Psych NPs Patient Schedules - Is this the norm?

[mangopeach]

Psych Eval is 1 hr and Med management is 20 mins - I get that  this is standard at most places.  However is every bit of your time booked to see patients?

So 8:00 am, 8:20 am, 8:40 am, 9:00 am and so forth.  No time in between?  

 I've been practicing for one year and some days I feel like I am being taken advantaged of. If patient A is supposed to get 20 mins that ends at 8:20  - By the time they are out of the office and patient B is in the office its 8:22 or 8:23. We are still working remotely but things can sometimes get even worse with doing things remotely because some patients have technical issues that can put us behind. Am I being petty here, or is this the norm?  

[myoglobin, ASN, BSN, MSN]

I don't see why. It's just math. I pay 30% of my insurance intake and a $600.00 per month fee for the services of insurance billing, scheduling, and taking care of intake forms.  The insurances that I take include Medicare, Cigna, Premera, Kaiser and many others.  If I am successful in "continuing" my practice I believe I could do something similar to the company that I work with and either pay 70% with benefits (which as noted I do not receive) or something on the order of 80% 1099.  My wife (also a Psych NP) has a former co worker now working with an MD psychiatrist in Alabama which is not even close to being an IP state and she is on pace to earn over 300K per year (the MD pays for the office and does the billing, and provides front office, but like me she is 1099).  Why is it so rare? My primary goal isn't to make a great deal of money but to provide good care and if I should be successful enough to start a company (unlikely but it's okay to dream) I would wish to provide an opportunity for others to do the same.  My wife also has several former classmates from USI who graduated in 2016 who do not take insurance and are earning far more than what I have referenced and do "telehealth only".  What am I missing about the fundamentals that make this so rare?

[DrCOVID, DNP]

5 hours ago, myoglobin said:

 What am I missing about the fundamentals that make this so rare?

It is rare because most people take the first job that comes to them. My colleagues are drowning in debt and don't really care about the job they get. My preceptor found while interviewing for colleagues that most just want to be "employed" and don't want to mess with/understand the details. Also, the majority of the psych NPs do not go into private practice. Those that go to work at FQHC's, military/government or inpatient hospital will be lucky to make over 120k (not accounting benefits).

The only way you can get break the 200k range is to be as independent from the physician as possible, have control over your schedule, the insurances and to understand billing & coding. Unless you meet the right people, it is very hard to see how you can get there. In my case, I am going to have to build patients and take quite a few extra steps under a PLLC. I have shared a little bit about the practice I am in where the NP is grossing 20-30k a month with my colleagues & teachers, and no one has any idea... 

[FullGlass, BSN, MSN, NP]

15 hours ago, adammRN said:

Those that go to work at FQHC's, military/government or inpatient hospital will be lucky to make over 120k (not accounting benefits).

The only way you can get break the 200k range is to be as independent from the physician as possible, 

PMHNP pay does vary a lot based on area.  In most of California, a PMNP that is an employee, including at FQHCs, will start at at least $150K per year.  Some places will start at $160K per year.  For PMHNP employees, pay can go up to $200K per year.

Yes, going the independent contractor route is definitely more lucrative, but not everyone wants to do that the minute they graduate.  Benefits are worth something, after all.  One must look at the worth of the total comp package.  And some people need benefits.

[myoglobin, ASN, BSN, MSN]

I think that what I'm ultimately getting at is that IP state or not pay and benefits for NP's (not just Psych NP's) is only going to improve when more NP's control and run their practices either individually or as a group.  Thus, one of the reasons that I believe pay and practice conditions is so much better in Washington state is that therapists control most of the practices rather than physicians (or NP's).  However, even in states like Florida, Alabama, or Tenn. there is not reason that NP's couldn't own the practice although they would still need to negotiate with an MD to be a collaborator. If I could find three psychiatrists in Florida to do this for me as a new graduate for rates ranging from 7 to 13%, I have not doubt that an NP group (which would also likely include therapists) could do much better (under 7% for sure).  They could probably offer at least 60% of insurance with full benefits or a higher percent 1099 and NP's (and therapists) would have the freedom to set the length of their intakes and followups to whatever length they found most effective 

[myoglobin, ASN, BSN, MSN]

Just now, myoglobin said:

I think that what I'm ultimately getting at is that IP state or not pay and benefits for NP's (not just Psych NP's) is only going to improve when more NP's control and run their practices either individually or as a group.  Thus, one of the reasons that I believe pay and practice conditions is so much better in Washington state is that therapists control most of the practices rather than physicians (or NP's).  However, even in states like Florida, Alabama, or Tenn. there is not reason that NP's couldn't own the practice although they would still need to negotiate with an MD to be a collaborator. If I could find three psychiatrists in Florida to do this for me as a new graduate for rates ranging from 7 to 13%, I have not doubt that an NP group (which would also likely include therapists) could do much better (under 7% for sure).  They could probably offer at least 60% of insurance with full benefits or a higher percent 1099 and NP's (and therapists) would have the freedom to set the length of their intakes and followups to whatever length they found most effective  California is an exception because pay for everything is so much better there. An RN couple that I used to work with in the ICU are each earning around 150K as travel nurses and getting their housing paid.  Then again much of California feels like something of a dystopian Hell-scape especially if you are a right of center or Libertarian individual.  

 

[umbdude, MSN, APRN]

On 10/23/2020 at 4:06 PM, myoglobin said:

I don't see why. It's just math. I pay 30% of my insurance intake and a $600.00 per month fee for the services of insurance billing, scheduling, and taking care of intake forms.  The insurances that I take include Medicare, Cigna, Premera, Kaiser and many others. 

