Facility Fees

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IAmTheOne1

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Would appreciate any advice on this situation:

Recently joined private practice in which I was signed as a 1099 independent contractor seeing patients in clinic and also doing procedures in an ASC (Clinic side and ASC are independent corporations - both owned by a senior member). On the clinic side, I collect professional fees for seeing patients minus a fixed percentage for overhead. On the ASC side, I perform procedures on my patients who I’ve seen in consultation/follow-up in the clinic and also collect the professional fee minus a fixed percentage for overhead. The owner would like to structure a way for me to make some money off the facility fees from my procedures in the ASC but doesn’t want to offer shares for ownership in the ASC. When asked why, a previous physician was given shares in the ASC and very soon after stopped performing procedures while continuing to collect a share of facility fees and it became a problem. The owner has asked me to come up with a solution(s) where I can make money off facility fees while not violating Anti-Kickback Law. Any thoughts or solutions would be greatly appreciated.

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Would appreciate any advice on this situation:

Recently joined private practice in which I was signed as a 1099 independent contractor seeing patients in clinic and also doing procedures in an ASC (Clinic side and ASC are independent corporations - both owned by a senior member). On the clinic side, I collect professional fees for seeing patients minus a fixed percentage for overhead. On the ASC side, I perform procedures on my patients who I’ve seen in consultation/follow-up in the clinic and also collect the professional fee minus a fixed percentage for overhead. The owner would like to structure a way for me to make some money off the facility fees from my procedures in the ASC but doesn’t want to offer shares for ownership in the ASC. When asked why, a previous physician was given shares in the ASC and very soon after stopped performing procedures while continuing to collect a share of facility fees and it became a problem. The owner has asked me to come up with a solution(s) where I can make money off facility fees while not violating Anti-Kickback Law. Any thoughts or solutions would be greatly appreciated.

Simple.
1-You need to get 100% of your professional fees on procedures.
2- they need to rethink your overhead percentage for clinic patients
 
Simple.
1-You need to get 100% of your professional fees on procedures.
2- they need to rethink your overhead percentage for clinic patients

#1 i actually a good idea.

the money is in the facility fees, so it'd be nice for you to see actual piece of that pie. the standard way is way ASC shares

you really need to flush out the legality of all of this, though.
 
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You can sign a PSA with the surgery center and then get paid on RVU’s.

would working for RVUs be any different than just collecting the professional fee? Looking for a way to collect the professional fee but ALSO share in some percentage of the facility fee. Not sure how RVU model would facilitate that. Would appreciate any further explanation or ideas. Thanks!
 
How does someone get paid in RVUs? Is it like a Bitcoin and you can spend it directly or convert it at an exchange? Or is each unit converted at a specific rate to US dollars that varies from individual to individual, situation to situation?
 
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How does someone get paid in RVUs? Is it like a Bitcoin and you can spend it directly or convert it at an exchange? Or is each unit converted at a specific rate to US dollars that varies from individual to individual, situation to situation?




Rvu is like 80s Wheel of Fortune shopping spree after winning a puzzle. 15 rvu is a porcelain Dalmatian.
 
Would appreciate any advice on this situation:

Recently joined private practice in which I was signed as a 1099 independent contractor seeing patients in clinic and also doing procedures in an ASC (Clinic side and ASC are independent corporations - both owned by a senior member). On the clinic side, I collect professional fees for seeing patients minus a fixed percentage for overhead. On the ASC side, I perform procedures on my patients who I’ve seen in consultation/follow-up in the clinic and also collect the professional fee minus a fixed percentage for overhead. The owner would like to structure a way for me to make some money off the facility fees from my procedures in the ASC but doesn’t want to offer shares for ownership in the ASC. When asked why, a previous physician was given shares in the ASC and very soon after stopped performing procedures while continuing to collect a share of facility fees and it became a problem. The owner has asked me to come up with a solution(s) where I can make money off facility fees while not violating Anti-Kickback Law. Any thoughts or solutions would be greatly appreciated.

Just do what the hospitals do: YOU become his W-2 employee on the clinic. He collects *ALL* your pro fees and facility fees in both the clinic and the ASC. Then, he takes some money from that pot and pays you. It's no different than how he would pay the janitor or receptionist. Why make it complicated?
 
