RVUs and the like

[WisNeuro]

Anyone using these in their facility to track productivity yet?

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[erg923]

Yes

 

[WisNeuro]

We're set to move to this next year. They're kind of piloting it this fall to use as projections. What are your thoughts on this? Has it changed your clinical load at all?

 

[erg923]

We're set to move to this next year. They're kind of piloting it this fall to use as projections. What are your thoughts on this? Has it changed your clinical load at all?

I have all kinds of other metrics that they look at for me including "penetration rates" (gigitty...) from PCC, number of unique encounters, and number of "warm-handoff" consultations. All I know is that my penetration rates is the highest off all CBOCs for our VAMC, and last time checked, I was at 110% of my productivity expectation. I was told I can back off the throttle some. I am busy but not anything near swamped.

 

[Therapist4Chnge]

Thankfully no, though I think we are in the minority. I'd be very weary of "estimated" RVU numbers your hospital provide as a benchmark, as they are often unrealistic for how psychologists practice in a medical center (compared to physicians either in the hospital or in out-pt).

*edit to clarify*

An RVU isn't the same at Hospital A as Hospital B. While it seems like it should be a standardized unit, there are various adjustments that are made that change the value. For example, the dollar conversion factor needs to be applied to compare apples to apples (or that is the assumption). There are also adjustments at the hospital level where administrators can adjust the total number of RVUs based on productivity goals. It is a mess of a system, but it is a popular approach these days.

 

[WisNeuro]

Hmm, we projected ours out and we would all be over our expectation. We also have other productivity measures, % of clinical time, and the ever ubiquitous time to see patient within 30 days of consult.

 

[smalltownpsych]

We use RVUs and that is factored into our compensation. The system is too complicated for me to understand without spending so much time on it that my productivity would go down. At this point, I am being compensated very well so am not complaining. The VP of finance told me that the RVUs are adjusted upward for psych by about 10% above the actual billing so that seems fair and helps to account for non-billable activities that I do for the hospital.

 

[Sanman]

My company recently moved to an RVU system and I have worked with them at my previous employer. I am not loving it, but is has not impacted my practice immensely. Having a system based largely on billable units, you can imagine the pressure.

 

[PikminOC]

My company recently moved to an RVU system and I have worked with them at my previous employer. I am not loving it, but is has not impacted my practice immensely. Having a system based largely on billable units, you can imagine the pressure.

Yep

 

[Therapist4Chnge]

We use RVUs and that is factored into our compensation. The system is too complicated for me to understand without spending so much time on it that my productivity would go down. At this point, I am being compensated very well so am not complaining. The VP of finance told me that the RVUs are adjusted upward for psych by about 10% above the actual billing so that seems fair and helps to account for non-billable activities that I do for the hospital.

I'd question it only being 10%….are you purely a consult service or out-pt referral? If I was the latter I'd be okay with that %, but if you are spending any significant amount of time in the hospital providing clinical services that 10% seems awfully low.

You'll want to know how the RVU and total RVU expected are being calculated, as those numbers are your bar and they can make a huge difference.

 

[smalltownpsych]

I'd question it only being 10%….are you purely a consult service or out-pt referral? If I was the latter I'd be okay with that %, but if you are spending any significant amount of time in the hospital providing clinical services that 10% seems awfully low.

You'll want to know how the RVU and total RVU expected are being calculated, as those numbers are your bar and they can make a huge difference.

They don't expect a certain amount of RVU, I just get a percentage of whatever that is converted to dollars. About 75% of my work is in the outpatient clinic and many of the consults that I do lead to more work there so it all works out pretty well.

 

[madeincanada]

Re-visiting this question of RVUs... I am curious if anyone on this board can share what RVU expectations their institution has for them, and if they know how much their institution is compensated per RVU they generate?

 

[WisNeuro]

Re-visiting this question of RVUs... I am curious if anyone on this board can share what RVU expectations their institution has for them, and if they know how much their institution is compensated per RVU they generate?

No clear mandate, but I hear ~1900 give or take 100 or so is in the realm.

 

[BuckeyeLove]

this is going to sound a bit naive I imagine, but what is an RVU?

 

[WisNeuro]

this is going to sound a bit naive I imagine, but what is an RVU?

Relative Value Unit. Just another semi-arbitrary measure of productivity.

 

[Therapist4Chnge]

Relative Value Unit. Just another semi-arbitrary measure of productivity.

