Six years on the same medication. Nobody ever explained why.

One independent look at a diagnosis that was made quickly and never revisited.

What a wrong diagnosis costs

Most psychiatric diagnoses are made in a single appointment, often under thirty minutes, frequently during a crisis. That is not negligence — it is how the system is built. But it means a substantial number of people are carrying a label that was a reasonable first guess and was never tested again.

The cost of that compounds quietly.

• Years of the wrong medication. Not dangerous, just not working. Side effects you have normalised. A ceiling on how well you can function that you assume is you.
• The thing underneath, still untreated. ADHD read as anxiety. Bipolar spectrum read as recurrent depression. A sleep disorder driving everything and nobody looked.
• Time. Six years at seventy percent instead of ninety is not a small thing. It is most of a decade of your career.

Six hundred dollars against six years of guessing is not an expensive question to ask.

Where this leaves you

This is for you if

• A diagnosis was made years ago, quickly, and never revisited
• You have been on the same regimen a long time without a clear rationale ever being explained
• Several medications have been tried without adequate response and you want to know what has actually been ruled out
• You suspect something underneath — ADHD beneath the anxiety, bipolar spectrum beneath the depression, sleep driving all of it
• You are considering a change and want an independent read before making it

What happens

1. You send records. Prior notes, medication history, testing, discharge summaries — whatever exists. Incomplete is fine.
2. I review them before we meet. On my time, not yours. This is the part most second opinions skip.
3. Ninety minutes. Full history and diagnostic assessment. We go back to the beginning rather than reviewing your current prescription list.
4. You receive a written formulation. My diagnostic impression, what fits and what does not, and specific options worth discussing — written so you can hand it to your own clinician.

Why the records review matters

Most second opinions are worth little because the clinician works from a fifteen-minute summary given by a patient under time pressure. You end up narrating six years of history from memory while the clock runs.

Reading the actual record beforehand is what makes the appointment useful. It means the ninety minutes goes to thinking rather than to reconstruction. It is also the reason this costs more than a standard initial evaluation despite being a single visit.

My commitment on the outcome

Common questions

Will my current clinician be offended?
Most are not. Second opinions are ordinary in every other speciality, and a good clinician would rather have another set of eyes than have you quietly stop taking something. If yours would take offence, that is itself information about the relationship.

Are you trying to take me as a patient?
No. This is a one-time consultation and most people go back to the clinician they already have, better equipped. If ongoing care with me made sense, that would be a separate conversation and a separate evaluation — and I would say so rather than steering you there quietly.

Will you prescribe or change my medication?
No. Prescribing from a single consultation is not safe practice. Recommendations go to you and, with your consent, to your treating clinician, who makes the actual decisions.

What if my records are incomplete?
Almost everyone’s are. Send what you have. Gaps in the record are themselves useful information — what was never documented is often what was never asked.

Can you guarantee you will find something?
No, and be suspicious of anyone who does. Sometimes the original diagnosis holds. What I guarantee is a thorough independent look and a clear written answer either way.

What you leave with

• A written diagnostic formulation — what I think is going on, and the reasoning
• An explicit account of what does not fit, which is often the more useful half
• Specific named options worth considering, with the reasoning behind each
• Where relevant, what workup or testing has never been done

A superbill is available if you choose to seek out-of-network reimbursement yourself. That is entirely your decision, and it does put a diagnosis code into your insurer’s hands — which is worth knowing before you submit one.

What it does remove is the automatic transmission of your diagnosis to an insurance company as a condition of receiving care. For the people who ask me about this, that is the part that was actually worrying them.

It is worth being precise, because overstating this would be its own kind of dishonesty. A clinical record still exists — I am required to keep one. That record remains subject to subpoena or court order, and mandatory reporting obligations apply regardless of how care is paid for. Cash-pay is not anonymity, and no clinician can offer you that.

What cash-pay does not do

No prior authorisation. No visit limits. No utilisation review deciding that six sessions should have been enough. How often we meet and for how long is a clinical decision made between us.

No one outside the room decides how much care you get

Without a payer in the room, the diagnosis in your record is the one I actually believe is correct. Sometimes that is a formal diagnosis. Sometimes it is an honest statement that the picture is not yet clear. Neither has to satisfy anyone but the clinical facts.

Insurance reimbursement requires a billable diagnosis, and it has to be one the payer accepts for the service provided. That creates quiet pressure toward codes that justify reimbursement rather than codes that best describe what is actually happening.

Your diagnosis reflects clinical judgement, not billing requirements

For a physician thinking about credentialing, an attorney thinking about the bar, or anyone who has ever wondered what a life or disability insurance underwriter might one day request, that distinction is not abstract.

When care is billed to insurance, a diagnosis code is submitted with the claim and becomes part of that insurer’s records. When there is no claim, there is no code to submit. Nothing about your care is transmitted to a third-party payer at all.

No claim means no diagnosis code sent to a payer

This practice does not bill insurance. For most people that is simply a cost consideration. For the people this practice is built for, it changes three things that matter more than the fee.

What cash-pay actually changes