EM Reimbursement

[docB]

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I recently was talking with some friends about the cost of medical procedures. One guy got a dental crown, cost $900. Another had a baby, bill for the epidural, $2400 ( he called them and wound up paying $1000).

The insane thing is that EMERGENCY procedures pay much less than this. I think Medicare pays $450 for a level 5 ED visit like a code or an MI. It pays about $600 for a critical care visit and about $400 for an intubation (we do all the inhouse intubations we we frequently bill for an intubation by itself). How crazy is it that a dental crown is worth more than a code?

 

[allendo]

are most EP's employed by groups that dont let them collect for their billing? In other words the group bills and collects the extras and the doc doesnt see them.

 

[EctopicFetus]

I think the point is how long these things take. I had a crown put in and it definitely took quite a while for the dentist to do his thing. While a code could run for a little while intubating someone takes only a few minutes. Additionally, from an experience with a family member you are also charged for all the meds and the tube itself. the cost for the crown is all inclusive.

 

[docB]

I think the point is how long these things take. I had a crown put in and it definitely took quite a while for the dentist to do his thing. While a code could run for a little while intubating someone takes only a few minutes. Additionally, from an experience with a family member you are also charged for all the meds and the tube itself. the cost for the crown is all inclusive.

But if we were getting paid based on time spent I'd be able to bill $1000 to do a complex lac or a procedure on a toddler either of which take longer than many codes. However, even long procedures in the ED bill much less. It is a good point that the crown covers all the costs while my figure for the code was physicina billing only. The bill to the payer for a code including doc, hospital, drugs, ect. is several thousand $.

 

[aphistis]

I recently was talking with some friends about the cost of medical procedures. One guy got a dental crown, cost $900. Another had a baby, bill for the epidural, $2400 ( he called them and wound up paying $1000).

The insane thing is that EMERGENCY procedures pay much less than this. I think Medicare pays $450 for a level 5 ED visit like a code or an MI. It pays about $600 for a critical care visit and about $400 for an intubation (we do all the inhouse intubations we we frequently bill for an intubation by itself). How crazy is it that a dental crown is worth more than a code?

Also, don't forget that you're comparing an ED's Medicare reimbursement to a dentist's unregulated fee schedule. Calculating Medicare reimbursement for dental care is easy--go through each item in the treatment plan, add the fees together, then multiply by 0. Medicaid is a little better in most states, but the extra coverage mostly disappears by adulthood.

 

[EctopicFetus]

I realize that a complex lac can take a great deal of time.. My understanding is that when this whole system was put in place they brought out some economist and he determined many of these numbers using his estimate of the minimal skill/training to do the job and multiplied it by the time used to perform the procedure. Then there was another factor took into account the level of training of the person doing the procedure. For example if a plastic surgeon fixed that same lac and it took the same amount of time as an ED doc the plastic surgeon would get paid more.

I am not gonna get into the details but this is simply how it works for many but not all procedures.

I hope this info helps.

 

[Febrifuge]

Yeah -- Dr. Gawande mentions this in a recent New Yorker article on compensation. Here's just a snip:

"In 1985, William Hsiao, a Harvard economist, was commissioned to measure the exact work involved in each of the tasks doctors perform. It must have seemed a quixotic assignment, something like being asked to measure the exact amount of anger in the world. But Hsiao came up with a formula. Work, he decided, was a function of time spent, mental effort and judgment, technical skill and physical effort, and stress. He put together a large team that interviewed and surveyed thousands of physicians from almost two dozen specialties..."

http://www.newyorker.com/fact/content/articles/050404fa_fact

 

[Spettro]

I recently was talking with some friends about the cost of medical procedures. One guy got a dental crown, cost $900. Another had a baby, bill for the epidural, $2400 ( he called them and wound up paying $1000).

The insane thing is that EMERGENCY procedures pay much less than this. I think Medicare pays $450 for a level 5 ED visit like a code or an MI. It pays about $600 for a critical care visit and about $400 for an intubation (we do all the inhouse intubations we we frequently bill for an intubation by itself). How crazy is it that a dental crown is worth more than a code?

work at a fee for service ED if you want to be reimbursed for what you do monetarily. otherwise be happy to collect a fraction of what you bill... certainly DO NOT work at county if it bothers you.

 

[Febrifuge]

work at a fee for service ED if you want to be reimbursed for what you do monetarily. otherwise be happy to collect a fraction of what you bill... certainly DO NOT work at county if it bothers you.

Where is there a "fee-for-service ED?" I've never seen one. Or heard of one. And considering EMTALA, I don't think there can be one.

Actually, I heard about one in Central America, where some of our people went on a mission recently. The doc writes you a slip, you get out of your bed, give the slip to a guy, pay the guy, he stamps your slip, and then you get your bloods drawn... is that the sort of thing you mean?

 

[docB]

work at a fee for service ED if you want to be reimbursed for what you do monetarily. otherwise be happy to collect a fraction of what you bill... certainly DO NOT work at county if it bothers you.

