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[deleted1115000]

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[sloop]

It's commonly known that PP has a higher average salary than other areas of medicine, but I recently came across this article that quoted some huge paychecks for top physicians at Maimonides medical center (3.5 million for chief of heart surgery) and I have heard anecdotally that many hospitals have similar heavy hitters, even prestigious academic hospitals which typically pay the lowest. Does employed medicine have a higher pay ceiling? I imagine it would be impossible to hit 3.5 million based on RVU

Exclusive | Struggling NYC hospital pays brass fat salaries despite staffing, money woes

Maimonides Medical Centers’ CEO Kenneth Gibbs saw his compensation skyrocket from $1.8 million to $3.2 million from 2019 to 2020, when the worst of the COVID-19 pandemic hit the facility.

nypost.com

Being a department chief isn’t fundamentally an academic job. The weird thing about those jobs is that the people who wind up in them usually have productive academic backgrounds, but it’s primarily a management position. A major part of my former department chief’s job was just to brown-nose rich people and elicit philanthropy to the department. Comparing clinical medicine to that type of job is kind of apples to oranges. I suspect that if you wanted a management role like that, you could just found and run a chain of clinics, surgical centers, etc. and make more.

 

[TakotsuboOkazaki]

I’m sure these salaries occur with some frequency.

One thing to think about is how hard those sort of positions are to come by. There’s a lot of politics and pedigree involved in obtaining them, and i’d doubt you’d obtain one shy of your 50s. If you didn’t train at Ivory tower X or train under person Y your candidacy might decrease. People usually don’t leave those jobs until they croak either. You can’t just “outwork” your 68 year old chair and take their job.

You’d probably have a better shot at that sort of income by applying some business and investment savvy to your private practice endeavors. Youth & hustle would be more likely to pay dividends here.

I suppose it depends on what you want. Making $1m/yr as chief of surgery at FancyU might be worth more than the money alone.

 

[operaman]

Not really but there are definitely exceptions. I think PP still wins overall simply because they have opportunities for entrepreneurship within their clinical framework. Most PP docs making big bucks have multiple streams of income - imaging, surgery center, cash only cosmetic stuff, medspas, etc. You can hire on additional partners and associates as you grow and take a cut of their earnings. The partners I know in PP make $700 on the low end to $1.5 typical higher end and some rare birds in the $2-3+ range.

Getting to those salaries in most employed and academic models is fairly challenging, and you are limited by the framework of the institution itself. If you’re at a place that starts assistant profs at $250 and fulls make $500 then that’s where you’re at. If you’re at the one where they start at $700 and fulls are $1.5m then you’ve got much more potential in terms of income (yes those are real and current numbers).

RVU based positions can have a lot of upward potential depending on your specialty and contract. Many places will cap your salary, but not all of them. If there’s no cap, a busy specialist can definitely hit 7 figures. The drawback is that you are at the mercy of the hospital. I have a buddy who was making around 1m a year and his hospital is moving to a capped system and I think the cap is only $700, so that’s a massive pay cut for the most productive docs. PP docs can maintain a little more control over their practice and business interests.

 

[mrbreakfast]

As others have said, only a minority of those chiefs/chairs' salary is coming from their actual clinical production. They're running a department. CT surgery at Maimonides billed over $100 million in 2022. The chief isn't a doctor as much as the CEO of a smaller company within a multi-billion dollar larger company (Maimonides).

Academic chairs do make additional salary based on their academic position/work. But they'd very likely make the same, or more, if they did the same volume of work that they do in academics as a PP physician and billed for it.

 

[voxveritatisetlucis]

I’m sure these salaries occur with some frequency.

One thing to think about is how hard those sort of positions are to come by. There’s a lot of politics and pedigree involved in obtaining them, and i’d doubt you’d obtain one shy of your 50s.

this is the weird thing because equivalent positions in other industries (ex managing director) are usually under 40 when initially promoted. If you’re over 40 and haven’t made it to MD, you probably never will.

Maybe it’s the age shift in medicine

 

[operaman]

Very interesting thank you for the response. What field are you in/citing these numbers from?

ENT.

There’s lots of variation though. A great example would be various academic centers in California. They’re all public record so you can look up salaries. Some places have faculty at 250-550 while others are more 300-1.7m. Most hospitals everywhere are nonprofits so you can pull their form 990 tax returns and see their highest paid employed docs and then Google to figure out their specialty.

