Pain practice in a Hopsital

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painfre

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Currently, I am working full time for a gov. hospital but soon becoming part time working for 3 days only. Got an offer to work in a pvt hospital for the about 2 days. The hospital is asking me to collect and bill the procedures I do. Hospital will provide the supporting staff, shared office,access to exam room and procedure room. Hospital will also do scheduling,records keeping, supplies etc. I need to have my own malpractice, DEA, Medicare provider number.
This information I got through email from the CEO of the hospital. I did not see the contract yet. I do not have private practice experience in the past. Is this a normal set up for a pain practice in a hospital?.
Thanks
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I did this for a while and it worked out ok. However, it takes good will on both sides.

Going into it I would want to know who your referral sources are and what the payor mix is. If it's all medicare/medicaid it could be tough for you. This is an 'eat what you kill' arrangement for you with the hospital keeping the facility fees. They will probably need to charge you some rent in order to avoid the appearance of 'inducement' & possible Stark violation.
 
101N said:
I did this for a while and it worked out ok. However, it takes good will on both sides.

Going into it I would want to know who your referral sources are and what the payor mix is. If it's all medicare/medicaid it could be tough for you. This is an 'eat what you kill' arrangement for you with the hospital keeping the facility fees. They will probably need to charge you some rent in order to avoid the appearance of 'inducement' & possible Stark violation.
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if they bill a facility fee for the office, which they can do, then u dont have to pay rent. if there are a lot of built in referrals, and you can decide what insurances you can take (ie, do not take medicaid) then you can do pretty well with no overhead. make sure there is no restrictive covenant to worry about...
 
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Thanks for the above info. With no previous experience of practice outside the government, I would like to more careful and less agressive initially. the hospital is a rehab hospital and I hope it has good payor mix. Initially I was told that I will be provided with malpractice but now they are telling that I need to have my own malpractice insurance in addition to DEA, Medicare provider number. What kind of insurance should I look for?. As I mentioned earlier, I work for a gov hospital which provides malpractice insurance from me while working there . What kind of restrictive covenant are you talking about ?
 
You may want to ask about a medical directorship if you are the only pain guy. They can then pay you for that. You may also want to have the hospital pay for a NP or PA.
 
mid|ine said:
You may want to ask about a medical directorship if you are the only pain guy. They can then pay you for that. You may also want to have the hospital pay for a NP or PA.
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excellent ideas...

make sure they cant lock you out of the area if it doesnt work out. No compete clause. i doubt it will apply to your govt. gig, but say you sign up and it sucks, make sure the no-compete is minimal, if non-existent. all these things are negotiable. You sound like you need a consultant or someone that help negotiate this for you. My attorney has a lot of experience in contract negotiations and helped me quite a bit, im sure you can find one in the your area, but they arent cheap...money up front that is well spent, in my opinion.
 
Doctors who don't have midlevels mostly agree we should not have them.

Doctors who employ midlevels often say "Well, mine are great, but the rest suck."
 
PMR 4 MSK said:
Doctors who don't have midlevels mostly agree we should not have them.

Doctors who employ midlevels often say "Well, mine are great, but the rest suck."
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Is it possible to run a profitable practice without employing some form of midlevel? I personally will stay away from the NPs and only hire PAs, because they are far less difficult to deal with in my experience.
 
PMR 4 MSK said:
Doctors who don't have midlevels mostly agree we should not have them.

Doctors who employ midlevels often say "Well, mine are great, but the rest suck."
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Mine is great...the others, well...
 
I agree with not hiring PA/NP. I like most of them, I think they are all ok people but I really think we should practice without them. Obviously unless you are a surgeon who can't do anything but be in the OR.
 
