Business and EM

No reimbursement = no pay. Even if you're salaried, the person who is paying for your salary must receive insurance reimbursements to continue paying you. Salaried employees often are given bonuses based on performance. Still, there are very many physicians who are part of groups that are fee-for-service.

Most EPs are not paid by hospitals. We get paid by billing patients for our services.

Most commonly EPs work as a part of a group that has a contract with a hospital or hospitals to staff their EDs. That group then bills the patients and distributes the money to the docs less overhead. Compensation models run the gamut between the doc getting paid whatever money is collected on his billing less overhead (ie. The strict fee for service model or “Eat what you kill.”) to straight hourly pay. Some groups pay salary but it is less common.

The driving force behind the differences is the desire on the part of groups to motivate docs to see more patients and document better. In a fee for service model there is a high degree of incentive to be more productive. In a straight hourly model there is little incentive.

The way you document and bill particularly with regard to insurance companies and CMS is important because it directly affects the amount of money your services bring in.

Your payor mix is crucially important as well. If your patient population is made up of more insured patients vs. uninsured or Medicaid patients then you will make more money.

anxiousnadd said:

So, then, EPs will bill according to patient population, procedures done, # of patients seen, etc.? So if money were a sole issue, wouldn't it make sense to work in the rich suburbs where more folks might have insurances that will actually pay for services?

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Yes. You can make more money in areas with better payor mixes and those areas tend to be rich and suburban.

However, you still have to have an ED that functions effeciently enough to move patients and see numbers. The rich areas also tend to have people who come in for less serious complaints which pay less and are less sick in general which also reduces the reimbursement.

For example peds patients tend to be well insured comparitively but peds EM docs often get paid less because so many of the visits are low billing virus checks which bill out to level 3 as opposed to a moderately complex chest pain that you admit for rule out which bills at a level 5.

anxiousnadd said:

I hate thinking about this kind of stuff. I absolutely hate numbers! And here I thought, thinking that another positive of EM for me would be the having not to deal with numbers (as much).

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Don't worry. EM is still a specialty where you can remain somewhat blissfully ignorant of medical business and survive. Most of the money matters are taken care of at the group level. If you want to trust your group and direct your energies elsewhere you will not be alone. If you want to get into administration you will need to get your head around the money issues.

Speaking of the number of patients vs level of billing, I built a spreadsheet to evaluate the effects of changes in each on reimbursement. It turned out (at least for the contract I was considering which paid hourly with an RVU bonus), you increased your pay more by increasing the number of level 3-4s than by increasing the hourly RVU.

Obviously, the best bet is to see more level 5s with procedure RVUs, but they tend to take more time.

I ended up taking a salaried job working single coverage for a large group practice so it turned out to be an academic exercise for me but interesting non the less.

Take care,
Jeff