 

[voxveritatisetlucis]

Not really but there are definitely exceptions. I think PP still wins overall simply because they have opportunities for entrepreneurship within their clinical framework. Most PP docs making big bucks have multiple streams of income - imaging, surgery center, cash only cosmetic stuff, medspas, etc. You can hire on additional partners and associates as you grow and take a cut of their earnings. The partners I know in PP make $700 on the low end to $1.5 typical higher end and some rare birds in the $2-3+ range.

Getting to those salaries in most employed and academic models is fairly challenging, and you are limited by the framework of the institution itself. If you’re at a place that starts assistant profs at $250 and fulls make $500 then that’s where you’re at. If you’re at the one where they start at $700 and fulls are $1.5m then you’ve got much more potential in terms of income (yes those are real and current numbers).

RVU based positions can have a lot of upward potential depending on your specialty and contract. Many places will cap your salary, but not all of them. If there’s no cap, a busy specialist can definitely hit 7 figures. The drawback is that you are at the mercy of the hospital. I have a buddy who was making around 1m a year and his hospital is moving to a capped system and I think the cap is only $700, so that’s a massive pay cut for the most productive docs. PP docs can maintain a little more control over their practice and business interests.

What universities/hospitals are starting full profs at 1.5 million? Is there a difference from being a physician vs a professor at these places

 

[DarkHorizon]

Multispecialty employed sub specialty surgeon here. Employed positions are easy to make 25th to 75th percentile salary. The referral system is built-in and all you have to do is show up. Median sub specialty surgeon salaries are mid 6 figures and higher. So it’s a lot of money with little risk.

Private practice has much higher ceiling with successful surgeons making 2-3 times median salary. But there’s some risk. For every guy making 7 figures, there are 2 or 3 younger surgeons taking huge pay cuts trying to become partners and establish themselves who never get there.

But in general, private practice guys make more and don’t report their income to salary surveys so you can’t gauge how much more. Speaking to my friends, most of them who made partners are making high 6 figures/low 7 figures. But as I said, there’s risk, and I also know quite a few guys who left private practice to become employed after crashing and burning for a few years.

 

[operaman]

What universities/hospitals are starting full profs at 1.5 million? Is there a difference from being a physician vs a professor at these places

Well not “starting” per se, obviously they’ve been there awhile at that point. One place I won’t reveal because those discussions were private but ucla has a number of ent docs in the 7 figures and those salaries are public record so you can pull them up yourself. In fact 3 of the highest paid people in the entire UC system are ucla ents.

Most all these docs are busy clinicians and the full professor is more their academic title.

 

[operaman]

GI doc making 2.5 mil 😵😵

Yeah I’ve done a ridiculous amount of study of salaries and practice patterns to figure out how these guys are making such salaries. I’m not at 7 figures yet since I just started but I’m heading that way quickly based on what I’ve learned from studying them and implemented into my own practice.

GI doc in employee rvu based system clearly has a highly efficient practice with APPs and residents billing incidentally to him and a generous per rvu reimbursement.

Rvus are a strange way of thinking because they’re not real money and they don’t always correlate with the time and difficulty of what I’m doing. I think this is why so many groups are capping rvu bonus pay as people like me figure out how to optimize ourselves in the system. Anything too good to be true in medicine won’t last forever, but I’m going to enjoy it while it lasts!

 

[DarkHorizon]

Yeah I’ve done a ridiculous amount of study of salaries and practice patterns to figure out how these guys are making such salaries. I’m not at 7 figures yet since I just started but I’m heading that way quickly based on what I’ve learned from studying them and implemented into my own practice.

GI doc in employee rvu based system clearly has a highly efficient practice with APPs and residents billing incidentally to him and a generous per rvu reimbursement.

Rvus are a strange way of thinking because they’re not real money and they don’t always correlate with the time and difficulty of what I’m doing. I think this is why so many groups are capping rvu bonus pay as people like me figure out how to optimize ourselves in the system. Anything too good to be true in medicine won’t last forever, but I’m going to enjoy it while it lasts!

So true. Also helps if your employer is honest and shares detailed RVU reports for you to study.

 

[operaman]

So true. Also helps if your employer is honest and shares detailed RVU reports for you to study.

Yeah this has been my biggest battle of late. They give me delayed data whereas my last shop sent out weekly emails.

