Career advice: Independent contractor vs employee

[okokok]

Hello, I'm a PGY3 considering taking a job upon graduation with a group private practice where I'd be an independent contractor. A former attending has worked at the group and has positive things to say about it. It is a very stable group with a strong presence in the area. The split is 70/30. They do all billing, admin support, provide office/computer/EMR etc. The attending said the admin support is reliable and good. You make your own schedule. Ballpark figure (after their take but before taxes) is $300k for 4 days per week, 7 pt hours per day. Can take as much leave as you want (I'm sure up to a point, but they mentioned parental leave and vacation leave etc is normal and fine) and other people cover you; call is by phone one week every six months. I think this all sounds good, but I want to make sure I'm not missing anything. I will get health insurance from spouse, but the IC route means I won't have paid time off or retirement matching. No sign on bonus or relocation bonus. No CME money. They do not provide malpractice insurance. I don't know much about IC 1099 taxes--people say you can deduct a lot of expenses but I'm not sure that makes up for all the benefits of an employed position. My main draw is the flexibility and freedom of making my own schedule. I hate the feeling of powerlessness in residency and I worry about feeling that way as an employee in a hospital group or something. Anything I'm missing or should consider? Thank you all. (So crazy I used to read this group as a pre-med a million years ago and am now finally posting about my first real doctor job.)

ETA - allowed to work in other types of practices (eg ED, residential, IOP/PHP) but can't work in any other outpatient setting including having my own private patients.

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[Candidate2017]

I don't know much about IC 1099 taxes--people say you can deduct a lot of expenses but I'm not sure that makes up for all the benefits of an employed position.

The only benefit of an employed position is you get to stick your head in the sand and not worry about math or figuring out your economic value. But realize healthcare, vacay, malpractice, bonus, CME etc aren't really benefits in an employed fee for service clinic. Those "benefits" are paid from your labor/billings. This is perfectly fine for some people. There is an incentive to work as little as possible as an employed physician, because that effectively increases your percentage cut of your billings.

PP split fee positions are more transparent because they tell you exactly what they will be taking from the sweat of your work. There are nifty things your tax and legal team (yes, you need a team of professionals) can talk to you about regarding deductions beyond malpractice and health insurance premiums, especially if you set up a business entity. You can defer compensation, distribute income as capital gains, sock away huge amounts into defined pension benefit plans, etc. This model benefits those who work a little harder.

 

[dl2dp2]

$300k should include 4 weeks off? This number is a low ball total revenue for this kind of arrangement.

In general, 1099 is always better, but what's even better is a pathway towards eventual ownership of the practice. It's the 30 in the 70/30 that actually accrues value. A restrictive covenant is also pretty annoying. These are parts of the equation you need to balance.

 

[Jules A]

1099 and W2 can be compared fairly accurately by putting a dollar value on everything. You might want to check out White Coat Investor's blog. In your career as a physician you will make a lot of money and risk leaving a lot on the table. It is important to understand the nuances of business, taxes, negotiating, retirement planning etc.

 

[AD04]

This type of job is a-dime-a-dozen type of job. It's not a bad option in the right group but you are taking a bigger risk for not a big payout. Ask for details on how the ballpark figure is derived. When you break it down into details, there are likely rosy (unrealistic) projections such as 100% show rate and 100% collection rate and more. The owner has little skin in the game with this set up. If you don't succeed and don't meet projected numbers, will the owner be penalized in any way?

You're not going to get wealthy from it, but it is a good way to learn about the business aspect if you're motivated to do so.

Negotiate hard the non-compete clause as per @sluox . You don't want to be locked out of your location in case things go south. I would tie the non-compete clause to your income. If you don't meet a certain threshold by year 1 or another threshold by year 2 or another by year 3, then non-compete is null and void. The threshold numbers the owner is willing to put into the contract is the real projected number.