It's technically a measure of efficiency that was twisted into a measure of productivity.

BL..think of it like a widget and a value is assigned to it, jobs are assigned a certain number, salaries are linked to them.

They are mostly bad for us, but widely utilized.

 

[WisNeuro]

It's technically a measure of efficiency that was twisted into a measure of productivity.

BL..think of it like a widget and a value is assigned to it, jobs are assigned a certain number, salaries are linked to them.

They are mostly bad for us, but widely utilized.

We're not officially on them yet, but I track mine and am already devising ways to game the system to up my RVU's without increasing my actual workload if it comes down to it

 

[AcronymAllergy]

Our productivity is currently tracked via RVUs. There's technically no direct/immediate recourse or bonus for poor/good numbers, at least at present (our salary isn't directly tied to them), but if they're consistently low enough, you'll get a talking-to.

As for specific #'s, I've heard anywhere from the 1900-ish WisNeuro mentioned to mid-2000's. This is in neuropsych, mind you; not sure about other areas of practice.

 

[smalltownpsych]

My RVUs are in the 3000 range. The only thing that counts for RVUs are procedure codes. If you are doing anything else like talking on the phone or reviewing records or charting or collaborating, then you get nothing. At least with testing you can code the time to score, interpret, and write up the results. I haven't really compared the various RVUs for various procedures to see what is most efficient. At this point, I just do whatever work comes my way that I am competent to perform.

edited to correct

 

[Pragma]

It probably would be tough to tie salary directly to RVUs at the VA given the larger salary structure, but it could be one of multiple performance indicators.

 

[erg923]

It probably would be tough to tie salary directly to RVUs at the VA given the larger salary structure, but it could be one of multiple performance indicators.

I tried to get interested and investigate in all this, but I just cant. Its boring. And there are so many problems with this given the nature of my position. I also have time time carved out for internship admin duties too, so I think my targets are bit lower than others.

They send me some number occasionally (not consistently). I have never had any problem with "productivity" as long as ive been here, so Ill just keep on keepin on.

 

[deleted343839]

My RVUs are in the 4000 range.

Wow. What's it like out there on the tail of the distribution?

 

[bmedclinic]

My RVUs are in the 4000 range. The only thing that counts for RVUs are procedure codes. If you are doing anything else like talking on the phone or reviewing records or charting or collaborating, then you get nothing. At least with testing you can code the time to score, interpret, and write up the results. I haven't really compared the various RVUs for various procedures to see what is most efficient. At this point, I just do whatever work comes my way that I am competent to perform.

We dont use RVU's, but I think prior to this the highest # I recall hearing was like 2700. Tell us your ways.

 

[smalltownpsych]

Wow. What's it like out there on the tail of the distribution?

It can be exhausting at times, but at least i get compensated for it.

We dont use RVU's, but I think prior to this the highest # I recall hearing was like 2700. Tell us your ways.

40 hours of patients booked solid every week and a bump every four weeks with being on-call.

 

[smalltownpsych]

I just looked into it further and that number is after the conversion that my company does for some unknown reason. I actually did 3200 work RVUs last year and then they converted that up to 4200. Then there are work RVUs verses regular RVUs, it can be confusing.

 

[deleted343839]

Still, 3200 wRVUs is a TON. I hope you are very well compensated!!

 

[AcronymAllergy]

My RVUs are in the 3000 range. The only thing that counts for RVUs are procedure codes. If you are doing anything else like talking on the phone or reviewing records or charting or collaborating, then you get nothing. At least with testing you can code the time to score, interpret, and write up the results. I haven't really compared the various RVUs for various procedures to see what is most efficient. At this point, I just do whatever work comes my way that I am competent to perform.

edited to correct

There are actually codes for telephone calls (that involve patient care) and chart review, but yeah, those would be for situations outside "the norm" for psychotherapy, assessment, etc. And I have no idea if/when/how they're reimbursed; I'd imagine they're probably just more for internal productivity tracking than actual external billing.

 

[smalltownpsych]

Still, 3200 wRVUs is a TON. I hope you are very well compensated!!

Tail end of the distribution on that too. I could actually work less, but I like the checks. I used to work as hard for almost half the money so I can't complain. This is the first time in my life where I have experienced direct rewards for hard work and success. Today is really a challenge because it was all kids and families and it looks like an 8 for 8 day. I actually will have done 36 appointments this week and used the four cancel/no shows to score and write up an assessment. Man, that hottub is going to feel good tonight.

