10% cms bump for office 2026

[stsa84]

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You are able to generate 70 procedures a week but you only see 56 patients a week? How many patients does the PA see? Do you trust this person that much?

Good question. I have basically 1.5 PA's, who see 15-20 patients per day. My new patient notes have some back up plans, such as TFESI at specific level with backup of ILESI at specific level. The PA will order the backup if not great lasting relief from the former. They'll also order MBB #2/2 and the RFA. Will also order simple joint injections. Or a patient with good relief that comes back in 6 months and just wants a repeat. Anything beyond that comes back to me for reevaluation. And all the notes come to me to co-sign, so nothing is being ordered without me being involved. Updated imaging patients come back to me for clinic follow up. I feel comfortable that I'm the one driving the ship on my patients. I also sit with the PA's, and we often go over plans or re-look at prior imaging together.

 

[Status Sciaticus]

I outlined mine in a different thread recently, but will throw in my hat here.

I'm 4 days a week, HOPD. I currently get $/RVU plus some compensation for the charts that I sign of my PA. Ends up being around $50k/year income from PA oversight. Have increased each of the past 4 years since fellowship, started at $400k and now on pace for $820k or so.

Mon: 28 patients (morning clinic, afternoon procedures)
Tue: 28 patients (either full procedures or half and half. alternates every other week)
Wed: 28 patients (full procedures)
Thur: 28 patients (full clinic)

Morning 0800 - 1130, afternoon 1300 - 1600. Eat a quick lunch then work on precharting for later in the week.

I often double book a few, with clinic often having 1-2 more, and procedures having maybe 2-4 more. I'm planning on just increasing my procedure days to mid-30's by default.

I don't know how some of you can see 40+ in clinic. I see 4 an hour, mostly new. If was seeing 5-6 per hour, I feel that, for me, some aspect of the quality of the visit would have to give. And I'd be extremely stressed about keeping on schedule.

Exercise 6 days a week, in the morning, at my home. Adjustable dumbbells to 90 lbs, pullup bar, and bench. Wake up 4:15, eat, exercise 5 - 6:30.

Sounds like a great job. How many years to go from the 400k to 820k?


The more I hear about HOPD and 4 day work-weeks, the more I'm inclined to look for another HOPD job.

 

[stsa84]

Sounds like a great job. How many years to go from the 400k to 820k?


The more I hear about HOPD and 4 day work-weeks, the more I'm inclined to look for another HOPD job.

4 years. I had a guaranteed salary of $400k for up to 18 months, to be followed by a production only model. I switched to the production model after about a year. Year 2 was about $550k, year 3 around $650k, and this year about $820k. I personally don't think that I can get much more efficient without sacrificing quality (I could never see 40 a day in clinic), but I'm sure I'll still be looking for small ways to speed things up.

 

[hyperalgesia]

I look at these posts and plan to seek a new gig. Then I remember I'm about to retire and get out of the game entirely...

 

[drusso]

Those of you who are working super hard and bringing in bank but are stressed/unhappy, what is motivating you?

Are you working on generational wealth?

I'm motivated mostly by spite.

 

[Malayil]

You are able to generate 70 procedures a week but you only see 56 patients a week? How many patients does the PA see? Do you trust this person that much?

If a patient comes for a repeat RFA the following year and the Provider sees them and the physician doesn’t that does add to the total procedures that the physician didn’t order

 

[lobelsteve]

I’m not unhappy at all. Taking care of the patients for me isn’t stressful. Office mgmt can be the biggest challenge. Yes, I’m trying to build generational wealth but my clinical practice is just part of that. Patent pending on my real chance for that.

Define generational wealth.

I think if you have $10M net worth, you can live comfortably and your kids can become artists or do whatever.
I will never reach that, so my kids gotta do the same. Hoping to die and leave each of my kids $1.5M.
My major life expenses are cars off BAT that I do not need, espresso machines, welding tables/new welders. And lots of tig gloves. Fetish: try every pair made. Defiant metal and Tillman 1328s so far.

 

[Agast]

Leave the inheritance to the grandkids. Tax advantages doing it this way apparently.

 

[po_boy]

Good point.

If the docs here making 7 figures are doing that because of PAs sending them procedures, then they are selling their soul for gold because PAs ordering procedures is not good medicine, and I doubt you would want that for your mother.

