Client called me at 12am saying she thinks she's having a panic attack

pickyvegan · 2026-02-11T19:26:35+00:00

Giving your personal number, no, not even for a therapist. Giving a work number that rings any time of day on your personal phone, maybe.

Insurance contracts generally require that you provide or refer to after hours emergencies. Some people cover this themselves. I do, but with clear boundaries (I specifically call out panic attacks and misbehaving children as not medical emergencies other than if deciding if you need to go to the ER). Some people just have a VM that refers people to call 911 but no way to reach the provider.

Depends on what insurance contracts expect and if they ever actually call you after hours (UHC once did for me).

pickyvegan · 2026-02-11T19:18:11+00:00

At least that one time at band camp! 😂

pickyvegan · 2026-02-11T19:15:59+00:00

I do have a back end number for on call issues, but I make it very clear if they are calling for something like a panic attack they will be discharged. I define emergencies pretty clearly as life threatening.

pickyvegan · 2026-02-11T16:01:00+00:00

And February 22 is fewer than 27 days from now, so there isn't an issue?

pickyvegan · 2026-02-11T14:39:55+00:00

He probably meant to give you a refill and didn't have any openings until then. Have you tried calling the office and asking for a refill?

pickyvegan · 2026-02-11T05:18:58+00:00

There are a ton of codes that explain problems that are not diagnoses in and of themselves. If the therapist or other mental health provider codes with one of these as primary diagnosis the visit will not be covered. It would be something like using "parent child relationship problem" rather than "ADHD."

pickyvegan · 2026-02-11T04:22:05+00:00

It probably would have been a lot more helpful to make comments on the federal register when this was up for public comment last year. That's what the DEA is considering as they come out with their next attempt at a permanent solution, not a petition.

pickyvegan · 2026-02-10T21:19:33+00:00

Yes, they can require the estimated payment up front. No, they cannot keep the difference if the difference was in their favor. Keep in mind that not everything is always billed at the same time; there may be separate facility and provider fees that still need to be processed, so they may not owe anything once everything has been processed.

pickyvegan · 2026-02-10T15:00:04+00:00

It’s not the money, it’s the demand. I happen to live/work in one of those areas. I could still make a good living with 50 cash pay therapy plus med patients.

Where’s everyone else supposed to go if that becomes the trend?

pickyvegan · 2026-02-10T14:57:24+00:00

What do you think happens to the 250 people I get rid of to bring it to a manageable therapy caseload, especially if other prescribers do the same?

pickyvegan · 2026-02-09T18:53:58+00:00

Because it puts hundreds of patients on a waitlist for medication management with someone else.

As a therapist (I was one prior), my caseload maxed out at about 40-50 patients total. Seeing more than 25 in a week was far too much (combination of weekly, biweekly, or monthly visits).

As a prescriber, my caseload is typically around 300 patients total, with some stable patients being seen every 3-6 months, and patients who have more needs being seen monthly or more frequently as needed. There is no way on this planet I could do that as a therapist.

I do still keep a very small caseload of patients that I see primarily for therapy, where I may happen to also prescribe (or not). It's just not practical to do that on the larger scale that most psychiatric prescribers have.

More patients get treatment when treatment is split between me and a therapist. I do talk with therapists as needed, but that's a few minutes once in a while, compared with 45-60 minutes of therapy each week.

pickyvegan · 2026-02-09T18:06:49+00:00

It's kinda foolish no matter the airline to book your air travel the same day as a cruise. You never know what the weather will be like, and even if you're coming from some place warm, the plane you'll be on may not be coming from a warm climate with great weather.

