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?  

[MarleyGrace, MSN, APRN, NP]

10 hours ago, myoglobin said:

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.

myoglobin, 

I am beginning as an independent contractor and am working as an LLC 1099. I will be in an office with two other independent providers along with multiple independent therapists. Nice atmosphere. I will be paying 20% of my income for my office space, billing, appointments made (although I'll probably schedule my own), office equipment, and office staff. 

My split as noted above is 80/20 which am told is a very good split just starting out. I do have an accountant who will be doing my taxes.

I start seeing patients in November and don't have to worry about building a clientele as the practice had a psychiatrist who retired and leaves behind 100's of patients looking for a new provider. 

Private practice is new to me and I almost turned the offer down. After talking with other independent providers, I am giving it a go. I do love that my time is mine to schedule and I have control over how long I see a patient. 

[ToFNPandBeyond]

3 hours ago, MarleyGrace said:

myoglobin, 

I am beginning as an independent contractor and am working as an LLC 1099. I will be in an office with two other independent providers along with multiple independent therapists. Nice atmosphere. I will be paying 20% of my income for my office space, billing, appointments made (although I'll probably schedule my own), office equipment, and office staff. 

My split as noted above is 80/20 which am told is a very good split just starting out. I do have an accountant who will be doing my taxes.

I start seeing patients in November and don't have to worry about building a clientele as the practice had a psychiatrist who retired and leaves behind 100's of patients looking for a new provider. 

Private practice is new to me and I almost turned the offer down. After talking with other independent providers, I am giving it a go. I do love that my time is mine to schedule and I have control over how long I see a patient. 

This is so ideal and is what I aspire to do! Please do update us with how working as an IC 1099 has worked out for you!

[MarleyGrace, MSN, APRN, NP]

4 hours ago, ToFNPandBeyond said:

This is so ideal and is what I aspire to do! Please do update us with how working as an IC 1099 has worked out for you!

I am trying to stay positive. The credentialing process is the worst as it takes some time. I am finally credentialed with two insurance companies and continue to wait on the rest. This has been the toughest part so far, waiting to be credentialed so I can see patients The office manager is taking care of credentialing also. 

[DrCOVID, DNP]

10 hours ago, MarleyGrace said:

I am trying to stay positive. The credentialing process is the worst as it takes some time. I am finally credentialed with two insurance companies and continue to wait on the rest. This has been the toughest part so far, waiting to be credentialed so I can see patients The office manager is taking care of credentialing also. 

Yeah, out of everything, seems this take the longest... You have to have your degree and license before you can get credentialed right? LOL

[MarleyGrace, MSN, APRN, NP]

1 hour ago, adammRN said:

Yeah, out of everything, seems this take the longest... You have to have your degree and license before you can get credentialed right? LOL

and your certification, MCSR, DEA, Physician collaboration agreement, and malpractice insurance. They also want your bank account numbers, NPI#, social security, copies of all my degrees, blank checks, and I can't think of anything else off the top of my head. What a process. 

[mangopeach]

On 10/24/2020 at 1:50 PM, FullGlass said:

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.

The benefits offered at my current job are excellent indeed. I suppose that is probably the main reason some people stay.  The health care plan aIone is unheard of anywhere else that I've worked. I contribute very little to my healthcare plan. It's paid for mostly by my employer. 

I have decided to move on to private practice though. Well, don't want to count my chickens before they hatch. I have a 2nd interview next week so hoping it all goes well. I am a bit disappointed to be going back to my home state. Almost feels like a loss, that I didn't make this work but looking forward to the next opportunity. 

[myoglobin, ASN, BSN, MSN]

17 hours ago, mangopeach said:

The benefits offered at my current job are excellent indeed. I suppose that is probably the main reason some people stay.  The health care plan aIone is unheard of anywhere else that I've worked. I contribute very little to my healthcare plan. It's paid for mostly by my employer. 

I have decided to move on to private practice though. Well, don't want to count my chickens before they hatch. I have a 2nd interview next week so hoping it all goes well. I am a bit disappointed to be going back to my home state. Almost feels like a loss, that I didn't make this work but looking forward to the next opportunity. 

Benefits are "nice" but they virtually "all" have a "cash" value. For example if you get health insurance there is a premium (say perhaps $1500 per month for a typical "gold" family style plan). Your employer typically pays at least half of the premium (sometimes more) and you pay the rest. Thus, in the above scenario where you paid 30% of the premium the "value" of the insurance benefit is around $12,600.  One can go through the same process for every benefit offered by an employer. Thus if your salary is 140K with benefits that may well be much better than say 160K 1099, but it will seldom be better than say 250K 1099. Were it up to me everyone would have to "buy" their own benefits (on an open and fair market) as well as pay the "whole" tax. That way there would be more transparency in our wages. Keep in mind that employers mainly offer benefits because it allows them to attract more quality employees at a lower "price" (your wage is their price). They do not do it as a service to humanity. It is true that they can sometimes harness "economies of scale" to acquire benefits at a marginally better price and or quality than you could purchase yourself, but these are generally maybe a 10% difference.