 

[WisNeuro]

There are actually codes for telephone calls (that involve patient care) and chart review, but yeah, those would be for situations outside "the norm" for psychotherapy, assessment, etc. And I have no idea if/when/how they're reimbursed; I'd imagine they're probably just more for internal productivity tracking than actual external billing.

Yeah, occasionally use the phone codes (967-968), I'm still trying to get the e-consult thing up and going here. Not much of an issue now, but, if they give us RVU targets in teh future, I'm going to insist on the e-consult to track that time.

 

[Therapist4Chnge]

We are at ~2400 RVUs/yr, which is 75th percentile for AMCs. We get time bought out for research, admin, clinical contracts, and other duties...so most are <2000 RVUs/yr. It is new for us, so I'm not sure how it will shake out. With the buy out adjustment, the #'s seem doable for the neuropsych faculty, not sure about other clinical faculty.

 

[Ollie123]

Sounds like it is pretty institution-specific, but can anyone recommend resources for getting a general sense of how this works for psychologists? Only resources I've found have been medical-heavy. I'm fortunately not tied to this right now (and likely won't be ever if I get my way).

I think no-shows/cancellations would be the killer for us - especially with a full caseload and no real room to rebook people. I think mine hovers around 15% right now, but I have a relatively higher SES/moderate severity caseload at present and the flexibility to reschedule since I'm only 40% clinical effort. For some populations I've worked with it isn't unusual to see no-show rates in the 30-40% range...

 

[Therapist4Chnge]

PM me your email and I can send along a few articles about understanding RVUs.

 

[smalltownpsych]

There are actually codes for telephone calls (that involve patient care) and chart review, but yeah, those would be for situations outside "the norm" for psychotherapy, assessment, etc. And I have no idea if/when/how they're reimbursed; I'd imagine they're probably just more for internal productivity tracking than actual external billing.

With assessments, you can count the chart review, I am pretty sure. We can't bill for phone calls at our hospital as to the best of my knowledge, no insurance will reimburse for it. The one exception would be when I use a crisis code where the phone calls can be part of the time that you are counting.

 

[Ollie123]

Sorry, had to bump this. I just found out our "target" RVUs beginning in September will be a bit over 4000 (assuming 100% clinical effort). Minimum to "not get fired" is apparently 2700. They are apparently changing the system significantly, but they had some things that are just flat out crazy built into their assumptions (475 new patient intakes?).

I'm fortunately insulated from this in my current role, but it came up in the context of ongoing discussion about my long-term plans within the department. My only thought is that we do work on a medical "attending" model with trainees billing under their supervisor. Between an attending and a couple interns or post-docs, those numbers start to look a little more realistic (though I still have no idea what individual practitioner does 500 intakes a year). If trainees don't count, I have no idea how anyone could manage to pull that off.

*re-reads self-care thread very carefully*

 

[Therapist4Chnge]

Those are completely unrealistic numbers.

I still owe you those articles. I'm out sick, but I'll get them to you when I'm back in the office.

 

[erg923]

Sorry, had to bump this. I just found out our "target" RVUs beginning in September will be a bit over 4000 (assuming 100% clinical effort). Minimum to "not get fired" is apparently 2700. They are apparently changing the system significantly, but they had some things that are just flat out crazy built into their assumptions (475 new patient intakes?).

I'm fortunately insulated from this in my current role, but it came up in the context of ongoing discussion about my long-term plans within the department. My only thought is that we do work on a medical "attending" model with trainees billing under their supervisor. Between an attending and a couple interns or post-docs, those numbers start to look a little more realistic (though I still have no idea what individual practitioner does 500 intakes a year). If trainees don't count, I have no idea how anyone could manage to pull that off.

*re-reads self-care thread very carefully*

 

[smalltownpsych]

Sorry, had to bump this. I just found out our "target" RVUs beginning in September will be a bit over 4000 (assuming 100% clinical effort). Minimum to "not get fired" is apparently 2700. They are apparently changing the system significantly, but they had some things that are just flat out crazy built into their assumptions (475 new patient intakes?).