 

[calvnandhobbs68]

Hello, I'm a PGY3 considering taking a job upon graduation with a group private practice where I'd be an independent contractor. A former attending has worked at the group and has positive things to say about it. It is a very stable group with a strong presence in the area. The split is 70/30. They do all billing, admin support, provide office/computer/EMR etc. The attending said the admin support is reliable and good. You make your own schedule. Ballpark figure (after their take but before taxes) is $300k for 4 days per week, 7 pt hours per day. Can take as much leave as you want (I'm sure up to a point, but they mentioned parental leave and vacation leave etc is normal and fine) and other people cover you; call is by phone one week every six months. I think this all sounds good, but I want to make sure I'm not missing anything. I will get health insurance from spouse, but the IC route means I won't have paid time off or retirement matching. No sign on bonus or relocation bonus. No CME money. They do not provide malpractice insurance. I don't know much about IC 1099 taxes--people say you can deduct a lot of expenses but I'm not sure that makes up for all the benefits of an employed position. My main draw is the flexibility and freedom of making my own schedule. I hate the feeling of powerlessness in residency and I worry about feeling that way as an employee in a hospital group or something. Anything I'm missing or should consider? Thank you all. (So crazy I used to read this group as a pre-med a million years ago and am now finally posting about my first real doctor job.)

ETA - allowed to work in other types of practices (eg ED, residential, IOP/PHP) but can't work in any other outpatient setting including having my own private patients.

So, that restrictive covenant is pretty unreasonable. If you get a lawyer to go over that contract for you, they'll be able to tell you what's a reasonable non-compete for a 1099 (there are legal non-competes for independent contractors but they tend to have to be pretty limited in scope in terms of restrictions and geographical area). It's totally unreasonable for them to say you can't do ANY work in ANY other outpatient setting universally.

I would not expect a 1099 position to give you any benefits (bonus, health insurance, malpractice, 401k/403b, "CME money", etc) as those kinds of things tend to negate the "independent contractor" part of it (ex. as soon as they start providing most types of insurance coverage, you should really be classified as a W2 employee since they're providing benefits). Legally, they also really can't restrict your time-off at all as an IC, within reason (like they'd probably have legal standing to terminate your contract if you suddenly decided to take 3 months off straight but if you're taking 12 weeks off spread out throughout the year, you're completely able to do that as an IC).

I agree with the above that unless you're very comfortable with doing your own taxes in that state, getting a tax professional involved. They can guide you in terms of maximizing your deductions, estimating quarterly taxes, etc. I also do agree with @AD04 that you should have a very good understanding of how they arrive at your "estimated" yearly salary (how many patients per day, what codes, what the insurance mix is, what their no-show fees/no-show rate is, collections efficiency). You can expect your collections to lag the first month or so while the practice actually starts getting reimbursed for your appointments from patients/insurance. 300k is pretty rosy for 28 patient contact hours a week at a 70/30 split but totally depends on what area of the country you're in and the reimbursement rates for the area (ex. are they estimating that off of billing all 99214 + 90833s which insurance companies balk at sometimes when they pick up on this pattern? are they estimating that based off billing 4x 99214s an hour?).

Self-employment tax as a 1099 is actually not that much when you start getting to higher income levels. The "half and half" employer/employee benefit from W2 only applies to the first $142,800 of earnings for 2021, so actually isn't as big of a deal as many people think it is (you do start incurring a very minimal 0.9% Medicare tax >200K single/250K married). Run a tax calculator and look at the difference between 250k/300k/350k...it's almost nothing.

Self-Employment Tax: What It Is, How to Calculate It - NerdWallet

The self-employment tax is 15.3%, which is 12.4% for Social Security and 2.9% for Medicare. Generally, it applies to self-employment earnings of $400 or more.

www.nerdwallet.com

 

[TexasPhysician]

There is a lot to compare and there is no right answer for everyone.

1099 positions have the possibility of high tax breaks, higher retirement accounts, and more autonomy. It comes with added frustrations like managing your own benefits, keeping up with deductions/expenses, and never getting paid when on vacations.

Employed positions are simpler. Much is decided or allotted to you. Vacations are built into your pay. You are forced to play by company rules and adapt when the company changes. You have less to worry about tax wise and the company manages expenses.