Find the right PA. Train the right PA.

 

[BobBarker]

Leave the inheritance to the grandkids. Tax advantages doing it this way apparently.

I will need to research this. I will inherit 1/3 of a large farm in the next 10 years. I’m ok being skipped. My brothers will want their share.

 

[ED50]

You all should read Die With Zero if so inclined. It's a great and relatively short book about financial philosophy. It's written by a wall street guy who made 9 figures on wall street. It certainly changed my thoughts on money/inheritance/wealth.

 

[MitchLevi]

Take this BS to the private forum

 

[clubdeac]

Define generational wealth.

I think if you have $10M net worth, you can live comfortably and your kids can become artists or do whatever.
I will never reach that, so my kids gotta do the same. Hoping to die and leave each of my kids $1.5M.
My major life expenses are cars off BAT that I do not need, espresso machines, welding tables/new welders. And lots of tig gloves. Fetish: try every pair made. Defiant metal and Tillman 1328s so far.

What?! You can totally reach that Steve.

 

[lobelsteve]

What?! You can totally reach that Steve.

Too much hookers and cocaine.

 

[SSdoc33]

10 is the goal. im not sure that gets it done nowadays.

 

[mdo1738]

10 is the goal. im not sure that gets it done nowadays.

Exactly. I’m worried that by the time I get 10, 20 will be the new 10.

 

[BobBarker]

Probably so with your age and inflation.

 

[Baron S]

10 is the goal. im not sure that gets it done nowadays.

10 is my magic number. But at the end of it my goal is to sit around and do nothing, maybe some volunteer work with animals or something, finally write a book. Why do I need 10 to do that? Why not just sit on my ass more now?

 

[SpineandWine]

10 is my magic number. But at the end of it my goal is to sit around and do nothing, maybe some volunteer work with animals or something, finally write a book. Why do I need 10 to do that? Why not just sit on my ass more now?

Likely you have a wife and kids

 

[hyperalgesia]

10 is my magic number. But at the end of it my goal is to sit around and do nothing, maybe some volunteer work with animals or something, finally write a book. Why do I need 10 to do that? Why not just sit on my ass more now?

I think ideally, as we reach financial milestones, we gradually change our priorities/lifestyle.

Money was always supposed to be a tool, not a goal itself.

 

[clubdeac]

The last 5 million accumulates much faster than the first 5 provided one’s invested wisely, heavy dollar cost averaging and a steady strong market

 

[drusso]

Exactly. I’m worried that by the time I get 10, 20 will be the new 10.

It's going to be $20M.

 

[giddyup]

I'll play. Larger midwest city, neurosurgical group, lifestyle is medium. we just got a new EMR (ECW) and the charting is taking me a bit longer so have some evening work. work out 3 days a week in home gym in AM (5-545am) 2 days strength 1 day cardio

Monday - procedures in office suite, 37 per day; 730-345
Tuesday - clinic, 30 patients; 8-4
Weds - same as Monday, in office procedures 37 per day; 730-345
Thurs - alternating, either same as Mon/weds or at surgery center doing sedation cases/SCS/Intracept; either 730-345 or 730-3 at surgery center
Fri - procedures in office suite, 28 per day; 730-130 no lunch

- Pro fees will be 1.1
- at 2 years can buy into surgery center which will add 300-400K
- supervising my NP 40K
- adding PRP soon, will see what that does
- injections ordered by myself, my NP, neurosurgeons/their APPs, all reviewed by me prior to scheduling

I also have various side hustles - 80K from an airbnb (not counting expenses), 150K from a 1099 that I do injections for a few Fridays a month, working on some other entrepreneurial ventures - mostly things I've lost money on so far like a *****

1 kid, 3 years old. 4 horses 😵 no regrets

 

[Dr. Ice]

Damn 20 mill huh? I guess divorce is out of the question,

What is the cost of peace..