I'm fortunately insulated from this in my current role, but it came up in the context of ongoing discussion about my long-term plans within the department. My only thought is that we do work on a medical "attending" model with trainees billing under their supervisor. Between an attending and a couple interns or post-docs, those numbers start to look a little more realistic (though I still have no idea what individual practitioner does 500 intakes a year). If trainees don't count, I have no idea how anyone could manage to pull that off.

*re-reads self-care thread very carefully*

If that 4000 mark is not based on trainees then it is an impossibly high mark. Are they going pay almost 200k a year if you hit it? That's about what I would get and even then it's not worth it for me to work that much more. The 3200 I did last year was close to my limit. If I was doing inpatient it might be different as I would have no no shows and I could do three 30'minute sessions an hour still be able to use the bathroom and squeeze more , but most patients need more than 18 minutes of treatment. A doc I work with does several 45 minute sessions at end of day with no break to squeeze in an extra appointment a day. Ultimately, if they pay for the productivity then there is motivation to do more and then we have to balance that with what we can do and still be clinically effective. I prefer to be the one in charge of that equation as opposed to the bean counters.

 

[Ollie123]

Those are completely unrealistic numbers.

I still owe you those articles. I'm out sick, but I'll get them to you when I'm back in the office.

No worries. I'll apparently be too busy working to read them anyways

 

[erg923]

If that 4000 mark is not based on trainees then it is an impossibly high mark.

I just looked at my numbers, and if salary were adjusted (which it wouldn't cause I'm at a VA), I would be making over 200,000/year if that happened. Meaning, my current RVU target is half that.

 

[Ollie123]

If that 4000 mark is not based on trainees then it is an impossibly high mark. Are they going pay almost 200k a year if you hit it? That's about what I would get and even then it's not worth it for me to work that much more. The 3200 I did last year was close to my limit. If I was doing inpatient it might be different as I would have no no shows and I could do three 30'minute sessions an hour still be able to use the bathroom and squeeze more , but most patients need more than 18 minutes of treatment. A doc I work with does several 45 minute sessions at end of day with no break to squeeze in an extra appointment a day. Ultimately, if they pay for the productivity then there is motivation to do more and then we have to balance that with what we can do and still be clinically effective. I prefer to be the one in charge of that equation as opposed to the bean counters.

I'd get around 130k for hitting it per the business office, but they also have some weird assumptions about billing (50% collection? That may be true department-wide if you factor in things like ED admissions to psych inpatient but I'm pretty sure collection in our relatively high SES outpatient clinic is immensely higher). We're eat-what-you-kill right now, so I think 200 is probably closer to reality. The whole system is in the process of changing though, so I don't think any of this should be taken too seriously. Its only semi-relevant to me personally since NIH-willing I won't ever be anywhere close to 100% clinical effort. I just found it funny to see the discussion of 2000 and have my department come in with double that and be like "Well...of course. Why wouldn't you do 500 intakes?." Note: The meeting was with an MBA with a background in medical billing, not a provider.

 

[Ollie123]

OH - it gets better.

I just saw in the spreadsheet they are basing it off a 42-week year. So 4000 RVUs in 42 weeks. Totally doable, right? 10 weeks vacation sounds nice though.

I just asked someone and I do think it includes trainees. That makes far more sense to me, but it still seems like an overly simplistic framework since it doesn't account for their salary/fringe, etc.. This is particularly funny to me since I'm at what is arguably one of the top institutions in the country when it comes to "big data" analysis. They could just release the data to one of a half dozen faculty in the department and we could likely have it all sorted out inside a week. Instead, there is one excel spreadsheet titled "psychologist" with a dozen columns.

 

[AcronymAllergy]

Keep us posted; 4000 as a target sounds ridiculous. Like erg said, my expectation last year was half that. Even with my abnormally low no-show rate for '15 (which has since righted itself and then some, unfortunately), I think I "only" came in around 2200-2300.

Although I do all my own testing and don't have any trainees billing under me.

 

[deleted343839]

I'd get around 130k for hitting it per the business office, but they also have some weird assumptions about billing (50% collection? That may be true department-wide if you factor in things like ED admissions to psych inpatient but I'm pretty sure collection in our relatively high SES outpatient clinic is immensely higher). We're eat-what-you-kill right now, so I think 200 is probably closer to reality. The whole system is in the process of changing though, so I don't think any of this should be taken too seriously. Its only semi-relevant to me personally since NIH-willing I won't ever be anywhere close to 100% clinical effort. I just found it funny to see the discussion of 2000 and have my department come in with double that and be like "Well...of course. Why wouldn't you do 500 intakes?." Note: The meeting was with an MBA with a background in medical billing, not a provider.