Neither necessarily offers better pay. 1099 (contractor) jobs have more potential, but they require effort and education to realize that potential.

 

[sloh]

300k is pretty rosy for 28 patient contact hours a week at a 70/30 split

Do you guys feel that $300k for a 70/30 1099 position is pretty low? If you have to be in the clinic those hours anyways, potentially the time is not being used up as efficiently as possible with patient scheduling/time slots? I bet psychiatrists with this type of split in an inpatient setting gross a lot more.

 

[rjs2131]

Try and get a sense for how many patients you'll be seeing during those 28 clinical hours to get to 300k - this could be a dealbreaker. If that 300k projection is based on 20-min 99214's...that will get old pretty fast (a 7-hour day = 21 follow-ups potentially). From my experience in looking into various group PP's, the better jobs I've come across will project 250-300k + benefits for ~30 patient hours/week (assuming you are relatively full) with 30-min follow-ups and 60-90 min new evals. As others have mentioned, you also want to have a clear idea about partnership and what that looks like (i.e. are there bonuses for partners, do you have access to other parts of the practice as a partner, etc).

 

[robellis]

Try and get a sense for how many patients you'll be seeing during those 28 clinical hours to get to 300k - this could be a dealbreaker. If that 300k projection is based on 20-min 99214's...that will get old pretty fast (a 7-hour day = 21 follow-ups potentially). From my experience in looking into various group PP's, the better jobs I've come across will project 250-300k + benefits for ~30 patient hours/week (assuming you are relatively full) with 30-min follow-ups and 60-90 min new evals. As others have mentioned, you also want to have a clear idea about partnership and what that looks like (i.e. are there bonuses for partners, do you have access to other parts of the practice as a partner, etc).

21 patients per day should be making minimum 500k per year if billing properly

 

[calvnandhobbs68]

21 patients per day should be making minimum 500k per year if billing properly

Not at a 70/30 split and certainly not at 4 days a week.

 

[rjs2131]

21 patients per day should be making minimum 500k per year if billing properly

More than 300k probably but 500k seems like a stretch...unless you're trying to bill 99214/90833's for all of these 20 min appointments but that doesn't seem sustainable.

 

[robellis]

More than 300k probably but 500k seems like a stretch...unless you're trying to bill 99214/90833's for all of these 20 min appointments but that doesn't seem sustainable.

99214/90833 for 16 patients per day would get you there so 20+ patients you wouldn’t bill them all that high but still be fine

 

[the5thelement]

21 patients per day - Thats a lot of patients for mediocre money. 1099 is the way to go though. These days its easy to outsource every thing(get Xero for accounting, accountant to calculate your pay check every month,or online payroll service like wagepoint also works, self directed 401k putting away 52K/year).

 

[clausewitz2]

To each their own in terms of volume, but want to agree with the chorus saying 21 patients a day 5 days per week probably is a ticket to burnout. I definitely notice myself stop caring nearly as much somewhere around patient 14 or 15 if I don't have no-shows, and I only do 30 minute f/u's. I could maybe swing 21 per day if I was only doing it a couple days a week but man that would be a slog.

EDIT: at least if you are actually trying to do things to justify that 90833 apart from making Empathy Face a lot. If you just blitzed through medication regimens and focused on changing dosages primarily 21 wouldn't be so bad.

 

[robellis]

To each their own in terms of volume, but want to agree with the chorus saying 21 patients a day 5 days per week probably is a ticket to burnout. I definitely notice myself stop caring nearly as much somewhere around patient 14 or 15 if I don't have no-shows, and I only do 30 minute f/u's. I could maybe swing 21 per day if I was only doing it a couple days a week but man that would be a slog.

EDIT: at least if you are actually trying to do things to justify that 90833 apart from making Empathy Face a lot. If you just blitzed through medication regimens and focused on changing dosages primarily 21 wouldn't be so bad.

Empathy face 😂😂 you can’t even do that with the masks these days I guess you can do empathy nodding

 

[Sushirolls]

That would be a good SDN name.

 

[comp1]

No non-competes, no restrictive covenants. Ever. We are in too high of demand to allow that sort of thing in any contract. There's certainly nothing special in this arrangement that justifies it. That needs to be your first demand.