 

[BoardingDoc]

I'll play. Larger midwest city, neurosurgical group, lifestyle is medium. we just got a new EMR (ECW) and the charting is taking me a bit longer so have some evening work. work out 3 days a week in home gym in AM (5-545am) 2 days strength 1 day cardio

Monday - procedures in office suite, 37 per day; 730-345
Tuesday - clinic, 30 patients; 8-4
Weds - same as Monday, in office procedures 37 per day; 730-345
Thurs - alternating, either same as Mon/weds or at surgery center doing sedation cases/SCS/Intracept; either 730-345 or 730-3 at surgery center
Fri - procedures in office suite, 28 per day; 730-130 no lunch

- Pro fees will be 1.1
- at 2 years can buy into surgery center which will add 300-400K
- supervising my NP 40K
- adding PRP soon, will see what that does
- injections ordered by myself, my NP, neurosurgeons/their APPs, all reviewed by me prior to scheduling

I also have various side hustles - 80K from an airbnb (not counting expenses), 150K from a 1099 that I do injections for a few Fridays a month, working on some other entrepreneurial ventures - mostly things I've lost money on so far like a *****

1 kid, 3 years old. 4 horses 😵 no regrets

I don't understand people who post this kind of schedule. You are seeing 30 clinic patients per week, and doing over 100 procedures a week. I mean, this clearly generates money, but it's also part of the reason our specialty gets so much flak.

Who is deciding these patients need an injection? It doesn't appear to be you. I know you say you review what the neurosurgery mid-level is ordering, but are you really looking through all their charts and saying, hey, this person doesn't need this injection?

I doubt it. Even if you are, the chart is only as good as the noctor who wrote it, and on the whole I don't want a mid-level deciding what sort of injection I need.

 

[Dr. Ice]

I don't understand people who post this kind of schedule. You are seeing 30 clinic patients per week, and doing over 100 procedures a week. I mean, this clearly generates money, but it's also part of the reason our specialty gets so much flak.

Who is deciding these patients need an injection? It doesn't appear to be you. I know you say you review what the neurosurgery mid-level is ordering, but are you really looking through all their charts and saying, hey, this person doesn't need this injection?

I doubt it. Even if you are, the chart is only as good as the noctor who wrote it, and on the whole I don't want a mid-level deciding what sort of injection I need.

People shouldn’t bitch about mid-level creep because this is why it’s happening. My numbers of clinic visits vs procedures are quite the opposite of what people are posting. This week I will be at 100 clinic visits and 34 procedures. That’s probably the norm for me. No mid level, grinding it out day by day

 

[giddyup]

I don't understand people who post this kind of schedule. You are seeing 30 clinic patients per week, and doing over 100 procedures a week. I mean, this clearly generates money, but it's also part of the reason our specialty gets so much flak.

Who is deciding these patients need an injection? It doesn't appear to be you. I know you say you review what the neurosurgery mid-level is ordering, but are you really looking through all their charts and saying, hey, this person doesn't need this injection?

I doubt it. Even if you are, the chart is only as good as the noctor who wrote it, and on the whole I don't want a mid-level deciding what sort of injection I

I don't understand people who post this kind of schedule. You are seeing 30 clinic patients per week, and doing over 100 procedures a week. I mean, this clearly generates money, but it's also part of the reason our specialty gets so much flak.

Who is deciding these patients need an injection? It doesn't appear to be you. I know you say you review what the neurosurgery mid-level is ordering, but are you really looking through all their charts and saying, hey, this person doesn't need this injection?

I doubt it. Even if you are, the chart is only as good as the noctor who wrote it, and on the whole I don't want a mid-level deciding what sort of injection I need.

Truly, do you really think a well trained NP can’t do a follow up with a patient I’ve done an injection on to document the results and consult with me if something else is needed? My procedure suite is in my clinic, they can literally walk 30 feet and talk to me. I see all the new patients and then they follow up after injections with my mid-level and they can very clearly read my last note and see what the plan is and if their are questions they can ask me. Try keeping staff members when patients call and are infuriated it takes two months to get into you. I think it’s reasonable to have a mid level and I’m sure multiple people on this forum do as this is literally what they are for. Many injections of mine are MBB/SIJ that require diagnostic first or are a series. Many are patients of mine who have called for a repeat injection. Many are diagnostic injections ordered by neurosurgeons. Our surgeons are good and I trust and value their opinions and we collaborate well. There are 18 of them. Yes, it’s a lot of injections. Also, all injection orders in our system are linked to Clinic notes so I can very easily review those when looking at injection orders and our PACS system is integrated into the EMR as well so it takes less than five minutes to read the note and review the imaging. It is possible that other people that have different practice patterns or styles than you may also be effective and doing a good job.

