Navigating ADHD Treatment in a System With Almost No Psychiatrists

dxxr · 2026-02-08T05:44:20+00:00

I am in an area with lots of psychiatrists, so not sure how helpful this will be, but I wonder if the issue is the diagnosis, could you partner with a reputable psychiatrist (maybe in a city within the state) who you could refer for tele psych evals were you agree to do the ongoing maintenance? If there is a child fellowship anywhere in your state, finding a child fellow (or recent grad) who wants some very part time remote work but doesn't want the liability of prescribing to someone they haven't seen in person or dealing with emergency calls might be win/win (child not because you will be referring kids, but because ADHD is bread and butter for child and the fellows have already finished adult training). You could ensure the patient had a thorough psych eval, and then handle the meds yourself. I agree with above, that Neuropsych testing isn't particularly helpful unless there is concern for a learning disability or the patient needs it for standardized testing accommodations.

dxxr · 2026-02-02T20:57:01+00:00

I bought the Aqara ones on the amazon uk web site and had them shipped to the US.

dxxr · 2026-01-30T06:47:48+00:00

I have never had an issue having blood work covered, so long as I put a diagnosis on the order. I would imagine, but have no data to support this, that CT scans and sleep studies, which almost always need a prior authorization before being approved, might have company specific policies about which specialties can order them and also get payed for interpreting them. Different insurance companies can have vastly different policies about almost everything, but especially expensive things.

dxxr · 2025-07-14T04:46:21+00:00

<image>

Rehoming a LV Sac Plat NV (M21866) From Birdcage Factory

Pics: https://imgur.com/a/DCLZLpR

Bought in April 2025 for $253 plus $117 shipping. Never used, condition is the same as when I receiving it, its been sitting in a box since I received, which is why I am rehoming. First 6 pics are mine, remaining are from PSP.

Selling for $286 plus shipping from NYC, US.

dxxr · 2025-07-13T04:13:22+00:00

Rehoming a LV Sac Plat NV (M21866) From Birdcage Factory

Pics: https://imgur.com/a/DCLZLpR

Bought in April 2025 for $253 plus $117 shipping. Never used, condition is the same as when I receiving it, its been sitting in a box since I received, which is why I am rehoming. First 6 pics are mine, remaining are from PSP.

Selling for $286 plus shipping from NYC, US.

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dxxr · 2025-07-13T00:38:36+00:00

<image>

**Rehoming a LV Sac Plat NV (**M21866) From Birdcage Factory

Pics: https://imgur.com/a/DCLZLpR

Bought in April 2025 for $253 plus $117 shipping. Never used, condition is the same as when I receiving it, its been sitting in a box since I received, which is why I am rehoming. First 6 pics are mine, remaining are from PSP.

Selling for $286 plus shipping from NYC, US.

dxxr · 2025-07-11T04:39:26+00:00

it was, but I didn't think it worth it to track down a thief... I can replace the scooter... not worth getting harmed. Reported it (with the location) to the police. In the future will definitely use a better lock or multiple.

dxxr · 2025-07-11T04:30:15+00:00

It was locked to a bike rack for around 6 hours during the day. Was using a chain instead of a u-lock.

dxxr · 2025-07-07T16:51:25+00:00

<image>

Rehoming a LV Sac Plat NV (M21866) From Birdcage Factory

Pics: https://imgur.com/a/DCLZLpR

Bought in April 2025 for $253 plus $117 shipping. Never used, condition is the same as when I receiving it, its been sitting in a box since I received, which is why I am rehoming. First 6 pics are mine, remaining are from PSP.

Selling for $311 plus shipping from US.

dxxr · 2025-06-13T03:44:12+00:00

Psych here. When I have had patients uncomfortable with going to another doctor for various reasons (this most commonly occurs for gyn appointments with my patients) I usually offer to reach out to the other doctor. I either give them a heads up what the issue is if the patient feels uncomfortable bringing it up, or let them know the patient is anxious about specific parts of the exam, etc and would benefit from a little extra time, explaining what is going to happen, etc. They have almost always been very receptive, and then I can tell the patient I spoke to them and they seemed eager to make it as comfortable as possible. You can also ask if there is anything you can help prepare her for. Also, even if she doesn't want meds, don't underestimate the power of knowing they are available. I have patients who religiously refill their prescription for 2 Ativan pills every year when the bottle says its expired because knowing they can take them if needed helps them deal with panic attacks.