 

[TexasPhysician]

No non-competes, no restrictive covenants. Ever. We are in too high of demand to allow that sort of thing in any contract. There's certainly nothing special in this arrangement that justifies it. That needs to be your first demand.

On the employee side, I wouldn’t want one. On the employer side, it is a must. Either way, the non-compete should be limited in time and distance to not prohibit other work in the city.

If a thriving cash only practice is hiring someone, you can’t have them open an additional shop next door and transition patients there. The hiring clinic would spend money on advertising and support staff that can result in a short term loss (long term profit from follow-ups). If patients are moved elsewhere, you are worse off bringing on a new psychiatrist. There is a lot to be gained by learning how a pp works.

The big box shop non-competes of 30 mile radius of any location is insane though. I know a developmental pediatrician that I’d like to bring on but this person isn’t allowed to work anywhere in the city for 2 years.

 

[Psychresy]

To each their own in terms of volume, but want to agree with the chorus saying 21 patients a day 5 days per week probably is a ticket to burnout. I definitely notice myself stop caring nearly as much somewhere around patient 14 or 15 if I don't have no-shows, and I only do 30 minute f/u's. I could maybe swing 21 per day if I was only doing it a couple days a week but man that would be a slog.

EDIT: at least if you are actually trying to do things to justify that 90833 apart from making Empathy Face a lot. If you just blitzed through medication regimens and focused on changing dosages primarily 21 wouldn't be so bad.

In the most general of ballparks how much is a 99214 + 90833 generating for you? How much does the 90833 add?

 

[robellis]

In the most general of ballparks how much is a 99214 + 90833 generating for you? How much does the 90833 add?

150 dollars

 

[clausewitz2]

In the most general of ballparks how much is a 99214 + 90833 generating for you? How much does the 90833 add?

99214 on its own is more than 120 less than 150. 90833 from the one payor I take adds about 50% to that.

 

[liquidshadow22]

150 dollars

Is this what you make before a split or after?

Would you say this rate in terms of production in an employed position, with close to full benefits would be good?

 

[robellis]

Is this what you make before a split or after?

Would you say this rate in terms of production in an employed position, with close to full benefits would be good?

Yes because that would be 300 dollars per hour with full benefits which I consider good

 

[liquidshadow22]

Yes because that would be 300 dollars per hour with full benefits which I consider good

i think so too. i assume the only way you end up in a better financial arragnement than that is actually having a partnership track in a private practice right?

 

[Bartelby]

So ballpark $200 for 99214+90833. With two per hour that makes $400/hr with insurance realistic (two 30-min med management + brief therapy slots). If you practice that way does insurance balk at all of the add-on codes?

 

[liquidshadow22]

So ballpark $200 for 99214+90833. With two per hour that makes $400/hr with insurance realistic (two 30-min med management + brief therapy slots). If you practice that way does insurance balk at all of the add-on codes?

definitely not, as i hear many people bill the 99214 + 90833 for 20 min visits without problems

 

[TexasPhysician]

So ballpark $200 for 99214+90833. With two per hour that makes $400/hr with insurance realistic (two 30-min med management + brief therapy slots). If you practice that way does insurance balk at all of the add-on codes?

Insurance can audit at any time, require notes before paying, and decline codes sporadically for a variety of reasons. You need your documentation to support your billing.

 

[calvnandhobbs68]

So ballpark $200 for 99214+90833. With two per hour that makes $400/hr with insurance realistic (two 30-min med management + brief therapy slots). If you practice that way does insurance balk at all of the add-on codes?

definitely not, as i hear many people bill the 99214 + 90833 for 20 min visits without problems

Not totally true. There are multiple threads on the private practice/psychiatry facebook groups about insurance starting to get stricter about the 90833 add-on codes especially when being used with 99214s and auditing more frequently or straight up rejecting all the 99214 + 90833 codes without you sending notes. Not universal but happening. It seems like there's much less pushback with 99213 + 90833 or straight 99214s but I wouldn't plan on billing 100% of your patients as 99214 + 90833s (even assuming those visits all actually qualify as that) without some annoyance from the insurance companies which might result in delayed reimbursement or straight up rejection/fighting. Projections I was getting were more like 50% of whatever codes you were billing would have psychotherapy add-on codes.

