SNF/SAR Private Practice for PM&R Docs

[vit8bsm]

I've been seeing a lot of talk recently about SNF/SAR work from PM&R attendings and residents. There's a couple big companies that I've seen offer splits (always majority in our favor like 70% collections we keep) on a 1099 but why not just go to the facility directly and set things up? Does anyone do this? You get your own billing service, malpractice etc. and bill directly which would yield a much better split in our favor. Why allow these middlemen companies to take a cut? I understand this may be harder in saturated areas but wanted to hear perspectives on it by people doing it. I did meet one guy, who's at 85%+ profit that he keeps pre-tax right now, with malpractice, billing etc. taking up less than 15% of his collections. He does a lot of volume though, no mid-levels. Private solo practitioner.

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[sloh]

The short of it is bigger companies that are nationally known will swoop in on your business. This has been discussed a lot in this sub forum. Just search it up

 

[RangerBob]

It seems to me going directly to the facility/medical director is the best way to go.

I believe the national companies only help with templates/billing/placement. If you already know where you want to work and can create your own templates/find your own biller, you'll be able to keep much more of what you earn.

I can't imagine how one of those companies would be able to swoop in on your business if you have a good relationship with the medical director/facility. I'd like to hear more about that concern--it's not something I've heard about before.

For the record I work IPR. But locally we only have one SNF with PM&R coverage, so it would be quite easy to go SNF if I wanted to.

 

[sloh]

It seems to me going directly to the facility/medical director is the best way to go.

I believe the national companies only help with templates/billing/placement. If you already know where you want to work and can create your own templates/find your own biller, you'll be able to keep much more of what you earn.

I can't imagine how one of those companies would be able to swoop in on your business if you have a good relationship with the medical director/facility. I'd like to hear more about that concern--it's not something I've heard about before.

For the record I work IPR. But locally we only have one SNF with PM&R coverage, so it would be quite easy to go SNF if I wanted to.

Nursing telephone post-care coordination to minimize hospital readmissions, AI PDPM scanning to help streamline MDS coordinator’s jobs.

 

[RangerBob]

Nursing telephone post-care coordination to minimize hospital readmissions, AI PDPM scanning to help streamline MDS coordinator’s jobs.

The SNF isn’t already doing that?

I guess if the national organizations are offering to do some of the SNF’s duties I can see why a SNF director may be willing to let the national SNF MD companies push out current docs, but I still think that would be unlikely if the current doc has a really good relationship with the medical director/SNF director.

Also, in our experience, when you start outsourcing those RN post-care calls, the quality goes way down. We resumed doing them on our own—better/easier/cheaper in the long run.

 

[sloh]

The SNF isn’t already doing that?

I guess if the national organizations are offering to do some of the SNF’s duties I can see why a SNF director may be willing to let the national SNF MD companies push out current docs, but I still think that would be unlikely if the current doc has a really good relationship with the medical director/SNF director.

Also, in our experience, when you start outsourcing those RN post-care calls, the quality goes way down. We resumed doing them on our own—better/easier/cheaper in the long run.

But you work IPR right? I could be wrong but I’d wager you guys have more funds than SNF’s to offer that

 

[RangerBob]

But you work IPR right? I could be wrong but I’d wager you guys have more funds than SNF’s to offer that

Yes, I work IPR, and you’re correct we generally have more funds/resources than SNF

 

[PMR2008]

I suppose might as well reply lol
I have been commenting on SAR work for 12 years now but here is another
- No one is preventing you to go to the facility directly. Many have tried. Most have failed but a handful have done it really well independently. You can still do it but much tougher competition. Good luck to you if you do so.
- If you have med director connections you can try that
- If you think that the national companies only help with templates/billing/placement you have a very old and wrong understanding of this.
- Med director relationships don't mean much. SNFs are usually owned by corporations. They have a very different focus and they call the shots. I have seen medical directors fired by corporate for not wanting to incorporate Physiatry. IM/FP docs are dime a dozen. Physiatrist who work in SAR are much harder to find.
- You will have pockets of the country where there is limited or so Physiatry in SAR
- Most of the SAR national companies hire inhouse nurses for post discharge services.
- There is a high likelihood old school Physiatrist working in SAR will be replaced by APPs in the future unless they innovate. The national companies tend to be innovative but not all.