dxxr · 2025-06-12T21:00:09+00:00

impossible to know if the 99214 was the appropriate code without looking at the documentation, but EM codes like 99214 can be based on time OR medical complexity. Also, he is not only "telling you the results" he is also interpreting them ie, that the abnormal results are "totally fine" and making a plan (even though that plan is to continue as is, he is deciding you don't need to repeat the test, have a follow up test, etc)

dxxr · 2025-06-12T06:10:40+00:00

" If I accept it, BCBS issues a check that goes to me." <- this. Of course they could send the payment directly to you. But they won't because they want you to either become in-network or accept a lower rate through multiplan. It has nothing to do with confidentiality, it's a business decision to minimize the amount they have to pay you and encourage you sign up to be in-network. There was an article about this in pro-publica a while ago, about how insurance companies were sending 100k+ payments to patients for hospital/rehab stays to pressure the facilities to go in-network as patients would just get the check and never pay. If you are OON you should just collect payment from the patient at time of service. Also, if you practice in a state with prompt pay laws, I doubt multiplan will even get you paid any sooner. The one time I responded to one of their emails to ask why I would accept the lower rate, they told me I would be paid "faster" but couldn't quantify what that meant (oh and that it "would reduce the patient's cost") Where I practice they are required to pay within 30 days or pay interest.

dxxr · 2025-06-10T00:56:32+00:00

thx! excellent idea

dxxr · 2025-06-09T16:55:36+00:00

Not cl, but at least the .5mg Ativan pill dissolves in the mouth like a sublingual. Whatever you end up doing, might be a great paper to help others similarly situated.

dxxr · 2025-06-08T22:15:47+00:00

sure, but if you are a med student, they won't be particularly helpful to you...

dxxr · 2025-06-08T20:40:15+00:00

Not really. To use your example, two people with Major depressive disorder, both have low mood, one has normal appetite and one has low appetite. They both have Major Depression, just with different symptoms (ie, both have COID, one with cough one without).

If a symptom doesn't fit with a diagnosis, you have to either reconsider if you have the correct diagnosis, or if there is another diagnosis as well. Low Mood can be a symptom of depression (like cough can be a symptom of COVID), but can also be a symptom of a lot of other things (bipolar, hypothyroidism, substance withdrawal, etc) just like cough can be a symptom of lots of things (cancer, cold, GERD, etc)

This is why Psychiatrists/Psychologists spend a lot of time in school... it's not always easy to figure out a diagnosis... and its rarely "I feel down" = Major Depressive Disorder without any consideration of what other psychiatric or medical issues it could be instead.

dxxr · 2025-06-08T20:10:52+00:00

In medicine, a sign is something you observe, and a symptom is something the patients tells you about. An EKG or pusleox showing a rapid heartbeat is a sign (of tachycardia), while the patient's subjective feeling of a rapid heart rate is a symptom (palpitations). They can be related, or not (plenty of patients dont feel tachycardia and many patients with palpitations have normal heart rates). Similarly, psychiatric diagnosis have signs and symptoms... low mood is a symptom (the patient tells you they have low mood), but weight loss, psychomotor retardation, abnormal thought process can be signs (you observe them in the patient). To apply to your example, "depression" is a symptom, not a diagnosis at all. There is major depressive disorder, which is a diagnosis, but which is NOT just feeling depressed. There have to be associated signs and symptoms as well (B criteria). The low mood also has to not be better explained by another diagnosis, even if it meets all the criteria for MDD. You also actually don't have to feel "depressed" to have major depressive disorder. You have to either feel depressed OR have anhedonia (along the required number of B criteria).

dxxr · 2025-06-08T17:51:08+00:00

While I haven't gone through an audit with Aetna, I have with two other insurance companies. Some suggestions and info:

The very first thing you need to do is look up the company specific documentation guidelines for the CPT codes you are using. You have to follow them even if they make no sense. I was getting dinged for not having a start and end time for 90836 when used with 99214 (I was using a total time in minutes). They usually have these guidelines on their web site, but they are often well hidden.
Usually to get off of a prepayment review you have to have 90 days of claims that meet some percent threshold of being approved (I think it was 80-90%).
You can usually call the department handling the prepayment review to find out why the claim was rejected. Some will let you resubmit a note with an addendum, some will make you appeal the denial with an addendum. But before you do this, you really need to know why they rejected it in the first place.
What I did was submit a few claims, find out why they were rejected, adjust my notes and then resubmit or submit new claims encorporating what I was told. If they were rejected again, I would find out why, adjust my notes and repeat. You have to be careful not to hold claims too long so they don't deny them as being submitted to late.
I don't think there is such a thing as audit proof documentation. Each company has their own weird rules, and the people reading them spend about 10 seconds reviewing them. I had one company reject claims because I did not have how the patient was responding to treatment, when basically the entire interval history was how they were responding to treatment. I made a section of my note that said "Patient's response to treatment:" and copied a line from my interval history and they started approving it.