I'm not even talking about what I collect. I'm talking about what these procedures bill for. It's just seems odd that I can code you and save your life (all my codes live by the way 😛 ) and my bill will be lower than you would get for a dental crown. I think EctopicFetus and aphistis answered it best by noting that I'm talking about the physician charge only while the crown bill covers everything and that my fees are based on Medicare rules while the DDS sets his own fee schedule.

 

[docB]

. Actually, I heard about one in Central America, where some of our people went on a mission recently. The doc writes you a slip, you get out of your bed, give the slip to a guy, pay the guy, he stamps your slip, and then you get your bloods drawn... is that the sort of thing you mean?

One of the surgery residents I used to work with was from Peru and he described the exact same system. It sounded wild. Families scrounging up cash to buy a blood test. One of the upshots was that pts didn't get a "routine lab panel and cxr" every day. The docs would make sure that they only ordered something if it was crucial. It sounded sort of neat in that they became better clinicians and less reliant on diagnostics. Keep in mind that they don't have the med mal issues to deal with that we do.

 

[southerndoc]

Where is there a "fee-for-service ED?" I've never seen one. Or heard of one. And considering EMTALA, I don't think there can be one.

Actually, I heard about one in Central America, where some of our people went on a mission recently. The doc writes you a slip, you get out of your bed, give the slip to a guy, pay the guy, he stamps your slip, and then you get your bloods drawn... is that the sort of thing you mean?

I know of two hospitals where physicians are fee-for-service. One hospital pays its physicians 31% of whatever is billed, not what is collected. Imagine, a $500 fee for a critical patient, $400 for an intubation, $400 for a central line, maybe $200 for a splint, and the physician gets 31% for all of that, regardless of what the insurance company pays.

 

[EctopicFetus]

Southern,

Im curious which hospitals? and in a more practical sense... doesnt it worry you that the only incentive to the docs is to order more stuff so they can make more $$$?

Sounds like a poor way to run a business.

 

[southerndoc]

Southern,

Im curious which hospitals? and in a more practical sense... doesnt it worry you that the only incentive to the docs is to order more stuff so they can make more $$$?

Sounds like a poor way to run a business.

Procedures, not labs or ancillary tests.

 

[Sessamoid]

Where is there a "fee-for-service ED?" I've never seen one. Or heard of one. And considering EMTALA, I don't think there can be one.

I think you are missing the common meaning for "fee-for-service". All it means is that a person is (or supposed to be) paid according to what they do. This term is in contrast to a straight salaried employee or physicians who see patients on a capitated basis.

In EM, "fee for service" too often becomes "free for service".

 

[Febrifuge]

I think you are missing the common meaning for "fee-for-service". All it means is that a person is (or supposed to be) paid according to what they do. This term is in contrast to a straight salaried employee or physicians who see patients on a capitated basis.

In EM, "fee for service" too often becomes "free for service".

Gotcha. I think I see where I was falling off the track. I was taking Spettro's comment that DocB should work in a fee-for-service ED if he wants to stop getting screwed on reimbursement on face value. Which is wrong, because Spettro is off the mark if he/she thinks billing that way prevents getting hosed.

Especially because, as you clarified, it's not that the EP gets paid for the services performed; they get to bill for those services. So EMTALA still applies, and no patient gets anything withheld for inability to pay.

 

[docB]

Southern,

Im curious which hospitals? and in a more practical sense... doesnt it worry you that the only incentive to the docs is to order more stuff so they can make more $$$?

Sounds like a poor way to run a business.

This is a really good point. In my group we are paid hourly with an additional incentive bonus based on our productivity (figured by RVUs). Some people within the group have argued that this creates an incentive to inflate workups to increase the RVUs per pt. If you have a system where this is the case it would be bad. For us this is not true because we all have too many pts to see. I have much more of an incentive to move a pt out and see another one than to hang onto them in the ED and get a bunch of unnecessary tests. There are situations where there could be an incentive for the docs to inflate work ups. For example a true fee for service set up where a doc is paid based on what he collects.

nd a few notes about the whole "fee for service" concept. A true fee for service system means that a doc gets paid what is collected from his billing less overhead like admin and maybe malpractice. A system where you are paid bassed on billing but not collections is not true fee for service. It is, in most instances, better though because true fee for service give the docs an incentive to skimp on workups for the uninsured and over do workups for the insured. A pure hourly causes problems with productivity because docs get paid if they see pts or not so charts sit in the rack forever. It's important to remember that every system has its pros and cons.

 

[Jeff698]

This is a really good point. In my group we are paid hourly with an additional incentive bonus based on our productivity (figured by RVUs). .

Is this incentive a percentage of group billings? Are there group requirements (i.e. staff meeting attendance, completed charts, etc) for getting the bonus? How often is it awarded? Does it come out to be a significant percentage of total income? Do you think this structure has a positive effect on your group practice?

I just heard a lecture on setting up this type of pay structure and was very interested. I'd just like to see how it works elsewhere.

Take care,
Jeff

 

[docB]

Is this incentive a percentage of group billings? Are there group requirements (i.e. staff meeting attendance, completed charts, etc) for getting the bonus? How often is it awarded? Does it come out to be a significant percentage of total income? Do you think this structure has a positive effect on your group practice?