The 20 minute add-on therapy visit thing has a very low chance of surviving an audit. Maybeee if it's 99213 + 90833 but for a 99214 have fun convincing insurance you did a moderate amount of MDM in 4 minutes if those charts get pulled.

 

[liquidshadow22]

Not totally true. There are multiple threads on the private practice/psychiatry facebook groups about insurance starting to get stricter about the 90833 add-on codes especially when being used with 99214s and auditing more frequently or straight up rejecting all the 99214 + 90833 codes without you sending notes. Not universal but happening. It seems like there's much less pushback with 99213 + 90833 or straight 99214s but I wouldn't plan on billing 100% of your patients as 99214 + 90833s (even assuming those visits all actually qualify as that) without some annoyance from the insurance companies which might result in delayed reimbursement or straight up rejection/fighting. Projections I was getting were more like 50% of whatever codes you were billing would have psychotherapy add-on codes.

The 20 minute add-on therapy visit thing has a very low chance of surviving an audit. Maybeee if it's 99213 + 90833 but for a 99214 have fun convincing insurance you did a moderate amount of MDM in 4 minutes if those charts get pulled.

How does the insurance even know how long you spend with a patient?It's whatever you are able to document in 20 min essentially right?

 

[clausewitz2]

Not totally true. There are multiple threads on the private practice/psychiatry facebook groups about insurance starting to get stricter about the 90833 add-on codes especially when being used with 99214s and auditing more frequently or straight up rejecting all the 99214 + 90833 codes without you sending notes. Not universal but happening. It seems like there's much less pushback with 99213 + 90833 or straight 99214s but I wouldn't plan on billing 100% of your patients as 99214 + 90833s (even assuming those visits all actually qualify as that) without some annoyance from the insurance companies which might result in delayed reimbursement or straight up rejection/fighting. Projections I was getting were more like 50% of whatever codes you were billing would have psychotherapy add-on codes.

I am very careful about my documentation. If I am billing the add-on I specify the particular modality I am using, the specific techniques, a general overview of content focus, and specific start and end times. I based my level of detail on the amount of detail I see in most therapist's notes (not that that is often a tremendous amount). Haven't had any pushback so far but we'll see. One of the benefits of over-documenting a bit although it has taken a while to start doing this efficiently.

I have so many different therapy dot phrases.

The 20 minute add-on therapy visit thing has a very low chance of surviving an audit. Maybeee if it's 99213 + 90833 but for a 99214 have fun convincing insurance you did a moderate amount of MDM in 4 minutes if those charts get pulled.

Yeah I wouldn't risk it. Honestly if my appointments end up being late enough to be less than 25 minutes I generally am going to just knock it down to straight E&M.

 

[FatherPsychiatry]

I had this option for a roughly identical job, ended up going with W-2 after running all the numbers. The other benefit was job security. This is a government job, and contractors are only available for positions not filled by employees. My facility was like 60% employee/40% contractor, but over the last five years it has become 100% employee (I was one of the last employees to join) because of the relatively chill work, good lifestyle, bennies.

 

[AD04]

There are multiple threads on the private practice/psychiatry facebook groups about insurance starting to get stricter about the 90833 add-on codes especially when being used with 99214s and auditing more frequently or straight up rejecting all the 99214 + 90833 codes without you sending notes. Not universal but happening. It seems like there's much less pushback with 99213 + 90833 or straight 99214s but I wouldn't plan on billing 100% of your patients as 99214 + 90833s (even assuming those visits all actually qualify as that) without some annoyance from the insurance companies which might result in delayed reimbursement or straight up rejection/fighting. Projections I was getting were more like 50% of whatever codes you were billing would have psychotherapy add-on codes.

I wouldn't doubt that the rejections are due to sloppy documentation. And because their documentation is lacking, they try to mix in 99213 just to fall under the radar to prevent an audit. Many psychiatrists are not well-versed in billing.