 

[BobBarker]

@giddyup your total pro fees should be higher than that with that many injections unless you are mostly doing esi’s and si joints.

 

[giddyup]

@giddyup your total pro fees should be higher than that with that many injections unless you are mostly doing esi’s and si joints.

My total collections this year will be 2.2-2.4. I will get 1.1 bc of overhead

 

[BobBarker]

Ok, great. Numbers make sense.

 

[hyperalgesia]

It's interesting how we approach medicine differently.

I could have a practice that's entirely algorithm driven. I could have a well trained PA at every point. They could evaluate based on the algo, triage, prescribe, and probably the easiest thing would be to inject/operate. My only job would be to design and fine tune the algo.

It's not the kind of practice I would want to be a part of but would probably appeal to others.

 

[hyperalgesia]

The last 5 million accumulates much faster than the first 5 provided one’s invested wisely, heavy dollar cost averaging and a steady strong market

It's easy to see how compound interest could keep people working until they croak on the job. Making a mil a year in passive investment income would be cool...

 

[po_boy]

People shouldn’t bitch about mid-level creep because this is why it’s happening. My numbers of clinic visits vs procedures are quite the opposite of what people are posting. This week I will be at 100 clinic visits and 34 procedures. That’s probably the norm for me. No mid level, grinding it out day by day

34 procedures/ week?

 

[Dr. Ice]

34 procedures/ week?

Yes I currently have just 1 procedure day/week. The rest is clinic. Mind you I just started this job in July

 

[SpineandWine]

My total collections this year will be 2.2-2.4. I will get 1.1 bc of overhead

I have similar set up/
My distributions are 0.8-1
My pro fees (albeit, I do less work than you and have less collections) are at 50% overhead, which seems high but glad they’re taking that much off you too (and our group is not only one with such high overhead)


How do you determine overhead in your group?

 

[po_boy]

I'll play. Larger midwest city, neurosurgical group, lifestyle is medium. we just got a new EMR (ECW) and the charting is taking me a bit longer so have some evening work. work out 3 days a week in home gym in AM (5-545am) 2 days strength 1 day cardio

Monday - procedures in office suite, 37 per day; 730-345
Tuesday - clinic, 30 patients; 8-4
Weds - same as Monday, in office procedures 37 per day; 730-345
Thurs - alternating, either same as Mon/weds or at surgery center doing sedation cases/SCS/Intracept; either 730-345 or 730-3 at surgery center
Fri - procedures in office suite, 28 per day; 730-130 no lunch

- Pro fees will be 1.1
- at 2 years can buy into surgery center which will add 300-400K
- supervising my NP 40K
- adding PRP soon, will see what that does
- injections ordered by myself, my NP, neurosurgeons/their APPs, all reviewed by me prior to scheduling

I also have various side hustles - 80K from an airbnb (not counting expenses), 150K from a 1099 that I do injections for a few Fridays a month, working on some other entrepreneurial ventures - mostly things I've lost money on so far like a *****

1 kid, 3 years old. 4 horses 😵 no regrets

What is the ASC buy-in? You don't have to post in the public forum if you're not comfortable.

 

[giddyup]

What is the ASC buy-in? You don't have to post in the public forum if you're not comfortable.

1 million

 

[po_boy]

1 million

This is an established ASC at fair market value or are you building a new one?

 

[BobBarker]

$1M hopefully includes the same share of the building/land as operations.

 

[giddyup]

I have similar set up/
My distributions are 0.8-1
My pro fees (albeit, I do less work than you and have less collections) are at 50% overhead, which seems high but glad they’re taking that much off you too (and our group is not only one with such high overhead)


How do you determine overhead in your group?

the group is owned by the surgeons. they take profits and split them amongst themselves by how many RVU they do. for non shareholders, we all negotiate our own contracts and they are all different. i get 60% of my pro fees, but all procedures in my office suite they skim half off the top as a "facility fee" then I get 60% of the rest. this is a point of contention but overall i liked the job and was bound to this city due to my spouse so i made the decision to take it because to me, it was the best job in the city and overall the numbers were satisfactory. this is something i hope to negotiate down over time once i show value to the practice by adding new services (intracept, PRP). the in office procedure skimming is why i make overall 39% of what i bring in when all things are factored in. they dont skim off in office ultrasound stuff like TPI, GON, bursa with US, etc.