I just heard a lecture on setting up this type of pay structure and was very interested. I'd just like to see how it works elsewhere.

Take care,
Jeff

The amount of money available for bonuses is dependent on group collections. We don't currently have any group requirements although that is a good idea. It's awarded monthly. It winds up being between 10 and 30% of income. I really like this as a system for compensation.

There are several reasons that this is such a good system. Since the majority of our pay is hourly you don't get penalized very much if you have a slow shift. Since you're making bonus for seeing more pt's you don't feel as bitter when you get hammered. Because we're paid hourly and the bonus is based on billing instead of collections the group as a whole bears the burden of seeing the uninsured. We also have shift differentials for nights and weekends so we don't have any problem filling those shifts.

 

[LADoc00]

The amount of money available for bonuses is dependent on group collections. We don't currently have any group requirements although that is a good idea. It's awarded monthly. It winds up being between 10 and 30% of income. I really like this as a system for compensation.

There are several reasons that this is such a good system. Since the majority of our pay is hourly you don't get penalized very much if you have a slow shift. Since you're making bonus for seeing more pt's you don't feel as bitter when you get hammered. Because we're paid hourly and the bonus is based on billing instead of collections the group as a whole bears the burden of seeing the uninsured. We also have shift differentials for nights and weekends so we don't have any problem filling those shifts.

So I had a high school buddy who went to a different med school who claimed he made 300 grand coming right out of training (of course he strolled around our home town announcing it) at an average program after having graduated from an average medical school. Was he blowing serious smoke up my a$$? I had to hear endless shiat from my mom after that asking why I could not get paid the same or more having had so much more prestigious training.... 😕

 

[Spettro]

Where is there a "fee-for-service ED?" I've never seen one. Or heard of one. And considering EMTALA, I don't think there can be one.

Actually, I heard about one in Central America, where some of our people went on a mission recently. The doc writes you a slip, you get out of your bed, give the slip to a guy, pay the guy, he stamps your slip, and then you get your bloods drawn... is that the sort of thing you mean?

as an ed doc, you are either paid hourly, salaried, or by rvu/fee for service. many community EDs are fee for service; i can name 3 off the top of my head in the city i live in. i suppose that most people dont know how an ED pays it docs... unless youre getting paid by one.

 

[Spettro]

Gotcha. I think I see where I was falling off the track. I was taking Spettro's comment that DocB should work in a fee-for-service ED if he wants to stop getting screwed on reimbursement on face value. Which is wrong, because Spettro is off the mark if he/she thinks billing that way prevents getting hosed.

Especially because, as you clarified, it's not that the EP gets paid for the services performed; they get to bill for those services. So EMTALA still applies, and no patient gets anything withheld for inability to pay.

thats exactly what i mean. look, ed docs come in essentially 2 or 3 flavors. county/academic physicians make the least... approximately 1/2 of what community docs make. typical hourly rates for academic physicians = $80/hr. kaiser= $120/hr. fee for service/rvu make a base around 130-140 plus an adjusted amount depending on number and complexity of patients seen, which is reflected by how you bill. so yes, if you see a larger number of complex/critical patients, you get paid more. forget emtala, it has no bearing on how you are paid.

 

[docB]

So I had a high school buddy who went to a different med school who claimed he made 300 grand coming right out of training (of course he strolled around our home town announcing it) at an average program after having graduated from an average medical school. Was he blowing serious smoke up my a$$? I had to hear endless shiat from my mom after that asking why I could not get paid the same or more having had so much more prestigious training.... 😕

Yes, it's possible to make $300 K fresh out in EM. Once you get a job no one cares where you went to school or residency. In fact, you may be more likely to make less if you go to a high power place because it may lead you into academics and there's more money to be made in the community. Remember that there's a LOT more to being happy in this field than money.

One thing to keep in mind is that many people in EM make whatever they're going to make for their whole careers. In other words many docs don't get periodic raises based on seniority. Their pay is based on their hours and workload which will likely remain constant.

 

[docB]

forget emtala, it has no bearing on how you are paid.

EMTALA affects how much you're paid if you work in an area with a poor payor mix, ie. if you have a high population of uninsured in your area you will be forced by EMTALA to see tham for free and you will get paid less.

 

[Febrifuge]

< ding ding ding! > We have a winnah. That's just what I mean. Thanks! 😀

 

[peksi]

$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

One of our grads just signed a contract for a START at 360K (1500 hours ) NOT incluiding bonus and bennies....BOOOHAY! And it's the real deal, reviewed the contract myself. Key there is a 70% payer mix.

Paul

 

[Sessamoid]

$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

One of our grads just signed a contract for a START at 360K (1500 hours ) NOT incluiding bonus and bennies....BOOOHAY! And it's the real deal, reviewed the contract myself. Key there is a 70% payer mix.

Paul

That's the key there. Was that a newly graduated doc or somebody who had been out for a while? That's a hell of a catch for a new grad!

 

[peksi]

That's the key there. Was that a newly graduated doc or somebody who had been out for a while? That's a hell of a catch for a new grad!

The Doc of note is finishing up an Admin fellowship, thus out 1 year!

Paul