NYCRES said:
I agree with not hiring PA/NP. I like most of them, I think they are all ok people but I really think we should practice without them. Obviously unless you are a surgeon who can't do anything but be in the OR.
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it depends what they do, mine is like a resident. No decisions are made without my DIRECT involvement, except little decisions. She sees all of my inpatients first, and sometimes ONLY, we have a busy inpatient that i would dump if it wasnt for her...
In the office she sees some patients, all of the grenades, if i am running behind, she will see a new patient get it all going so i know whats up and i can see them efficiently. She fills my pumps, and does all kinds of office management cuz she's smarter than the average bear.

but she does NOT work as MD REPLACEMENT. nor does she want to.

i will truly say our professional relationship is what NPs are for, not to just see more patients and provide sub-par care. No one gets seen by her, that she doesnt discuss with me before they leave, and she may have a plan, but if i disagree, its always exactly how i want it to be. So she really is an extension of me, as opposed to a substitution.

Granted, she does not generate the same revenue as other NPs that see 20 narc patients a day functioning as a refill service...but for me, its worth it.
 
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She is fulfilling her role as a "physician extender"... and most good nurse practitioners realize that is the role that they perform the best.
 
painfre said:
Currently, I am working full time for a gov. hospital but soon becoming part time working for 3 days only. Got an offer to work in a pvt hospital for the about 2 days. The hospital is asking me to collect and bill the procedures I do. Hospital will provide the supporting staff, shared office,access to exam room and procedure room. Hospital will also do scheduling,records keeping, supplies etc. I need to have my own malpractice, DEA, Medicare provider number.
This information I got through email from the CEO of the hospital. I did not see the contract yet. I do not have private practice experience in the past. Is this a normal set up for a pain practice in a hospital?.
Thanks
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Hopefully they will do the PAs for their facility and your professional end. If you aren't comfortable doing your own billing and collecting then you might offer them a percentage to do that for you. They will be getting plenty from the facility fees that your procedures generate so it shouldn't be 10%. They have to be careful about providing anything without charging for it because of STARK, and it has to look like a fair price, but they should be able to do things cheaper because they already have the staff. I've got a contract with a small rural hospital where I just show up and don't bring any staff. They do my PAs, billing and collecting. I have my MA put together the schedule. I have insurance, ... I pay nothing for the PAs, billing and collecting, and for the office staff while I do clinic (or any other staff or anything else at that site). I didn't think that would fly with STARK but I had the lawyer for my group write it up and she says its good. I've been doing it for 2 years now. I could look for the contract if you want a copy.
 
thanks for the info. I will be meeting the CEO this week and discuss what to write in the contract. I would appreciate if you can PM me copy of your contract. Initially I was under impression that do not pay anything for the facility and draw about 40 or 50 percent of collections. But I realize there may stark law violation with this. As I mentioned the Hosp is offering me all the staff but I have to do my own billing and collecting which I am not comfortable right now and will ask their staff to do for me. Hospital did not talk about any facility fee till now. I will show the contract to ATTY once it is written. I
 
painfre said:
thanks for the info. I will be meeting the CEO this week and discuss what to write in the contract. I would appreciate if you can PM me copy of your contract. Initially I was under impression that do not pay anything for the facility and draw about 40 or 50 percent of collections. But I realize there may stark law violation with this. As I mentioned the Hosp is offering me all the staff but I have to do my own billing and collecting which I am not comfortable right now and will ask their staff to do for me. Hospital did not talk about any facility fee till now. I will show the contract to ATTY once it is written. I
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I hope you understand just how important the facility fee is the the hospital. They will make several times what you make for most procedures(which is why they want you there doing procedures).
That's why they're offering to pay for staff and supplies, and you should negotiate your contract so they pay for as much as possible while not breaking Stark rules. To start, no way in hell should they take 40-50% of your collections when they're already getting all the facility fees. You may consider them taking a very small percent of your collections for billing fees, but you should keep the vast majority of what you collect in this setup.
 
bedrock said:
I hope you understand just how important the facility fee is the the hospital. They will make several times what you make for most procedures(which is why they want you there doing procedures).
That's why they're offering to pay for staff and supplies, and you should negotiate your contract so they pay for as much as possible while not breaking Stark rules. To start, no way in hell should they take 40-50% of your collections when they're already getting all the facility fees. You may consider them taking a very small percent of your collections for billing fees, but you should keep the vast majority of what you collect in this setup.
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Also to piggy back what bedrock said.