 

[RangerBob]

I suppose might as well reply lol
I have been commenting on SAR work for 12 years now but here is another
- No one is preventing you to go to the facility directly. Many have tried. Most have failed but a handful have done it really well independently. You can still do it but much tougher competition. Good luck to you if you do so.
- If you have med director connections you can try that
- If you think that the national companies only help with templates/billing/placement you have a very old and wrong understanding of this.
- Med director relationships don't mean much. SNFs are usually owned by corporations. They have a very different focus and they call the shots. I have seen medical directors fired by corporate for not wanting to incorporate Physiatry. IM/FP docs are dime a dozen. Physiatrist who work in SAR are much harder to find.
- You will have pockets of the country where there is limited or so Physiatry in SAR
- Most of the SAR national companies hire inhouse nurses for post discharge services.
- There is a high likelihood old school Physiatrist working in SAR will be replaced by APPs in the future unless they innovate. The national companies tend to be innovative but not all.

Out of curiosity, why do you think physiatrists at SARs will be replaced by APPs? The physiatrists don’t actually cost the SNF anything, do they? I always assumed they SAR physiatrists) were dependent on their collections—whether independent or working with one of the large staffing companies. (An assumption I'm guessing is wrong base on your statement)

 

[PMR2008]

The SNFs don't care who provides the Physiatry service. A dedicated, present APP who brings services/products the SNFs are asking for will always trump a fly by night Physiatrist.

 

[lejeunesage]

I can answer this as someone who's tried it.

1. Non competitive market: facility answered right away. They were happy to have me. I made a case for what I could do. Then I waited... all I got were random, sporadic inappropriate consults instead of being consulted on the volume I'd requested. I decided that I was busy enough at my hospital and pulled the plug on the whole thing.
2. Competitive market 2 different metro areas where I was considering moving. I only ever got one administrator on the phone, and she wasn't interested. No one else bothered answering any of my calls or emails. I must have contacted upwards of 20 facilities.

There's the perception among many physiatrists that all you have to do is show up and these SNFs will be happy to pull out the red carpet. This may have been true once upon a time but the landscape has changed. Even if you're able to make the case that your services will be billed directly to Medicare, chances are, they won't be interested. In competitive markets, they have more than enough physicians/groups/national companies trying to staff their buildings. These large groups can afford to hire marketing directors to do market analyses and make a specific pitch designed to help these facilities in the specific locale where they're situated.

Unless you somehow have a ton of experiences in SNF or you're able to build a relationship with the leadership with some of the big SNF owners in your area, there's no way you can compete. Are you offering any post-discharge services other than rounding on patients? Probably not. Even if you manage to get in, you'll serve at the pleasure of the leadership. You'll be very replaceable if there's a change in administrator or if the facilities where you work are sold to a new company.

I looked into this and decided that if I wanted to do SNF, I'd a few choices:
1. Stay independent in a non-competitive market (even then, it's not a given that you'll be able to get your foot in the door and get the number of consults you want).
2. Join one of the big companies like Medrina or US Physiatry. Here, you have to know yourself. How many patients can you see in a day? How many notes can you write? You can make good money, but you're only keeping 70% of your collections. You only make money by seeing super-high volumes. Can you see 40 patients a day? 50? 60? If not, you might as well stick to IPR.
3. Work as SNF Medical Director. Been there, done that... never again. I'm pretty comfortable with medical management but the ratio of medicine to rehab was too damn high.
4. Join a new company like Lightyear Health, which seems to have a different compensation structure.

After looking into my options, I decided to stick with IPR. It's better to know your own strengths and weaknesses.