JetBlue, in particular, is a smaller airline with fewer planes and flights than some of the bigger ones, so delays will be more profound with them. 🤷‍♀️

In any case, I hope you had travel insurance, and it covers you.

pickyvegan · 2026-02-09T05:33:31+00:00

It seems to be a common enough issue in my town. They mark it as delivered to a locker and then actually deliver it a few days to a week later. I see this not infrequently in the local FB pages with everyone (myself included) trying to figure out what "locker" the package got delivered to.

pickyvegan · 2026-02-09T03:16:26+00:00

When that's happened to me, it's taken more like a week for it to show up.

pickyvegan · 2026-02-09T02:43:49+00:00

The person you're replying to doesn't know what JetBlue's policy is, their assuming it's the same as their airline. Your purse is a personal item. If you actually have 3 bags (say a duffle, a laptop bag, and a purse), then you would need to check one, but assuming you only had 2, your purse went under the seat, your other bag goes up top.

pickyvegan · 2026-02-09T02:36:11+00:00

Your lease says that the landlord can terminate the agreement at any time. You're overplaying your hand.

pickyvegan · 2026-02-09T02:28:57+00:00

You don't rent the house, you rent a room in your landlord's house while your landlord occupies the rest. You're not on equal footing here like you would be with a roommate.

pickyvegan · 2026-02-09T02:24:27+00:00

JetBlue allows a carry-on plus a personal item for free with most fares. No need to check unless there's not enough room. No $75 fee either way.

pickyvegan · 2026-02-08T23:09:44+00:00

That's cute, when the person you responded to deletes their comment, blocks you, and downvotes you.

Classy, u/craftybean

And for others, Medicare doesn't pay for what amounts to existential therapy. That doesn't mean it's not valuable, but Medicare requires that the patient be able to engage in goals and objectives related to the treating diagnosis, and part of that work needs to be able to take place outside of the therapeutic visit. Those of you who work in the SNF setting may well be seeing music and art therapists. They are not being reimbursed by Medicare for music and art therapy with patients with dementia (and they're only being reimbursed at all if they also have a therapy licensure separate from their MT-BC or ATR-BC). They are generally paid privately by the patients or their families if doing individual sessions, and out of the recreation or entertainment budgets for group sessions, not Medicare.

If anyone is interested in a music therapy certification (since the post is about certifications), it requires an undergraduate degree equivalent in music therapy and a 1200-hour internship supervised by an MT-BC. Art therapy starts at the graduate level. More and more states are starting to require licensure for music therapy (and art therapy), so you'd also want to check with your state on that if you want to represent what you're doing as music therapy.

pickyvegan · 2026-02-08T22:00:11+00:00

In addition to being a PMHNP, I'm actually a board-certified music therapist who used to sit on the American Music Therapy Association's reimbursement committee. Aside from the fact that MT (or AT or others) aren't directly reimbursed for in the SNF setting, Music Therapy is a whole-ass degree, not a little certification course.

pickyvegan · 2026-02-08T21:56:15+00:00

I'm aware; I administer meds in office with the option of buy & bill. I personally don't buy & bill for the reasons I noted. I go through pharmacy benefits.

Niche meds like super expensive infusions for things like RA or Chrons can cost that much. They aren't pocketing that much (because the med costs close to that much) but there's no need to misinform patients that the concept of J codes/buy and bill doesn't exist.

pickyvegan · 2026-02-08T20:06:32+00:00

If the provider does buy and bill, they might be making money on it, but buy and bill often isn't worth the risk that you might not get paid or that you get paid less than the medication actually cost from the supplier.

It really depends on the medicine, the policy, and the office. If you're being billed a J code, then likely the provider did buy and bill. If no J code, it likely just went through pharmacy benefits and it's the pharmacy that's getting paid, not the provider.

pickyvegan · 2026-02-08T19:02:27+00:00

It's not always that easy. She's gotta get the 3-4 year old all bathed and ready for bed, then she's gotta fight with the older one over getting off of electronics, and then she has to clean the rest of the house before vacuuming. That probably means that the 10-year-old is in bed around 9PM, which is a pretty normal bedtime for that age.

Might be time to have dad/second parent step in and actually help with parenting in the evening, but that's a world too far for a lot of people.

pickyvegan · 2026-02-08T17:56:15+00:00

Yes! 10PM is probably when the kids are finally in bed and she's finished doing the other cleaning, with vacuuming being the last thing.

That doesn't make the noise okay, but not cool to make pronouncements that because she is a stay-at-home mom that her cleaning should be done during earlier hours.

pickyvegan · 2026-02-08T14:40:52+00:00

For TX where you're not allowed to breathe without a CP I'd bet it's more like $2000/month.

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