Hospitals are making huge dividends of of you, which is ok. But they are sometimes making even 3 times as much on ESis,etc.

If you can get a RVU system made. Try not to go off of collections,etc. You should be RVU based. There should not be any difference in compensation for Medicare/Medicaid/Commercial Insurance.

This way you are just billing RVUs out. It's up to the hospital 'collect' via their billing service, if they dont, that's their problem not yours. Additioanlly, by having no difference to you as to what type of insurance the pt has, then you will less likely need to 'cherry pick' and also even if you get 'dumped' on by a whole lot of less desirable insured patients (trust me this WILL happen as PCPs will try to get them to your office and out of theirs) you are still ok.
 
PinchandBurn said:
Also to piggy back what bedrock said.

Hospitals are making huge dividends of of you, which is ok. But they are sometimes making even 3 times as much on ESis,etc.

If you can get a RVU system made. Try not to go off of collections,etc. You should be RVU based. There should not be any difference in compensation for Medicare/Medicaid/Commercial Insurance.

This way you are just billing RVUs out. It's up to the hospital 'collect' via their billing service, if they dont, that's their problem not yours. Additioanlly, by having no difference to you as to what type of insurance the pt has, then you will less likely need to 'cherry pick' and also even if you get 'dumped' on by a whole lot of less desirable insured patients (trust me this WILL happen as PCPs will try to get them to your office and out of theirs) you are still ok.
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Agree that an RVU system is often the way to go in this scenario. You can just focus on treating people and still be fairly compensated. Important as many hospital pain clinics don't have the best payor mix.
 
I'll dig up that contract when I get back to work and have my MA scan and email it.
RVUs are great as it sets your pay at a fee for service rate. I know of one doc who does a daily fee rate. With small hospitals they can often collect more. One hospital that is very upfront with me (and so gets most of my business) collects 1100 for a medicare LESI,and almost 2000 for a BC LESI (for the facility fee). Another wasn't so upfront or nice and so I stopped working there. I had done a 2 level bilat lumbar MBB on a patient who then came to another facility for RFA. She showed me her bill for the MBB and the hospital had billed BC 12000, and was paid 10000. Any kind of outpaitient service is very profitable for these facilities. They may be able to break even on inpatient medicine, and minimize their losses on OB, but the more specialty service they can recruit and provide the better they will do. Thus for you to establish an ASC in their area can be a killer, so they should reimburse you well for working in their facility.
 
I am planning to have Malpractice insurance on my own though hospital offered me if I want to. Any suggestions ? Which one is better. I am thinking of having occurrence based insurance for part time only. Less than 20 hrs. Is there a separate insurance for a pain practice. I saw some websites where they give PMR or Anesthesiology but not pain. How is the insurance for a PMR with Pain compared to Anes. with pain.
The hospital gave me the option of having my own billing and collections and I can use all their staff and space with out any rent (I can use their billing soft ware If I want to) and they get facility fees.
Other wise, they pay insurance, provider numbers etc, do billing and collection and give certain percentage of collections(they are going to tell me exact% this week after calculations.
I can do this way up to an year and can change then if I want to.
payer mix I was told is 60-65 Medicare, 30-35 Manged care, 4-5 Medicaid and some charity
 