 

[PMR2008]

A few thoughts. I would not want to join lightyear. Very very APP heavy. They are pushing APPs to be independent.
Regarding your post , I have been saying the above for 12 years lol. Definitely started to sound like a broken record.
I do disagree with your assessment about "you only make money by seeing super high volume". You actually make 300k+ if you see 22-25 patients a day. Obviously if you want to make 500k than you have to see more. Also most of the docs don't spend more than 1-2 hrs a day doing notes and 4-5 hrs or less of rounding. Not because the quality of care is poor but because there are process in place. Integrated EMRs, scribes, templates, mentorship, process to get consults, back office support, better reimbursement per patient(insurance contracts), flexibility to move around, profit sharing from APPs etc. The national companies are not for everyone but those who fit into the system do very well.

 

[lejeunesage]

=)

I suppose "super high volumes" is relative.
In IPR, you make north of 300K seeing only 15 patients a day. And that's without a directorship stipend. If you're looking to have IM do the admissions and PM&R as consultant, there are plenty of Encompass facilities where that's the set up. It might be more time-intensive because you have to do team conferences but that's a trade-off many people would be comfortable with.

Personally, if I were seeing 22-25 patients a day, I'd hire my own scribe and still expect to earn north of $500K. But, then again, IPR is what I grew up with, so to speak.

Assuming 22-25 patients a day with an average of 3 discharges and 3 admissions a day (fairly conservative), I'd expect to bill:
Admissions: 99223 ($200) X 3 = $600
Discharges: 99239 ($100) X 3 = $300
Progress notes: 99232 ($70) X 19) = $1330

[YMMV. I'm using Medicare rates for the above calculations. If you live in an area with generous commercial insurance plans, you'd make more. If you live somewhere with a ton of Medicaid, you might make a lot less.]

That comes to $2230/day and $11,150/week in billings, and that's if you never bill a level 3 progress note.
Assuming a 15% loss to unpaid bills and billing company cut, you still get something like $9477.5/week.
You can take 6 weeks off and still expect to take home $435,965 before any directorship stipend.
Depending on whether you work for Encompass, HCA, Vibra, or Lifepoint, you can expect to add another $80-150K/year to that as medical director.

On the other hand, if you take a good employment contract with a hospital medical group and you see that kind of volume, your directorship stipend will be much lower ($30-60K) but you'd essentially get a 100% collections rate (in the scenario above, you'd take home $512,900 before any stipends) + benefits + [sometimes] call pay.

I still think there are some advantages to SNF and many people would thrive a lot more with SNF work. The highest grossing SNF physiatrist I know makes way way WAY more than the highest grossing IPR doc I know. But your average physiatrist seeing an average number of patients is likely to do a lot better financially in IPR. Personally, like I said, I know my limits. 25-30 patients is the absolute maximum I could every see myself seeing in any setting. And at that level, I'm sweating, even with a scribe. And I feel like my chances of making a bad mistake increase exponentially.

I'm not the slowest doc I know but I was never anywhere near some of the speed demons I've encountered in my years of training. There was a guy in 3rd year of Med school who was already faster, more organized, and efficient than most attendings I knew in residency. My guess is that today, his billings are somewhere in the stratosphere, wherever he works.

 

[PMR2008]

You are getting one thing wrong. Everyone should base their income on an hourly wage and not yearly income. None of the docs doing subacute for a few months are spending more than 4-5 hrs rounding (when seeing 25+) and 1-2 hrs of notes. If they are than they didn’t get training or mentorship. No call, no evening, no weekend, no peer to peer, no paperwork, no meetings, no medicine etc. Again YMMV but hourly wage and flexibility it is hard to beat SNF. I know there are other docs here who do full time SNF work and they would back me up on this. There is a role for all of us across the continuum. Ideally the doc who does consults also does IPR, follows the patients in the SNF and than as outpatient. Obviously that’s not possible for most of us. The key thing is we do what we love and support others that so the same.

 

[Iamnew2]

=)

I suppose "super high volumes" is relative.
In IPR, you make north of 300K seeing only 15 patients a day. And that's without a directorship stipend. If you're looking to have IM do the admissions and PM&R as consultant, there are plenty of Encompass facilities where that's the set up. It might be more time-intensive because you have to do team conferences but that's a trade-off many people would be comfortable with.

Personally, if I were seeing 22-25 patients a day, I'd hire my own scribe and still expect to earn north of $500K. But, then again, IPR is what I grew up with, so to speak.