A lot of us on SDN are well-versed in billing. Most of us probably over-document and can withstand an audit.

Personally, I've shifted to more 15 minute medication checks (99214), which comprises about 10% of my patients so far, just because I've gotten them so stable and there is nothing to talk about.

3x 99214 + 90833 per hour just feels scummy to me. I know someone who does 15-minute sessions and include add-on psychotherapy in the billing code. This person didn't have an audit yet but I'll be curious how well it holds in a few years.

 

[calvnandhobbs68]

I wouldn't doubt that the rejections are due to sloppy documentation. And because their documentation is lacking, they try to mix in 99213 just to fall under the radar to prevent an audit. Many psychiatrists are not well-versed in billing.

A lot of us are well-versed in billing. Most of us on SDN probably over-document and can withstand an audit.

Personally, I've shifted to more 15 minute medication checks (99214), which comprises about 10% of my patients so far, just because I've gotten them so stable and there is nothing to talk about.

3x 99214 + 90833 per hour just feels scummy to me. I know someone who does 15-minute sessions and include add-on psychotherapy in the billing code. This person didn't have an audit yet but I'll be curious how well it holds in a few years.

Agree, some of this is probably due to crappy documentation to justify 99214 + 90833. So there was someone on the PP facebook group who basically said one of their insurance panels was auto-rejecting all 99214+90833s and downcoding it to a 99213+90833. Prob illegal based on parity laws but a real pain in the ass until it would get changed.

 

[calvnandhobbs68]

How does the insurance even know how long you spend with a patient?It's whatever you are able to document in 20 min essentially right?

Depends on how many insurance panels you take. If you only take 1-2 insurance panels and they can see you billed for 24 of their patients in one day and tried to bill psychotherapy add-on codes for all of them...highly unlikely you were taking 30 minutes for each of those patients unless you're working a 12 hour day.

The fat goose tends to be the first one to get cooked. It's okay to want to get paid for the work you do but get too fat/too much of an outlier and you're gonna make people pay attention.

 

[clausewitz2]

Personally, I've shifted to more 15 minute medication checks (99214), which comprises about 10% of my patients so far, just because I've gotten them so stable and there is nothing to talk about.

I wish I could get all my now-stable, high-achieving ADHD folks to come in one day a month and blaze through all of them in a morning. I think most of them would prefer that, to be honest.

 

[Sushirolls]

I wish I could get all my now-stable, high-achieving ADHD folks to come in one day a month and blaze through all of them in a morning. I think most of them would prefer that, to be honest.

I've thought about doing that. Changing up my appointment time slot and do evening hours, group medical appointment.

Residency training exposed me to the shared medical appointment construct and I even utilized at one of my Big Box shop jobs. Majority of patients loved it and those who didn't simply opted out.

I'll probably make this switch once my panel is more full, and I have an office that has a large enough room to function as a conference room - which is key.

 

[Mass Effect]

On the employee side, I wouldn’t want one. On the employer side, it is a must. Either way, the non-compete should be limited in time and distance to not prohibit other work in the city.

If a thriving cash only practice is hiring someone, you can’t have them open an additional shop next door and transition patients there. The hiring clinic would spend money on advertising and support staff that can result in a short term loss (long term profit from follow-ups). If patients are moved elsewhere, you are worse off bringing on a new psychiatrist. There is a lot to be gained by learning how a pp works.

The big box shop non-competes of 30 mile radius of any location is insane though. I know a developmental pediatrician that I’d like to bring on but this person isn’t allowed to work anywhere in the city for 2 years.

City wide non-competes are thrown out of court all the time. The reasoning is that you can't prevent someone from making a living through their profession in their hometown. Places can do restrictions around miles or neighborhoods, but any restriction of the state and/or city is likely not going to make it past the first round of an attorney's review.

 

[Mass Effect]

I've thought about doing that. Changing up my appointment time slot and do evening hours, group medical appointment.