How much more do these private insurance reimburse on average? Medicare reimbursements I see are pretty low (~$136 for intake and $94 for 30-min f/u), and medicaid pays even less. 1099 has to take time off, holidays, and no shows into account also.

[myoglobin, ASN, BSN, MSN]

I average around $150 to $200 for a 30 minute followup visit with my combo codes that I use (those would be 99214, 90833 and 90785 when applicable). even Medicare pays OK on these.  On my 90 minute new intakes I tend to use 99205, 90838 and 90785 if applicable and earn from $300 to $500 on average depending on the insurance.  Keep in mind that I have to pay 30% to the company I work with.  My no show rate is around 20% and most providers at the practice where I work are less than 10% no show however I do not charge no show fees, late cancellation fees, nor do I ever report or pursue unpaid debts.  We do not take Medicaid. Most of the NP providers at the practice I work with who have been there over a couple of years are above 300K on three days of patient contact (1099).  I am adding a fourth day, but probably won't be able to beat those numbers because I do 90minute intakes (which is not as profitable as 60 minutes, but honestly I could use 120minutes with the information I like to cover).  I see patients on most holidays except Christmas, the 4th of July, and Thanksgiving (and had a full schedule on Memorial day, and Labor day).  I also take pride in providing a litany of lifestyle interventions, supplements, and holistic approaches that often mean my less severe patients do not need to be seen very often (although this costs me money relative to the many providers who see patients every two weeks or more).  I consider success getting a client "off the wheel" of monthly visits. I also ask all of my clients to listen to The Carlat Report podcast (especially the March 16th  2020 episode that examines numerous lifestyle tips for depression and bipolar disorder)and Dr. David Puder's excellent podcast and many do.  

[DrCOVID, DNP]

On 10/24/2020 at 5:23 PM, myoglobin said:

99214, 90833 and 90785 

I do not charge no show fees, late cancellation fees, nor do I ever report or pursue unpaid debts. 

I am adding a fourth day

I do 90minute intakes

The structure I'm learning is basically this. I don't know how you can only work 3 days and make that much though. She works every day, and does a lot on weekends to make that 30k/month. She charges no shows which is low like 20-40 dollars or something. And she does try to collect non-payments. But most everyone she has commercial insurance. She keeps telling me you can negotiate your rates with private companies. Max intake is 60 minute but most follow ups are 15 minutes.

[myoglobin, ASN, BSN, MSN]

4 hours ago, adammRN said:

The structure I'm learning is basically this. I don't know how you can only work 3 days and make that much though. She works every day, and does a lot on weekends to make that 30k/month. She charges no shows which is low like 20-40 dollars or something. And she does try to collect non-payments. But most everyone she has commercial insurance. She keeps telling me you can negotiate your rates with private companies. Max intake is 60 minute but most follow ups are 15 minutes.

When I get my next distribution packet that details my reimbursements I will post some of the amounts from specific companies/codes. That may better illustrate how I come to these numbers.  I do much better on repeats than on initial evaluations.

[ToFNPandBeyond]

6 hours ago, myoglobin said:

When I get my next distribution packet that details my reimbursements I will post some of the amounts from specific companies/codes. That may better illustrate how I come to these numbers.  I do much better on repeats than on initial evaluations.

Myoglobin, can you explain how you save on taxes as a 1099 employee making the high income that you do?

[DrCOVID, DNP]

6 minutes ago, ToFNPandBeyond said:

Myoglobin, can you explain how you save on taxes as a 1099 employee making the high income that you do?

From what my preceptor tells me, it doesn't matter the structure, whether you are 1099 or SCorp or LLC whatever... you end up paying the same tax. I would really like to know as well. Whenever people talk about income, seems they forget about tax. From what I have been hearing from those that making this much is there really isn't much you can do except try to write off as much as you can for business expenses and spend it (buying real estate, bonds, maxing retirement accounts...).

[myoglobin, ASN, BSN, MSN]

I don't "save" on taxes. In fact I have to pay the whole social security and Medicare tax (normally your employer pays half of these). Thus, when I get a check I take around 33% of the gross amount an put in a "tax" account. This is the same method that my SO has used for years (she earn $85,00 1099). Normally, at the end of the year as soon as she pays her taxes on Turbo Tax (which I normally do for her) she gets an "instant" refund of whatever is left over in the account (usually around 10K).  Now since we don't own a home, and I am such a poor record keeper that I take nothing but the "standard" deduction (not even Head of Household since my SO and I are not married I even let her take our son for the HOH deduction) my taxes are about as inefficient as possible. If I kept better records I could probably put another 5K or more each year in my pocket from things like licenses, Liability Insurance, and fees that I pay to the company that I work for.  However, for me the "hassle" to this point isn't worth it (I aspire to be more organized in the future). It is important to realize that most of the providers where I work are much more efficient. They did things like form LLC's before getting licensed and they pay themselves a "salary" and are even able to write off things like the health insurance (that they pay for themselves). However, the mechanics of setting up an LLC, getting the business license, and getting credentialed are more complex and my priority was on getting started out of school (but it would be optimal to have health insurance and to be able to write off the premiums).  Note, that since I earn money in the state of Washington I also have to pay a 2.5% state "business tax" on my gross billings which is why I take out 33% rather than the 30% that my SO takes out as an Arizona NP.  Just figure taking 30% out of your check (more if you live in a state with income taxes) and you will get a nice "instant refund" when you file your returns.