painfre said:
I am planning to have Malpractice insurance on my own though hospital offered me if I want to. Any suggestions ? Which one is better. I am thinking of having occurrence based insurance for part time only. Less than 20 hrs. Is there a separate insurance for a pain practice. I saw some websites where they give PMR or Anesthesiology but not pain. How is the insurance for a PMR with Pain compared to Anes. with pain.
The hospital gave me the option of having my own billing and collections and I can use all their staff and space with out any rent (I can use their billing soft ware If I want to) and they get facility fees.
Other wise, they pay insurance, provider numbers etc, do billing and collection and give certain percentage of collections(they are going to tell me exact% this week after calculations.
I can do this way up to an year and can change then if I want to.
payer mix I was told is 60-65 Medicare, 30-35 Manged care, 4-5 Medicaid and some charity
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Do not under any circumstances use their staff. THen you can't fire them, and they are not answerable to YOU. Make sure you have your own billing and collections. The hospital would **** you over ROYALLY if you let them do the billing and collecting. 65% medicare is high. Negotiate out all medicaid and charity. You can't afford to lose that kind of money and don't want the risk.

Try to get a cut of the facility fee, thats where the big money is.
 
Realize with Medicaid, you get paid diddly squat, and so does the hospital on the front-end of the billing. However, most hospitals are getting paid behind the scenes extra money from Medicaid and their state, as well as sometimes local governments, to help offset the "indigent" population, which includes Medicaid.
 
The physician reimbursement for Medicare procedures and Anthem is effectively reduced to 1/3 of what is published in the physician fee schedule. You do a TFESI in your office and you collect $220. Same exact procedure in the hospital or ASC yields 1/3 of this. Because of the site of service differential that exists for Anthem and Medicare, it is almost impossible to make a decent living doing these procedures in a hospital or surgery center in which you do not have significant ownership. A payor class mix rich in Medicare/Anthem drives most physicians out of the hospital and into their own offices.
 
algosdoc said:
The physician reimbursement for Medicare procedures and Anthem is effectively reduced to 1/3 of what is published in the physician fee schedule. You do a TFESI in your office and you collect $220. Same exact procedure in the hospital or ASC yields 1/3 of this. Because of the site of service differential that exists for Anthem and Medicare, it is almost impossible to make a decent living doing these procedures in a hospital or surgery center in which you do not have significant ownership. A payor class mix rich in Medicare/Anthem drives most physicians out of the hospital and into their own offices.
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On one hand I hear comments like this, and at the same time I hear people say, "Work for a hospital or join a big group, because solo docs will be out of business in 5 years". Where it's really going to go, I'd like to know.

Does anyone have a crystal ball they'd like to sell?
 
No crystal ball, but here are the facts.
1. Just over 50% of doctors are employees of hospitals now
2. When physicians become hospital employees, their productivity decreases
3. Hospitals buy out physicians practices at inflated rates, and it takes approximately 3-5 years for the hospital to begin to break even on the purchase
4. Hospitals use the physician income controls to steal from Peter to pay Paul. PCPs make 10% more in a hospital employment setting: specialists make 15% less.
5. ACOs will decrease income to the system. They are effectively a HMO in which doctors are paid bonuses to not give care. Half the savings go to the doctors and the other half to medicare. The ACOs may either take over Medicare or the regulations and requirements (over 32 quality measures on every patient) may be so cumbersome, that the system will not work. Or if Congress fails to fix the SGR, then all hell breaks loose, and ACOs and Medicare will become fractured, non-functional systems.
6. Pain medicine could either be left alone for awhile or undergo more draconian restrictive rules adopted by insurance and Medicare. If the latter is true, then many will leave the field...
 
I must be living in heaven. I collect 150 from medicare for a TFESI done in the hospital but if the hospital collects for me it is about 250. I collect 515 from medicare for an RFA for bilat L4-5 and L5-S1 facets done in the hospital, and if the hospital collects for me it is 895. If the hospital staff doesn't cooperate then I let the HR manager know that we are losing money and changes are made. I'm not Mr efficiency myself, but the staff has to be open to change and improvement. I did have a bad experience with one hospital but I saw that coming after the first few weeks and so cut my losses, but all the others are good to me. Of course I am the only pain doc for a 2.5 hour radius so if they want the service then they have to play nice. For medicaid and public aid they won't cover any procedures so I apologize and tell them to call me when they get medicare. I suspect that if I lived in the city then I would be considered expendable and have to deal with the abuse and wouldn't be able to write the contract.
 