Residency training exposed me to the shared medical appointment construct and I even utilized at one of my Big Box shop jobs. Majority of patients loved it and those who didn't simply opted out.

I'll probably make this switch once my panel is more full, and I have an office that has a large enough room to function as a conference room - which is key.

What's a group medical appointment?

Those of you doing 1099 work or PP work, are you finding that you're paying insane fees for health insurance? I'm in an employed position and plan to stay that way, but hearing from my colleagues who are doing full time locums or 1099 and it's crazy what they're paying. We're talking relatively healthy 30 and 40 somethings, one with a family and one single.

 

[liquidshadow22]

Depends on how many insurance panels you take. If you only take 1-2 insurance panels and they can see you billed for 24 of their patients in one day and tried to bill psychotherapy add-on codes for all of them...highly unlikely you were taking 30 minutes for each of those patients unless you're working a 12 hour day.

The fat goose tends to be the first one to get cooked. It's okay to want to get paid for the work you do but get too fat/too much of an outlier and you're gonna make people pay attention.

But if you take 5 or 6 insurances. You should be ok?

 

[clausewitz2]

What's a group medical appointment?

Those of you doing 1099 work or PP work, are you finding that you're paying insane fees for health insurance? I'm in an employed position and plan to stay that way, but hearing from my colleagues who are doing full time locums or 1099 and it's crazy what they're paying. We're talking relatively healthy 30 and 40 somethings, one with a family and one single.

I qualify for exactly zero subsidies and have dependents and pay $700 a month for very solid gold epo plan. Again, super dependent on market though and we have real insurance competition locally.

 

[TexasPhysician]

What's a group medical appointment?

Those of you doing 1099 work or PP work, are you finding that you're paying insane fees for health insurance? I'm in an employed position and plan to stay that way, but hearing from my colleagues who are doing full time locums or 1099 and it's crazy what they're paying. We're talking relatively healthy 30 and 40 somethings, one with a family and one single.

It is expensive. I pay $2100+ for a family PPO high deductible plan that allows a HSA. That said I’ve had 2 recent W2 offers in which my portion of these plans would still be over $1000/month.

 

[Sushirolls]

My area I went straight to the insurance company as not eligible for the ACA subsidies. Chose the high deductible HSA plan specifically to get the HSA. So for my family its ~$1050/month. Then to fully fund the HSA for the year ~$7200/year. Dental coverage splurged a bit $2400/year.

All of this is tax deductible. I put the money in an HSA account that allows stock / mutual fund type purchases, so the bulk is growing in this tax sheltered account.

I consider this one of the biggest benefits of private practice or even contractor work. The ability to chose your insurance, and chose your HSA bank/carrier. You can get a cheap or platinum plan, up to you.

Non-HSA / High deductible plans, the premium high cost plans with lowest out of pocket, was about ~$1700/month for my family. So really the annual cost is the same for what you put in to it for an HSA / high deductible plan versus a platinum plan. The real question is what's your utilization? My family has low utilization so the HSA just makes more sense.

Buying your own health insurance before I started my practice was a fear. A barrier. Can I do this? Will it be good? Is this a mistake? etc, etc, fears, etc. In hindsight, incredibly easy, good coverage, more control is in my hands and no need for fear. Actually feel better knowing I have MORE choices than when I was employed. Don't let the prospect of buying your own health insurance by on the con list when facing new work opportunities.

 

[Sushirolls]

*Be aware 1099 is on track to be less and less. I know this will be debated amongst SDN folks here. Nationally there are things the Biden administration is doing to fold more people into W2.

In my state I just got a letter from the labor department of the state specifically to health care business entities basically saying 1099 isn't 1099 unless it truly meets all of these criteria. Basically a shot off the bow to entities that they at minimum need to be paying the workers comp portion for their 1099 people. Which then beckons, if paying workers comp for a 1099, are they really a 1099... I've already known one doc who was 1099 and the separation with the Big Box shop was really quite bad, so the person tossed into the mix a lawsuit for being misclassified as 1099 when actually a W2 job - doc won.