Assuming 22-25 patients a day with an average of 3 discharges and 3 admissions a day (fairly conservative), I'd expect to bill:
Admissions: 99223 ($200) X 3 = $600
Discharges: 99239 ($100) X 3 = $300
Progress notes: 99232 ($70) X 19) = $1330

[YMMV. I'm using Medicare rates for the above calculations. If you live in an area with generous commercial insurance plans, you'd make more. If you live somewhere with a ton of Medicaid, you might make a lot less.]

That comes to $2230/day and $11,150/week in billings, and that's if you never bill a level 3 progress note.
Assuming a 15% loss to unpaid bills and billing company cut, you still get something like $9477.5/week.
You can take 6 weeks off and still expect to take home $435,965 before any directorship stipend.
Depending on whether you work for Encompass, HCA, Vibra, or Lifepoint, you can expect to add another $80-150K/year to that as medical director.

On the other hand, if you take a good employment contract with a hospital medical group and you see that kind of volume, your directorship stipend will be much lower ($30-60K) but you'd essentially get a 100% collections rate (in the scenario above, you'd take home $512,900 before any stipends) + benefits + [sometimes] call pay.

I still think there are some advantages to SNF and many people would thrive a lot more with SNF work. The highest grossing SNF physiatrist I know makes way way WAY more than the highest grossing IPR doc I know. But your average physiatrist seeing an average number of patients is likely to do a lot better financially in IPR. Personally, like I said, I know my limits. 25-30 patients is the absolute maximum I could every see myself seeing in any setting. And at that level, I'm sweating, even with a scribe. And I feel like my chances of making a bad mistake increase exponentially.

I'm not the slowest doc I know but I was never anywhere near some of the speed demons I've encountered in my years of training. There was a guy in 3rd year of Med school who was already faster, more organized, and efficient than most attendings I knew in residency. My guess is that today, his billings are somewhere in the stratosphere, wherever he works.

I am not sure I am following the math. No employed physician is going to get $512,900 plus a stipend for PM&R. Certainly with RVUs/independent contractor that's a different story.

I guess like they say different strokes for different folks. I have worked both SNF and IPR, consults, etc.
I am now more in administration with pretty heavy admin role in addition to clinical role.

I think some docs prefer the SNF environment and some the IPR environment however as I have learned at the end of the day it really comes down to what the contracted rate is - our contracted rate payment wise is sky high. I find that I am making a hefty income seeing about 11-15 patients on average (some days up to high 20's if I'm covering for one of my partners occasionally) due to a high contracted/RVU rate. In my prior medical director role, the income was significant however I had to see a substantial number of patients given a lower contracted rate.
Granted my administrative duties have also increased significantly in my current institution.

Good money is available in both set ups really.

 

[lejeunesage]

I am not sure I am following the math. No employed physician is going to get $512,900 plus a stipend for PM&R. Certainly with RVUs/independent contractor that's a different story.

I guess like they say different strokes for different folks. I have worked both SNF and IPR, consults, etc.
I am now more in administration with pretty heavy admin role in addition to clinical role.

I think some docs prefer the SNF environment and some the IPR environment however as I have learned at the end of the day it really comes down to what the contracted rate is - our contracted rate payment wise is sky high. I find that I am making a hefty income seeing about 11-15 patients on average (some days up to high 20's if I'm covering for one of my partners occasionally) due to a high contracted/RVU rate. In my prior medical director role, the income was significant however I had to see a substantial number of patients given a lower contracted rate.
Granted my administrative duties have also increased significantly in my current institution.

Good money is available in both set ups really.

You won't get that as a salary but you definitely can when you move to productivity, assuming:
1. The volume is there (that's way more than your average IPR employed physiatrist sees).
2. Your wRVU conversion factor is decent. As of 2023, the wRVU for 99223 is 3.5 (same as for 99306, by the way). For PM&R, I've seen conversion factors generally in the range of $55-63/RVU. You can do pretty well with something like that. Again, I was going with the figure of 22-25 patients per day.

