be accepting his offer, laid out my reasons why I thought 80 percent was fair. He agreed to immediately increase my cut to 80% effective next paycheck and extending for one year period from today. I conceded nothing, essentially.

Don't undervalue yourselves out there on the job market, folks. Thanks to all y'all who replied in public and in private, very helpful.

Thats a high %. You did really well.

From an overhead perspective on an insurance practice:
Credit card fees are 2-4% of gross
Billing services outsourced are usually 5-7% of gross.
I assume you are getting dedicated space. If not also subleased when you are absent, a low estimate of value is $1,000 per month of cost. Generating $20k/month would put owner cost at 5% overhead.

Office staff numbers are hard to estimate, but psychiatric patients require much more assistance compared to hourly therapy patients that come 2-4x/month. Unless outsourced overseas, a 0.5 share of 1 office staff is minimum $1500/month for a half-time psychiatrist. That’s a 7.5% overhead on $20k gross.

The owner must be finding significant cost savings somewhere or the internal referrals are greatly helping with expansion or something.

 

[clausewitz2]

Thats a high %. You did really well.

From an overhead perspective on an insurance practice:
Credit card fees are 2-4% of gross
Billing services outsourced are usually 5-7% of gross.
I assume you are getting dedicated space. If not also subleased when you are absent, a low estimate of value is $1,000 per month of cost. Generating $20k/month would put owner cost at 5% overhead.

Office staff numbers are hard to estimate, but psychiatric patients require much more assistance compared to hourly therapy patients that come 2-4x/month. Unless outsourced overseas, a 0.5 share of 1 office staff is minimum $1500/month for a half-time psychiatrist. That’s a 7.5% overhead on $20k gross.

The owner must be finding significant cost savings somewhere or the internal referrals are greatly helping with expansion or something.

Practice only accepts one insurance and billing is not very effortful, so the admin/receptionist/staff person can handle all of it. Cost is also split over me and five therapists.

Office space is kind of notional, i do not have a dedicated space but then have been 100% tele with this job. Our one payor has indicated they intend to keep reimbursing tele at full parity so they actually plan to cut back on office space. A lot of the therapy patients are also private pay (it's a very specialized therapy they offer so their cash waiting list is months long).

 

[calvnandhobbs68]

Thats a high %. You did really well.

From an overhead perspective on an insurance practice:
Credit card fees are 2-4% of gross
Billing services outsourced are usually 5-7% of gross.
I assume you are getting dedicated space. If not also subleased when you are absent, a low estimate of value is $1,000 per month of cost. Generating $20k/month would put owner cost at 5% overhead.

Office staff numbers are hard to estimate, but psychiatric patients require much more assistance compared to hourly therapy patients that come 2-4x/month. Unless outsourced overseas, a 0.5 share of 1 office staff is minimum $1500/month for a half-time psychiatrist. That’s a 7.5% overhead on $20k gross.

The owner must be finding significant cost savings somewhere or the internal referrals are greatly helping with expansion or something.

Insurance companies don’t pay you via credit card so you’re only getting dinged CC fees (possibly) on the patient portion of payments for those patients who do pay by credit card.

If billing services are split between multiple providers in house, that can come out to a lot less than 5-7% gross. You can easily have one billing person for 10 providers. Therapy billing also tends to be pretty simple with less patients per day (there’s only like 5 codes they use and none of it is anywhere near as complex as E+M codes) so they can handle a lot more therapists if those are being submitted to insurance. If they don’t take insurance, the only work is keeping track of who still owes money.

I don’t get why a half time psychiatrist would need a whole half time office staff member. It’s not 1:1, an office staff member can easily be split between 3-4 full time psychiatrists + some therapists.

 

[TexasPhysician]

Insurance companies don’t pay you via credit card so you’re only getting (possibly) dinged CC fees (possibly) on the patient portion of payments for those patients who do pay by credit card.

If billing services are split between multiple providers in house, that can come out to a lot less than 5-7% gross. You can easily have one billing person for 10 providers. Therapy billing also tends to be pretty simple with less patients per day (there’s only like 5 codes they use and none of it is anywhere near as complex as E+M codes) so they can handle a lot more therapists if those are being submitted to insurance. If they don’t take insurance, the only work is keeping track of who still owes money.

I don’t get why a half time psychiatrist would need a whole half time office staff member. It’s not 1:1, an office staff member can easily be split between 3-4 full time psychiatrists + some therapists.