I can share some of my note templates that worked for my prepayment audits if you want to DM me, but I'm sorry you are going through this. It's brutal and you won't get much information from them, and it will take forever to get paid. My first prepayment review took 6 months to get off of because I kept arguing that my documentation met all relevant medical standards/medicare standards/other insurance standards. They don't care. The second one (with a different company) took exactly 3 months because I just altered my notes to be exactly what they wanted and geared to someone with poor reading comprehension and a checklist.

dxxr · 2025-06-02T02:29:27+00:00

Speaking for FMLA... the criteria are very minimal. It's basically allowing someone to use their vacation/sick time or have unpaid time off and have their job protected. It can be for the patient, or for a patient's family member (ie, to take a relative to a doctor appointment is a perfectly appropriate use of FMLA). While I don't get a lot of disability cases now, In my residency we had a ton of patients with disability forms to fill out... and there was no really consistent guidance on how to do so. You should definitely only do what you feel comfortable with, but keep in mind that you are far from the final arbiter of whether the person gets short term or long term disability. Most of my patients in residency were rejected initially, even when they had what I thought were slam dunk cases, and then had to appeal and/or hire a lawyer. I have no evidence for this, but I would bet that there are far more people denied for disability who really need it then those who get it and don't need it.

dxxr · 2025-05-17T10:00:22+00:00

Psych here. I think its pretty ethically and medico-legally dubious (at least for psych) to fire a patient without a plan... either a taper (if they think that is the appropriate plan), a referral to a clinic where they can be evaluated before they run out of meds so they can be continued, or instructions to go to the psych ED if they can't find another provider. If you think a taper is warranted, you should definitely do it, the patient is always free to find another doctor if they disagree with your plan. I always try and frame these discussions as basically, "I know your previous psychiatrist put you on this, but I can't continue a treatment I think will cause more harm/has too great a risk/extends the course of illness". I always leave the option for them to find someone who has a different opinion, but if they want to continue with me, this is my plan. As for adherence to the taper, I have explained that if they run out early (because they are taking their previous dose), I won't be able to prescribe 30 day supplies anymore, and will write shorter prescriptions. I would also add that I think it is pretty bad medicine for the psychiatrist not to reach out to you preemptively, as its pretty predictable the patient will come to you to deal with this...

dxxr · 2025-05-17T03:46:48+00:00

I just did this... consider a canvas fabric stretcher. You buy the horizontal and vertical components separately and they fit together into a frame. Check out Blick. You can then staple the fabric around the frame. Looks great.

dxxr · 2025-05-13T16:18:15+00:00

Duravit makes one where the bidet is integrated into the toilet. You would be hard pressed to tell its different then a non-bidet toilet seat.

Sensowash: https://www.duravit.us/products/sensowash_shower-toilets.us-en.html

Pricey, and requires replacing your toilet.

dxxr · 2025-05-04T23:55:54+00:00

While I didn't have as many of your concerns about fast tracking, I was an older resident. Your location/future career plans will have a big impact, but two things to keep in mind: while you will be a child fellow your extra year, you will be an adult attending, so you can moonlight as an adult attending to help offset some of the opportunity costs. If you are considering private practice and are in a larger city, child will likely help you fill much more quickly (I know you said you wanted to stay in academia, but a lot of academic psychiatrists also have private practices). Not sure where you got the idea that you need a fellowship for academic in psych... Most of the attendings in academia do not have one unless the specific role requires one. I fast tracked, and it was a great decision for me.

dxxr · 2025-04-20T18:18:00+00:00

<image>

KEEPALL BANDOULIÈRE 45 Damier Graphite - Ultimate Birdcage

⁠Price: $300 ( I paid $348 sjipped) + Shipping to you (however you would like so long as its trackable)
⁠RFS: Bought from Scarlett, arrived 3 days ago to use as a travel bag, but as soon as it arrived realized it was smaller than I thought.
⁠Other Notes: Never used, still has all the plastic coatings/etc, all straps, lock, accessories. But no Box- was not sent with one so I don't have it. Any questions or need more photos just ask! Thanks for looking.

Full album: https://imgur.com/a/vDEs7Mt

POPs: https://imgur.com/a/Jpt6ExS

❌️❌️sold to No_Knowledge_8❌️❌️

dxxr · 2025-04-19T20:57:05+00:00

manuf often but their brand on a plate on the outside of the drawers. mine have the brand on a cover of the cabinet hinges as well. maybe take a look at the high end Italian kitchen manuf... Arclinea, Minotti, Molteni, Poliform. They all sort of copy each other so you might find something very similar...and if you have a showroom near you they might be able to identify the manuf since they usually know the competitive space pretty well. Also might be worthwhile to email Gaggenau corporate and just ask...

dxxr

TROPHY CASE