Otherwise I’ve done a lot of public record searching for top earners, then pulled their raw Medicare billing data and data mined it looking for patterns, codes they use, etc. And then as I see patients who have seen any of those docs I can look at past notes and encounters to see how they’re documenting and coding. Have definitely borrowed quite a few of my templates using this method!

 

[ACSurgeon]

Yeah this has been my biggest battle of late. They give me delayed data whereas my last shop sent out weekly emails.

Otherwise I’ve done a lot of public record searching for top earners, then pulled their raw Medicare billing data and data mined it looking for patterns, codes they use, etc. And then as I see patients who have seen any of those docs I can look at past notes and encounters to see how they’re documenting and coding. Have definitely borrowed quite a few of my templates using this method!

This is impressive!!

 

[mrbreakfast]

Otherwise I’ve done a lot of public record searching for top earners, then pulled their raw Medicare billing data and data mined it looking for patterns, codes they use, etc. And then as I see patients who have seen any of those docs I can look at past notes and encounters to see how they’re documenting and coding. Have definitely borrowed quite a few of my templates using this method!

This is smart, and I too have gotten some inspiration from the templates of my surgery colleagues.

In my field one secret to getting lots of RVUs is to seek out consults that wouldn't otherwise be placed. There are people who make the ED their home base and bill for 30 consults a day, many of which only take a few minutes to complete.

 

[operaman]

This is smart, and I too have gotten some inspiration from the templates of my surgery colleagues.

In my field one secret to getting lots of RVUs is to seek out consults that wouldn't otherwise be placed. There are people who make the ED their home base and bill for 30 consults a day, many of which only take a few minutes to complete.

Yeah it’s amazing how my view of consults changed after training! I’ve done something kinda similar - I’ve made a point to befriend key docs and SLPs and make myself very available so now they frequently call me with inpatient stuff even when not on call. Gotta love those inpatient consult E&M codes plus a procedure or two at bedside, then usually some kind of operative procedure comes out of it too.

Yeah 30 consults in the ED is pretty sweet - that’s easily 100+ rvus in a day. Do that 3- 4 days a week and you’re over 7 figures easily. I don’t think my ED would have that many for me in a day or I would do that in a heartbeat!

 

[DarkHorizon]

Yeah this has been my biggest battle of late. They give me delayed data whereas my last shop sent out weekly emails.

Otherwise I’ve done a lot of public record searching for top earners, then pulled their raw Medicare billing data and data mined it looking for patterns, codes they use, etc. And then as I see patients who have seen any of those docs I can look at past notes and encounters to see how they’re documenting and coding. Have definitely borrowed quite a few of my templates using this method!

The other battle is to fight your own coders. They down code, or completely miscode all the time. If you work for a large health system with majority of your patients part of their ACO, the coders make every effort to downcode you. And often they’ll change it once you fight it, but it’s very exhausting. I get that on daily basis, they are almost like admins lapdogs that are unleashed on procedurealists to keep production low to keep reimbursement low. I can give so many examples but I’m sure you know what I mean.

 

[operaman]

The other battle is to fight your own coders. They down code, or completely miscode all the time. If you work for a large health system with majority of your patients part of their ACO, the coders make every effort to downcode you. And often they’ll change it once you fight it, but it’s very exhausting. I get that on daily basis, they are almost like admins lapdogs that are unleashed on procedurealists to keep production low to keep reimbursement low. I can give so many examples but I’m sure you know what I mean.

Yeah I’m currently blessed in that I do all my own coding, both in clinic and the OR, but yes I’m sure this battle will come my way eventually.

I code pretty aggressively so a couple times they’ve caught issues where I did something incorrectly - so many random rules around this stuff. It’s been awhile now though so I think I’ve tweaked my documentation pretty well to cover the bases and keep the coders happy.

 

[Lost in Translation]

The other battle is to fight your own coders. They down code, or completely miscode all the time. If you work for a large health system with majority of your patients part of their ACO, the coders make every effort to downcode you. And often they’ll change it once you fight it, but it’s very exhausting. I get that on daily basis, they are almost like admins lapdogs that are unleashed on procedurealists to keep production low to keep reimbursement low. I can give so many examples but I’m sure you know what I mean.

Why would they want to down-code? Doesn’t that mean less money for their hospital system?