50% collection might be a reasonable target depending on your institution's billing practices. You might find out for yourself what your collection rate has been recently. There's no reason why someone shouldn't be able to give the historical collection rates for each service, or each clinician.

4000 RVUs is insane. That's how you run a psychology service into the ground.

 

[Sanman]

The answer to

Sorry, had to bump this. I just found out our "target" RVUs beginning in September will be a bit over 4000 (assuming 100% clinical effort). Minimum to "not get fired" is apparently 2700. They are apparently changing the system significantly, but they had some things that are just flat out crazy built into their assumptions (475 new patient intakes?).

I'm fortunately insulated from this in my current role, but it came up in the context of ongoing discussion about my long-term plans within the department. My only thought is that we do work on a medical "attending" model with trainees billing under their supervisor. Between an attending and a couple interns or post-docs, those numbers start to look a little more realistic (though I still have no idea what individual practitioner does 500 intakes a year). If trainees don't count, I have no idea how anyone could manage to pull that off.

*re-reads self-care thread very carefully*

The answer to who does 500 intakes per year is I probably do about that many in sub acute rehab. Our rvu requirements look similar to yours as well. Which is why I started the self-care thread....

 

[deleted760483]

Is 4,000 RVU really that crazy? I thought a 90837 (53+ min psychotherapy session) was 3 RVUs. Based on that, seeing 6 clients a day for 50 weeks is 4,500 RVU.

 

[erg923]

Is 4,000 RVU really that crazy? I thought a 90837 (53+ min psychotherapy session) was 3 RVUs. Based on that, seeing 6 clients a day for 50 weeks is 4,500 RVU.

Most people take more time off than 2 weeks in a given year (you've basically accounted for all the major holidays and nothing else. I think I was out a total of 15 work days last year in addition to the 10 major holidays).

Patients no show/cancel.

Department meetings

CEUs

Many carriers have limits on, or require pre-cert, for 90837.

To me, 6 hour-long patients 5 days a week would be nauseating.

 

[Therapist4Chnge]

+1 to everything erg923 wrote.

One of the biggest issues psychologists have is the vast majority of our codes are time-based, so increased RVU req= increased HOURS. We have a very limited ability to add on codes/RVUs to an encounter. There are complexity codes, but you need to have adequate documentation for them and over-utilization is a flag for an audit.

90791 is untimed, though it generally can only be used once (with a few exceptions). That's fine, but after that it is a downward slide of fighting no shows, lost time, pre-auth, etc. because everything else is time-based.

In the neuro world it's juggling pre-auth and/or medical necessity, reimbursement rates, and arbitrary audits and changes in policies.

Many students incorrectly assume that it's merely "hit your RVUs", though revenue still matters because someone is reviewing the books.

 

[Ollie123]

Schedule 8 to get 6 seems a reasonable goal for someone in private practice. Not what I would want to do (for similar reasons to erg) but if that is someone's goal I don't think its incredibly unreasonable. 8-5, notes during lunch/no-shows (since you've eliminated that 15 minute "gap" you get when scheduling 45 minute sessions).

That said, there are some other issues I think may play into this that I am hoping someone else can comment on. I'd think ONLY doing 60 minute sessions would raise flags with insurers. I think our collection rate on these is lower, presumably for that reason. Standard of care issues and all that. Neither insurance nor our billing staff seems to understand that the length of session is more dependent on the length of session is more dependent on the patient's tendency to keep talking despite repeated attempts to shuffle them out the door than it is on medical necessity, problem severity or anything else. I suspect the same is true in medicine/primary care practices.

That said - if I can I'll do back-to-back 60 minute sessions on my clinic days. Bmed/primary care type settings it makes financial sense to pile in 30 minute sessions if patient flow allows. I might do this with CBT-I patients too. Both models would pay better than 45-minute sessions would.

 

[psych844]

I was out a total of 15 work days last year

That's it?
The VA doesn't give you 4 weeks off at least? (on top of holidays)?

 

[erg923]

That's it?
The VA doesn't give you 4 weeks off at least? (on top of holidays)?

No, I didn't exhaust my leave days. Need to keep some in there for rainy days. Some of those days I was out were sick days too, which is separate bank of time.