Ive got 3 psychiatrists and no insurance accepted. We have 4 staff. They do perform PA’s which this group doesn’t. A counselor can be full with 40-60 patients. Psychiatrists have hundreds to thousands. They get vitals, schedule, get new cc’s, ensure new patient paperwork is completed, handle ROI’s, send clinicals, take down questions, navigate Rx problems with pharmacies/patients, etc. While 1 staff can probably handle 10 counselors, I wouldn’t be able to operate efficiently without 1 FT staff myself and that isn’t even me hitting 35 hrs/week of patients. I don’t do non-clinical stuff many weeks though.

 

[SourceOfDenial]

Ive got 3 psychiatrists and no insurance accepted. We have 4 staff. They do perform PA’s which this group doesn’t. A counselor can be full with 40-60 patients. Psychiatrists have hundreds to thousands. They get vitals, schedule, get new cc’s, ensure new patient paperwork is completed, handle ROI’s, send clinicals, take down questions, navigate Rx problems with pharmacies/patients, etc. While 1 staff can probably handle 10 counselors, I wouldn’t be able to operate efficiently without 1 FT staff myself and that isn’t even me hitting 35 hrs/week of patients. I don’t do non-clinical stuff many weeks though.

A counselor seeing 40-60 people?! This a community mental health center? That’s twice to three times the normal patient load of just about every private practice FT therapist I know.

 

[clausewitz2]

Ive got 3 psychiatrists and no insurance accepted. We have 4 staff. They do perform PA’s which this group doesn’t. A counselor can be full with 40-60 patients. Psychiatrists have hundreds to thousands. They get vitals, schedule, get new cc’s, ensure new patient paperwork is completed, handle ROI’s, send clinicals, take down questions, navigate Rx problems with pharmacies/patients, etc. While 1 staff can probably handle 10 counselors, I wouldn’t be able to operate efficiently without 1 FT staff myself and that isn’t even me hitting 35 hrs/week of patients. I don’t do non-clinical stuff many weeks though.

Maybe that's the issue. I see almost all of my patients for 30 minute f/u visits and have 3-4 weekly psychotherapy clients at any time, so my panel is fairly full for 30-odd hours per week with a bit under 200 patients. Most of the f/u's are monthly. I do do my own PAs and my own f/u scheduling (later by my choice). I also handle Rx stuff, but with 200-odd it's not that bad.

 

[TexasPhysician]

A counselor seeing 40-60 people?! This a community mental health center? That’s twice to three times the normal patient load of just about every private practice FT therapist I know.

PP counselors generally see most patients every 1-2 weeks with some 1x/month. To fill 30 clinic hours per week, you will need over 40 patients.

 

[clausewitz2]

PP counselors generally see most patients every 1-2 weeks with some 1x/month. To fill 30 clinic hours per week, you will need over 40 patients.

Literally all of the PP therapists I know see people either weekly or twice per week. I imagine we are talking about therapists serving very different populations.

 

[PsyDr]

PP counselors generally see most patients every 1-2 weeks with some 1x/month. To fill 30 clinic hours per week, you will need over 40 patients.

Evidence based psychotherapies, such as CBT, are generally administered once per week.

 

[SourceOfDenial]

PP counselors generally see most patients every 1-2 weeks with some 1x/month. To fill 30 clinic hours per week, you will need over 40 patients.

I don’t think seeing patients monthly counts as ‘therapy’, but maybe that’s just me.

 

[calvnandhobbs68]

I don’t think seeing patients monthly counts as ‘therapy’, but maybe that’s just me.

I mean maintenance CBT can be like that but not indefinitely.

 

[TexasPhysician]

I don’t think seeing patients monthly counts as ‘therapy’, but maybe that’s just me.

The definition of “therapy” is probably best for another thread as it could be lengthy. E&M considers 16 minutes therapy with medication.

 

[hebel]

Yeah, I've seen a lot of employed therapist have panels approaching 80-90 "clients" who they often see monthly.

They don't like it, and it's not good for patients. But admin and regulators don't seem to care because it looks like patients have faster "access" to care even if the quality of care is jeopardized.

 

[Therapist4Chnge]

Yeah, I've seen a lot of employed therapist have panels approaching 80-90 "clients" who they often see monthly.

They don't like it, and it's not good for patients. But admin and regulators don't seem to care because it looks like patients have faster "access" to care even if the quality of care is jeopardized.

I have heard Kaiser does this and it is common in the VA (obv a little diff patient pop). Once a month is usually a waste, but that's a discussion for another day.

 

[PsyDr]

The definition of “therapy” is probably best for another thread as it could be lengthy. E&M considers 16 minutes therapy with medication.

I don’t know how E&M codes apply to the subject of PP counselors, who cannot use E&M codes.