 

[DarkHorizon]

Why would they want to down-code? Doesn’t that mean less money for their hospital system?

Yes, traditionally. But You need to understand how ACOs work.

 

[qwerty89]

Yeah I’ve done a ridiculous amount of study of salaries and practice patterns to figure out how these guys are making such salaries. I’m not at 7 figures yet since I just started but I’m heading that way quickly based on what I’ve learned from studying them and implemented into my own practice.

GI doc in employee rvu based system clearly has a highly efficient practice with APPs and residents billing incidentally to him and a generous per rvu reimbursement.

Rvus are a strange way of thinking because they’re not real money and they don’t always correlate with the time and difficulty of what I’m doing. I think this is why so many groups are capping rvu bonus pay as people like me figure out how to optimize ourselves in the system. Anything too good to be true in medicine won’t last forever, but I’m going to enjoy it while it lasts!

Optimal practice is to have your medical school, residency and fellowship trained physician being a scope monkey and having the APPs see new consults in clinic...

Terrible medicine though.

 

[voxveritatisetlucis]

Where does the line get drawn between “upcoding” and medicare/insurance fraud

 

[Lost in Translation]

Yes, traditionally. But You need to understand how ACOs work.

In what way are the coders down-coding? For example, if I do an EUA prior to the actual surgical procedure, I will bill for the EUA as well as the surgical code if the surgical code alone doesn’t include “EUA”. That’s not upcoding, that’s me billing for exactly the exam I did. Would a coder remove the EUA code?

 

[RangerBob]

Where does the line get drawn between “upcoding” and medicare/insurance fraud

If your documentation supports it (and represents what you actually did), it's kosher.

If your documentation doesn't, it's fraud.

Simple as that.

I notify my billers of my codes/charges, and they take care of the rest. At first I thought it was annoying (never having had to code inpatient visits in residency), but it's actually nice, because I hear how often the hospital billers mess things up.

I'm not paid by RVU's though, like those above. 100% fee-for-service, so sometimes I just don't get paid.

 

[DarkHorizon]

In what way are the coders down-coding? For example, if I do an EUA prior to the actual surgical procedure, I will bill for the EUA as well as the surgical code if the surgical code alone doesn’t include “EUA”. That’s not upcoding, that’s me billing for exactly the exam I did. Would a coder remove the EUA code?

Down coding happens on bundling stuff…. Or for example in Ortho trauma, not billing E&M codes at the same time as initial frscture care for non op frsctures. Or not letting you use the 24 modifier for polytraumatic patients with multiple injuries in post op period.

 

[operaman]

Where does the line get drawn between “upcoding” and medicare/insurance fraud

Fraud is just that - untrue billing whether above or below what you actually did. Yes, under coding is just as fraudulent as overcoding though probably not as noticed.

I think what worries me and others most is all the little nuances we don’t know. Like there are a couple of different procedures I commonly do in clinic and when I did both I would code both, but apparently there was some cms document that was different than the various books and apps I have which said you can’t bill those two specific codes together on the same day.

I’m actually not sure if that counts as fraud since I definitely did everything I documented, but I’d rather not find out. I’ve seen notes from other docs in town who code it that way so maybe it’s just a cms rule and other commercial payers allow it.

This stuff is nuts but I’d rather be in control of it myself rather than leave it entirely to coders who don’t understand what I do.

 

[DarkHorizon]

Fraud is just that - untrue billing whether above or below what you actually did. Yes, under coding is just as fraudulent as overcoding though probably not as noticed.

I think what worries me and others most is all the little nuances we don’t know. Like there are a couple of different procedures I commonly do in clinic and when I did both I would code both, but apparently there was some cms document that was different than the various books and apps I have which said you can’t bill those two specific codes together on the same day.

I’m actually not sure if that counts as fraud since I definitely did everything I documented, but I’d rather not find out. I’ve seen notes from other docs in town who code it that way so maybe it’s just a cms rule and other commercial payers allow it.

This stuff is nuts but I’d rather be in control of it myself rather than leave it entirely to coders who don’t understand what I do.

Funny you mention that. So CMS has CCI rules. And they bundle random things together, however, private insurances allow many of these to be billed individually. Many many times, they’ll downcode it for reimbursement, but bill it out to private insurance. They’ll always downcode if it’s their own private insurance/HMO patient and follow CCI rules.