"Good money is available in both set ups really."

No argument from me there. All I'm saying is that you have to know your own strengths and weaknesses. Most of us are likely to do better in one of those settings than the other. Assessing my own strengths, I think IPR is better for me. There are also many people I trained with who would struggle to see more than 15 patients a day, irrespective of setting. It doesn't make them bad doctors but they should choose their jobs accordingly.

 

[nleeds24]

I have been working at SNF #1 for about 5 months. I have received good feedback from the DON, exec director as to my performance. I then asked their sister facility about an hour away if they would allow me round on their patients. After failing to answer my emails or return my calls I drove out there and sat in their lobby until the exec director spoke to me. She seemed skeptical as to how beneficial PM&R could be for her facility despite the fact that I work at their sister site within the same company! The same sister site which gave me a good review. I am flabbergasted. I thought picking up SNF #2 would be a slam dunk. Can someone please explain this?

 

[sloh]

How'd you pitch it? Also, admins and exec directors are quite variable in how receptive they are to physiatrists.

 

[Iamnew2]

How'd you pitch it? Also, admins and exec directors are quite variable in how receptive they are to physiatrists.

Great question.
As others have pointed out also, the ease of entrance also depends on whether the area you are in is competitive or not.
Where I was before, I was literally one of the few PM&R doctors within a significant range, and there were a million (figuratively) SNFs, none with PM&R doctors. It would have been relatively easy to provide services had I not been swamped with work from the IRF already.
Where I'm at now, the city is swimming with specialists and plenty of PM&R doctors - I'm sure every SNF in the area has a PM&R doctor in it. So I'd have pretty much 0 luck if I wanted to break in - so that might also have an impact on your success vs lack thereof.

 

[nleeds24]

SNF #2 is in Maryland near DC. I don't know how saturated that area is but the fact that they already didn't have a physiatrist makes me think its not too crowded. After the brief face to face meeting, I later emailed them a proposal detailing how I thought physiatry could benefit them. Citing how I could help their facility score higher in metrics such as quality care measures etc. That was 2 weeks ago...

 

[sloh]

SNF #2 is in Maryland near DC. I don't know how saturated that area is but the fact that they already didn't have a physiatrist makes me think it’s not too crowded. After the brief face to face meeting, I later emailed them a proposal detailing how I thought physiatry could benefit them. Citing how I could help their facility score higher in metrics such as quality care measures etc. That was 2 weeks ago...

Tbh not sure if email is the best way to go about this. In person is better and you have about ~5 minutes to make a succinct and effective elevator pitch to hook them in. There’s an art to that and I’ll admit I’m not even that good at it. But I’ve seen that pitch delivered effectively and I respect it tremendously.

 

[PMR2008]

know your audience. Can not use the same pitch of "I am a Physiatrist that will help your patients" to everyone.

 

[nleeds24]

know your audience. Can not use the same pitch of "I am a Physiatrist that will help your patients" to everyone.

I am pretty new to the SNF world. This was the first time I approached one on my own. What do you think I should have said?

 

[PMR2008]

I don’t know. Depends on the SNF and what you find out their needs are. Cold calling does not work in SNFs anymore unless you have real solutions to real problems.

 

[lejeunesage]

I am pretty new to the SNF world. This was the first time I approached one on my own. What do you think I should have said?

My suggestion is to bypass the administrator and make your pitch to the person above her. You already have a relationship with the administrator of one facility. Ask to be connected with the person they report to. Show what you've been able to do for that facility.
At the end of the day, they're going to want to know that you're making/saving them money somewhere. You'll be in good shape if you can show that.
But going to individual administrators is going to be like reinventing the wheel every single time. It's a hard thing to pull off because you would need to be familiar with what each specific facility is struggling with. Of course, nothing guarantees that this higher-up person is going to want to sit with you. You're an individual doc. You don't have any training in marketing or consulting. I found out the hard way that getting them to listen to you takes a skillset I:
1. Didn't have.
2. Didn't have the time to acquire.
3. Didn't want to hire. But you could hire a consultant with SNF experience to help you make your pitch/reach the higher-ups if you wanted to.