Realistically physicians aren't ever 1099, in my opinion, and don't pass the muster as a 1099 for any of the jobs. States and feds are only now catching up to this misclassification. Personally I can argue the merits of 1099 expanding, or coming to an end, not exactly a clear issue when viewing only from a policy level.

 

[michaelrack]

Realistically physicians aren't ever 1099, in my opinion, and don't pass the muster as a 1099 for any of the jobs. States and feds are only now catching up to this misclassification. Personally I can argue the merits of 1099 expanding, or coming to an end, not exactly a clear issue when viewing only from a policy level.

1099 makes sense for some "side jobs" as well as for stipends.

 

[FatherPsychiatry]

Realistically physicians aren't ever 1099, in my opinion, and don't pass the muster as a 1099 for any of the jobs. States and feds are only now catching up to this misclassification. Personally I can argue the merits of 1099 expanding, or coming to an end, not exactly a clear issue when viewing only from a policy level.

This is the case at my government job as well... W2 employees, and 1099 "contractors" that fill spots until enough W2 employees can be hired. Even though the "contractors" and employees pretty much do the exact same job, shifts, etc. Admin hinting that everyone will be W2 soon... contractors threatening to "quit" (or, stop offering their services? Terminology is a major part of this issue) so I wonder how we will fill these spots. Maybe pay raises for all employees! (yeah right.) I bet they will temporarily fill the spots with mid-level employees. And soon, once admin realizes an NP can prescribe 40mg Zyprexa and 2000mg Depakote with as many mouseclicks as an MD, they won't be temporary anymore.

 

[michaelrack]

Here's a situation from a few years ago in which 1099 makes sense: a private psych hospital has several psychiatrists on staff, who bill commercial insurers/Medicare for seeing the patients. The hospital has negotiated with medicaid for a daily global rate that covers both the "bed fee" as well as physician rounding; the hospital pays the psychiatrists 1099 income for seeing these patients. A few of the docs (including the medical director), also receive a stipend (also 1099 income).

 

[Sushirolls]

Here's a situation from a few years ago in which 1099 makes sense: a private psych hospital has several psychiatrists on staff, who bill commercial insurers/Medicare for seeing the patients. The hospital has negotiated with medicaid for a daily global rate that covers both the "bed fee" as well as physician rounding; the hospital pays the psychiatrists 1099 income for seeing these patients. A few of the docs (including the medical director), also receive a stipend (also 1099 income).

It was one of those docs at one of those facilities that won a case that I referenced earlier that also had one of those stipends!

-docs there don't get to set their call coverage schedule themselves.
-docs there don't get to assign their own rounding times.
-docs there don't get to chart using their own EMR or note system, they are dictated to what the note taking policies are, which facility approved notes are to be used.
-Docs there use all the faxes, phones, printers, and staff there to do their work. And the prescription pads for that facility, too.
-Docs there report to the committees and shape the policies that make the hospital work.

Simply put it doesn't pass the muster of an IC. Think about the electrician or plumber who might come to your home. They say when they will show up. They use their tools. Their van. Their supplies. And direct their work themselves.

Independent contractors have criteria they must meet:
1) Be free from direction and control of the hospital entity
2) Pass one of the 3 subtests:
2a) perform a service which is outside the course of the hospital business
2b) perform the service away from all the hospital locations, including the hospital clinic sites
2c) be responsible, both under the contract and in fact for the costs of the principal place of business from which the service is performed
3) Need to pass one of the following two subtests:
3a) be customarily engaged in their own business to provide the services which are of the same nature as those performed under the contract or,
3b) Provide a principal place of business that qualifies for an IRS business deduction; the place must be used regularly and exclusively for business purposes
4) Be required under IRS rules to file a business ta return with the IRS
5) maintain their own set of books and records showing business income and expenses

 

[michaelrack]

At the facility I worked at, the docs set their own rounding times (and days, only being required to see patients 5 x per week). I don't know if they met all of the independent contractor criteria, but the docs also had separate places of business (offices) and often saw patients at more than 1 hospital (owned by different companies). I am not sure about criteria 2, but they did have to pay for their malpractice but I am not sure if they met #2 (may have met 2c)