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Just do what the hospitals do: YOU become his W-2 employee on the clinic. He collects *ALL* your pro fees and facility fees in both the clinic and the ASC. Then, he takes some money from that pot and pays you. It's no different than how he would pay the janitor or receptionist. Why make it complicated?

with W2, can you be paid on a variable rate each month? The issue is that my earnings need to be directly tied to my production. A janitor’s work doesn’t fluctuate and isn’t tied to anything he or she does. With my situation, I can work really hard or not so hard and the compensation should reflect that. If I do 10 stims a week vs 5 interlaminar epidurals a week, that’s a big difference. If I’m paid a flat rate W2 then that could potentially be unfair to both sides depending on my productivity. If he’s allowed to pay me a variable rate W2 based on my productivity isn’t that violating the spirit of the Anti kickback law? I guess that law is just very nebulous and that’s at the heart of the issue...
 
with W2, can you be paid on a variable rate each month? The issue is that my earnings need to be directly tied to my production. A janitor’s work doesn’t fluctuate and isn’t tied to anything he or she does. With my situation, I can work really hard or not so hard and the compensation should reflect that. If I do 10 stims a week vs 5 interlaminar epidurals a week, that’s a big difference. If I’m paid a flat rate W2 then that could potentially be unfair to both sides depending on my productivity. If he’s allowed to pay me a variable rate W2 based on my productivity isn’t that violating the spirit of the Anti kickback law? I guess that law is just very nebulous and that’s at the heart of the issue...

Yes, it can fluctuate every month but can't be tied to your production volume. It can't be based on volume or metrics that derive from volume to be Stark compliant (assuming you take federal payers). Also, your compensation needs to meet a minimum IRS standard for physicians (it's a pretty low bar). We give the janitor a perk and bonus for timeliness of cleaning the toilets, no customer complaints about the bathrooms, and no unexpected outages of toilet paper (it's a never event). As long as she hits those metrics she gets her bonus. You can set up the same scheme.
 
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You can sign a PSA with the surgery center and then get paid on RVU’s.

Bob had suggested the best option in my opinion. Signing a PSA and him paying you based on RVU will let you get a piece of the facility fee in that it will be disguised in the RVU payment. Your pro fee on an ESI is around $100. RVU for an ESI is 1.5. Negotiate an RVU payment of $100/RVU if you’re attorneys say it will be ok from legal standpoint (that amount is about 90th percentile of MGMA I believe). Then, instead of getting $100 for every ESI you will instead get $150.

On a side note, no way should the dude be currently getting all the facility fee AND a portion of the pro fee for “overhead”. The overhead portion of the ASC costs should be taken care of with the facility portion of the payment.

Drusso has another idea of just packaging everything together and letting them keep it and making you an employee but in my opinion, from a legal standpoint, you’d really just have to pick a salary everyone agrees is fair and go with it. Could maybe throw some bonuses in there but it would b had to figure something out to pay you for the amount of work you do without it clearly being based on volume without making it an RVU deal.
 
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sorry to resurrect this thread. but i'm about to be in a similar situation.
i'm currently on collections type model with gaurantee base. essentially i am on 45% collections with gaurantee base until I hit 800,000. then it is simple 45% payment to me for everything higher than this. this has been easy to compute since we have only been in - office for everything.
practice owner is about to open up his first ASC so we will be shifting some of our procedures to his ASC instead of the office.

now that we are shifting some work into the ASC (i have no ownership and there will probably be no buy-in option), if I have to collect 800,000 before getting my percentage of collections, can we count all the professional and facility fees into the 800,000 ?
based off some of the stark law comments you made, obviously I won't be able to get any percentage of facility fees once I start collecting my portion.

ultimately I was going to ask for 100% of pro fees, after I hit the 800,000, for anything done in ASC.

thanks for the clarification.
 
sorry to resurrect this thread. but i'm about to be in a similar situation.
i'm currently on collections type model with gaurantee base. essentially i am on 45% collections with gaurantee base until I hit 800,000. then it is simple 45% payment to me for everything higher than this. this has been easy to compute since we have only been in - office for everything.
practice owner is about to open up his first ASC so we will be shifting some of our procedures to his ASC instead of the office.

now that we are shifting some work into the ASC (i have no ownership and there will probably be no buy-in option), if I have to collect 800,000 before getting my percentage of collections, can we count all the professional and facility fees into the 800,000 ?
based off some of the stark law comments you made, obviously I won't be able to get any percentage of facility fees once I start collecting my portion.

ultimately I was going to ask for 100% of pro fees, after I hit the 800,000, for anything done in ASC.

thanks for the clarification.
The ASC opening will cut deeply into your reimbursement. The facility fee will NOT count towards your 800K and to make it worse, your professional fees will go down.

With this new development, if you're not being offered an ASC buy-in, you need to renegotiate your contract. 100% of the professional fees in an ASC is less than 45% of the same procedure in office.
 
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The ASC opening will cut deeply into your reimbursement. The facility fee will NOT count towards your 800K and to make it worse, your professional fees will go down.