 

[giddyup]

This is an established ASC at fair market value or are you building a new one?

this is for the one we have, we are building a second in a few years

 

[BoardingDoc]

Yes I currently have just 1 procedure day/week. The rest is clinic. Mind you I just started this job in July

Similar. I'm averaging about 30 procedures a week right now, but I just got here in August and am trying to ramp up ASAP. Taking much longer than I would like. Existing pain doc does 100-140 procedures/week and I feel like I'm fighting for referrals.

 

[SSdoc33]

Similar. I'm averaging about 30 procedures a week right now, but I just got here in August and am trying to ramp up ASAP. Taking much longer than I would like. Existing pain doc does 100-140 procedures/week and I feel like I'm fighting for referrals.

140 inj/week is stupid.

he is probably glowing (from the radiation, not from the cash he is generating)

 

[BoardingDoc]

140 inj/week is stupid.

he is probably glowing (from the radiation, not from the cash he is generating)

Yeah, that has honestly occurred to me and I'm curious what all of our dosimeters are going to read when we get new ones in Dec/Jan.

 

[SSdoc33]

Yeah, that has honestly occurred to me and I'm curious what all of our dosimeters are going to read when we get new ones in Dec/Jan.

the numbers really are meaningless. they just tell you that you have had X amount of radiation. it only means something if/when you get brain cancer. but maybe the cancer has nothing to do with the radiation?

i struggle with this all the time.

but i dont like standing in front of a cancer machine for my entire adult professional life

regardless. if he is doing 140 shots, he is not deciding which injections need to be done

 

[Ducttape]

thats one way of looking at it. the other way is to consider that radiation could increase your risk of developing cancer in the first place.

just like a smoker is not guaranteed to get cancer, their risk of cancer is much greater than a nonsmoker.



i dont struggle at all. i am willing to take action to prevent illnesses later on, be it wearing seat belts, vaccination, not driving under the influence or not smoking. ive seen too many of the consequences of not doing preventative health...


i get it. preventative health tactics are not appreciated in American social norms.

 

[SpineandWine]

Yeah, that has honestly occurred to me and I'm curious what all of our dosimeters are going to read when we get new ones in Dec/Jan.

Offer things he’s not able to or unwilling to offer- tendon injections, MSK related pain treatment
- does your partner offer US guided interventions?
- does he offer PRP- those patients take an hour if you want to do it “right”
Have same day availability for patients or within next day. Talk to urgent cares and state you can treat their acute pain

Why did they bring you on if they didn’t see a need?

 

[BoardingDoc]

Offer things he’s not able to or unwilling to offer- tendon injections, MSK related pain treatment
- does your partner offer US guided interventions?
- does he offer PRP- those patients take an hour if you want to do it “right”
Have same day availability for patients or within next day. Talk to urgent cares and state you can treat their acute pain

Why did they bring you on if they didn’t see a need?

Appreciate the suggestions. I do offer a few things he doesn't do. ganglion impar blocks, botox for migraine/cervical dystonia and he doesn't do any advanced, so that will all come to me (only 1 stim trial in the pipeline right now though).

We don't even have an US machine in office. They will buy one for me if I want it and can make the business case for it. As of right now, I certainly don't have the case for it. US injections don't pay well and I only have a couple of people who may or may not benefit from things like a suprascapular block.

The ortho guys in the group do PRP for joints.

I do have same day availability and it definitely does help.

At the end of the day, I'm definitely getting busier, it's just that I feel like it's taking longer than it could, or maybe simply longer than I would like.

In EM, I was the fastest doc in my group by a decent margin. In this job, I'm not only twiddling my thumbs, but I'm watching the existing pain guy continue to hustle like a madman and I wish I were closer to that. That said, I don't know that I'm ever going to be as fast as he is.

This week for example, his schedule is:
Mon: 58 clinic
Tues: 43 clinic and 55 injections
Wed: 66 clinic
Thurs: 66 clinic
Fri: 49 injections.

Mine for comparison:
Monday 19 inj
Tues 13 clinic
Wed 12 inj
Thurs 12 clinic then a kypho in the PM
Fri 18 clinic

I mean, this probably isn't bad for having started in Aug, I'm just bored out of my mind most of the time at this pace.