There is a related thread about student loan debt where someone (I think from Belgium) talks about not having to pay anything for their nursing degree (education is provided by the government without tuition in many cases). However, it is not "free" in that taxes like income taxes, value added taxes and other taxes are much "higher" than in the United States. Thus, if you earned 100k salary you might pay 50K income taxes alone as opposed to say 20K in the United States. That extra 30K per year represents the "fee" for those benefits and you have no option to "opt out" if you don't want the benefit. Even, in the United States this hold true to some extent. If I worked and lived in California I might earn an income of say 200K, but I would have to pay an income tax of around 10%. Thus, I would every year have a 20K "fee" for the privilege of living in California over Florida (and here a six bedroom house  with a nice pool in a gated community goes for about 400K, not sure what that would be in California, but I would wager it would be higher). 

[ToFNPandBeyond]

On 10/28/2020 at 7:29 AM, myoglobin said:

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.

Ouch! Your tax liability will be through the roof if you're not actively trying to reduce your tax liability (incorporate, business expense right offs, etc.)...

I would only consider doing 1099 if I can reduce my tax liability, otherwise uncle Sam will be taking a HUGE chunk of your profits and you'd be better off making less money for more gain ??‍♀️

However, Myoglobin, do you have an assistant that helps with scheduling and other admin tasks? I'm curious to know how does it work when you work as a 1099 co-op style with other 1099 providers, and you need assistance with admin grunt work? Does the owner provide an assistant that you all share, or are you responsible for hiring your own assistant through the money you earn? Ty for your response!  ?

[ToFNPandBeyond]

On 10/29/2020 at 2:07 AM, MarleyGrace said:

I am trying to stay positive. The credentialing process is the worst as it takes some time. I am finally credentialed with two insurance companies and continue to wait on the rest. This has been the toughest part so far, waiting to be credentialed so I can see patients The office manager is taking care of credentialing also. 

So I take it your employer provides an office manager that you don't have to pay for? Do they complete prior authorizations, scheduling and other admin work for you? That would be so ideal!

[myoglobin, ASN, BSN, MSN]

They do most of my scheduling, but I do some myself. I  do my own prior auth’s. I could use Covermymeds but find my rejection rate is higher than when I personally make calls. My, total taxes are still less than 30 percent of my income which seems fair to me. Setting up as a Corp or LLC would have taken far longer and would be considerably more complex. In retrospect I might not have even started yet because after covid there was a three month period where they were not adding NP’s also some insurance companies like Kaiser have paused paneling in Wash.Note, I also I pay a fee of about six hundred per month on top of my 30% for office space (if and when I need it) front office phone support and other services.

[MarleyGrace, MSN, APRN, NP]

2 hours ago, ToFNPandBeyond said:

So I take it your employer provides an office manager that you don't have to pay for? Do they complete prior authorizations, scheduling and other admin work for you? That would be so ideal!

I don't have an employer. We are three independent contractors working together and we have an office manager, scheduler, and billing staff. Yes, my office manager will complete prior auths, do admin work, and schedule my patients. I will be doing my own scheduling though for maximum flexibility. As independent contractors, we cover office expenses with 20% of the income we make. Our split is 80/20. 80% is our portion and 20% covers the office expenses. We also have 5 therapists who are also independent contractors and they have the same split.

 

[myoglobin, ASN, BSN, MSN]

1 hour ago, MarleyGrace said:

I don't have an employer. We are three independent contractors working together and we have an office manager, scheduler, and billing staff. Yes, my office manager will complete prior auths, do admin work, and schedule my patients. I will be doing my own scheduling though for maximum flexibility. As independent contractors, we cover office expenses with 20% of the income we make. Our split is 80/20. 80% is our portion and 20% covers the office expenses. We also have 5 therapists who are also independent contractors and they have the same split.

 

I believe that you describe an optimal arrangement for many if not most NP's. Even states without IP should be able to arrange a roughly equivalent set up with the difference being that they would have to "pay" one or more psychiatrists to act as collaborators.  However, even with a typical "10%" payment for such a service most NP's would still come out ahead earning 70% of revenue as opposed to the salaries of less than 150K which they often earn.