The 2011 Medicare Fee Schedule shows a TFESI lumbar performed in a hospital pays $116 and in an office pays $234. A IL ESI or caudal ESI pays $98 in a hospital and $221 in an office. A 3 level RF lumbar bilateral pays $819 in an office and $411 in a hospital.
The overall patient cost for doing these procedures is much much higher in a hospital than in an office. The cost in a hospital for the Medicare paid hospital fee plus physician fee for a IL ESI/Caudal is $620, for a lumbar TFESI is $638, and for a three level RF bil lumbar is $3,336. The costs to the medical system and to the patients are therefore 300% higher in a hospital for routine injections and over 400% higher for RF, for no added benefit or safety.
 
Algos,

Why doesn't anyone else "get" this. The numbers are obvious and well known. I know that hospitals have strong lobbyists, but so do insurance companies. Things that can be safely performed in a physician's office are cheaper to "the system."
 
The hospital lobby has been very strong. Perhaps over time even the CMS and Congress, as dense as they are, will recognize we cannot continue to afford the most expensive and unnecessary care on earth.
 
Pisses me off that the "system" (at least CMS) thinks this is due to "overpaid and greedy" pain doctors and responds by decreasing physician fees through bundling of MBB, TFESI, and now RF & SIJ, while ignoring the enormous amount of money is being paid to hospitals/ASCs in unnecessary facility fees.
 
bedrock said:
Pisses me off that the "system" (at least CMS) thinks this is due to "overpaid and greedy" pain doctors and responds by decreasing physician fees through bundling of MBB, TFESI, and now RF & SIJ, while ignoring the enormous amount of money is being paid to hospitals/ASCs in unnecessary facility fees.
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This is always the selling point used to gain traction politically to get public support from the masses. The government isn't stupid. They know which "overpaid and greedy" people line their pockets the most, and its not pain doctors, or doctors at all. It's the hospitals and insurance companies who have the deepest pockets (and lawyers who earn less on average, but contribute way more to politicians). Politics is a brutal game, and docs have always been terrible at it. We're too busy focusing on the Medicine. Therefore, they steer the ship, and we go along for the ride, waves and all. Until we flex our political muscles more, this how its going to be. Exhibit A: The malpractice situation, Exhibit B: Medicare cuts in payments to MDs, Exhibit C: JAHCO, Exhibit D: Press Gainey scores, Exhibit E: Obamacare. Doctors have a tremendous amount of power, but in general we are afraid of being painted as "overpaid and greedy". For some reason, those that really are overpaid and greedy, have no fear whatsoever of being painted this way. Whether or not we can right the ship, I don't know. I do know we need to fight back, for our sake, for patient's sake and for America.
 
emd123 said:
This is always the selling point used to gain traction politically to get public support from the masses. The government isn't stupid. They know which "overpaid and greedy" people line their pockets the most, and its not pain doctors, or doctors at all. It's the hospitals and insurance companies who have the deepest pockets (and lawyers who earn less on average, but contribute way more to politicians). Politics is a brutal game, and docs have always been terrible at it. We're too busy focusing on the Medicine. Therefore, they steer the ship, and we go along for the ride, waves and all. Until we flex our political muscles more, this how its going to be. Exhibit A: The malpractice situation, Exhibit B: Medicare cuts in payments to MDs, Exhibit C: JAHCO, Exhibit D: Press Gainey scores, Exhibit E: Obamacare. Doctors have a tremendous amount of power, but in general we are afraid of being painted as "overpaid and greedy". For some reason, those that really are overpaid and greedy, have no fear whatsoever of being painted this way. Whether or not we can right the ship, I don't know. I do know we need to fight back, for our sake, for patient's sake and for America.
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the question is how? Docs are prevented from 'striking' or collusion? "Anti Trust" laws is what's been thrown around. But no none can pin point why we can't. We need docs to all join in on the efforts, across all specialities and w/i the specialty.
 
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