 

[SpineandWine]

Appreciate the suggestions. I do offer a few things he doesn't do. ganglion impar blocks, botox for migraine/cervical dystonia and he doesn't do any advanced, so that will all come to me (only 1 stim trial in the pipeline right now though).

We don't even have an US machine in office. They will buy one for me if I want it and can make the business case for it. As of right now, I certainly don't have the case for it. US injections don't pay well and I only have a couple of people who may or may not benefit from things like a suprascapular block.

The ortho guys in the group do PRP for joints.

I do have same day availability and it definitely does help.

At the end of the day, I'm definitely getting busier, it's just that I feel like it's taking longer than it could, or maybe simply longer than I would like.

In EM, I was the fastest doc in my group by a decent margin. In this job, I'm not only twiddling my thumbs, but I'm watching the existing pain guy continue to hustle like a madman and I wish I were closer to that. That said, I don't know that I'm ever going to be as fast as he is.

This week for example, his schedule is:
Mon: 58 clinic
Tues: 43 clinic and 55 injections
Wed: 66 clinic
Thurs: 66 clinic
Fri: 49 injections.

Mine for comparison:
Monday 19 inj
Tues 13 clinic
Wed 12 inj
Thurs 12 clinic then a kypho in the PM
Fri 18 clinic

I mean, this probably isn't bad for having started in Aug, I'm just bored out of my mind most of the time at this pace.

I think it takes 5-7 years to get to a place that’s full. So maybe time thing if you’re attached to area.
I had a similar feeling at my first job. I took one out of fellowship and was in a market where I had a slow build like you. I was still supported by hospital PCPs but grew fast as hospital PCPs were funneling patients to me (mostly fibromyalgia). I saw my colleagues at the time have a completely different market such that they were fed by surgeons for all the procedures.

2 years later, I switched to different area (closer to home)- an entirely new market where I was being fed and my practice grew without an ounce of effort. All it took was a calculated job switch to what I wanted.

If you like the area though and you stay for like 3-4 years, my guess is you’ll be busy just like him as you get more senior. You’ll also get to know more of the partners in the practice.

 

[Taus]

Appreciate the suggestions. I do offer a few things he doesn't do. ganglion impar blocks, botox for migraine/cervical dystonia and he doesn't do any advanced, so that will all come to me (only 1 stim trial in the pipeline right now though).

We don't even have an US machine in office. They will buy one for me if I want it and can make the business case for it. As of right now, I certainly don't have the case for it. US injections don't pay well and I only have a couple of people who may or may not benefit from things like a suprascapular block.

The ortho guys in the group do PRP for joints.

I do have same day availability and it definitely does help.

At the end of the day, I'm definitely getting busier, it's just that I feel like it's taking longer than it could, or maybe simply longer than I would like.

In EM, I was the fastest doc in my group by a decent margin. In this job, I'm not only twiddling my thumbs, but I'm watching the existing pain guy continue to hustle like a madman and I wish I were closer to that. That said, I don't know that I'm ever going to be as fast as he is.

This week for example, his schedule is:
Mon: 58 clinic
Tues: 43 clinic and 55 injections
Wed: 66 clinic
Thurs: 66 clinic
Fri: 49 injections.

Mine for comparison:
Monday 19 inj
Tues 13 clinic
Wed 12 inj
Thurs 12 clinic then a kypho in the PM
Fri 18 clinic

I mean, this probably isn't bad for having started in Aug, I'm just bored out of my mind most of the time at this pace.

Just started in August??!! I think you’re doing just fine. Take the time to hone your skills, market, etc. not just your clinical skills, master your EMR, build up your templates/macros, review all the insurance LCD for every procedure, make those templates during your downtime at work instead of night/weekends.

Your partner’s volume is truly insane imho…. You sure there’s no mirrors covered in white powder lying around?

I am full of the gills, don’t see how I could do any more, with 22 to 23 clinic (half new consults) per day and 25-30 procedures per day (incl 2-3 rfa and 1-2 Kypho, rare scs). Three days clinic, two days per procedure per week. About 1/3 to 1/2 of my procedures are directly referred by my partners who did not do cervicals, rfa and some ESI directly from spine surgeons. I don’t take direct referrals for the bigger procedures (Kypho, scs, etc)… those all get full office consult by me first.