With this new development, if you're not being offered an ASC buy-in, you need to renegotiate your contract. 100% of the professional fees in an ASC is less than 45% of the same procedure in office.
ok i figured as much. wishful thinking.

at this point, I will just hope for higher base with previously discussed RVU type model

thank you for clarification.
 
Yeah just take a look at the ASIPP fee schedules for pro fees. You will get a sense of how much your reimbursement for pro-fees will drop after doing procedures in the ASC. In some cases, it can be a staggering drop (example: CESI will pay you far less in pro fees vs a 99214 office visit). Owner will be collecting a boatload on facility fees as well.

Just to get a better understanding - you are getting 45% of everything you produce on top of a separate base salary? If that's the case, could be a good deal depending on what the base salary is. If not, seems like not that great of a deal seeing as how in order to earn 800k you would have to produce almost $1.8 Million.

If your guaranteed base is separate from production, and then after 800k turns into simple 45% then you have a diminishing incentive to work harder. I have always questioned this type of set up? Why would someone want to work harder to get a reduced pay-off? Generally speaking, as volume picks up, the margins should go up (certain fixed costs like rent, equipment, etc do not fluctuate - so higher volume should increase margins).
 
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Yeah just take a look at the ASIPP fee schedules for pro fees. You will get a sense of how much your reimbursement for pro-fees will drop after doing procedures in the ASC. In some cases, it can be a staggering drop (example: CESI will pay you far less in pro fees vs a 99214 office visit). Owner will be collecting a boatload on facility fees as well.

Just to get a better understanding - you are getting 45% of everything you produce on top of a separate base salary? If that's the case, could be a good deal depending on what the base salary is. If not, seems like not that great of a deal seeing as how in order to earn 800k you would have to produce almost $1.8 Million.

If your guaranteed base is separate from production, and then after 800k turns into simple 45% then you have a diminishing incentive to work harder. I have always questioned this type of set up? Why would someone want to work harder to get a reduced pay-off? Generally speaking, as volume picks up, the margins should go up (certain fixed costs like rent, equipment, etc do not fluctuate - so higher volume should increase margins).
sorry for confusion.
everything we do is currently in -office.
i get 45% of collections but they'll gaurantee me a base (360k) to protect me financially as a young physician.. so 45% of 800k = 360k.


but now that we will be moving into ASC, it will be harder to hit anything about 800k. so we are trying to figure out a way where I can reasonably obtain bonus .
 
Yeah just take a look at the ASIPP fee schedules for pro fees. You will get a sense of how much your reimbursement for pro-fees will drop after doing procedures in the ASC. In some cases, it can be a staggering drop (example: CESI will pay you far less in pro fees vs a 99214 office visit). Owner will be collecting a boatload on facility fees as well.

Just to get a better understanding - you are getting 45% of everything you produce on top of a separate base salary? If that's the case, could be a good deal depending on what the base salary is. If not, seems like not that great of a deal seeing as how in order to earn 800k you would have to produce almost $1.8 Million.

If your guaranteed base is separate from production, and then after 800k turns into simple 45% then you have a diminishing incentive to work harder. I have always questioned this type of set up? Why would someone want to work harder to get a reduced pay-off? Generally speaking, as volume picks up, the margins should go up (certain fixed costs like rent, equipment, etc do not fluctuate - so higher volume should increase margins).
the last time i looked, before ASIPP locked the information, the pro fee for CESI was within a couple of dollars of the fee for 99214.

if you have the 2021 or the anticipated 2022 numbers from ASIPP, please let us know the difference.
 
the last time i looked, before ASIPP locked the information, the pro fee for CESI was within a couple of dollars of the fee for 99214.

if you have the 2021 or the anticipated 2022 numbers from ASIPP, please let us know the difference.

For 2021, a 99214 in the office is $132.94 vs a CESI in an ASC pays $110.26. So you can see patient and prescribed gabapentin/more PT for their radiculopathy and get reimbursed $132.94 or shove a needle millimeters from their spinal cord in their neck and get $110.26. Decisions, decisions...
 
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For 2021, a 99214 in the office is $132.94 vs a CESI in an ASC pays $110.26. So you can see patient and prescribed gabapentin/more PT for their radiculopathy and get reimbursed $132.94 or shove a needle millimeters from their spinal cord in their neck and get $110.26. Decisions, decisions...

How much does it cost to have the NP prescribe the gaba?

When I was a kid I had a thriving lawn mowing business. I figured out I could sleep in on Saturdays and just rent my lawnmower to Julio for the day and he'd mow the lawns. I was literally making money in my sleep.

That's the first time I understood the difference between being a professional versus a businessman.
 
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How much does it cost to have the NP prescribe the gaba?

When I was a kid I had a thriving lawn mowing business. I figured out I could sleep in on Saturdays and just rent my lawnmower to Julio for the day and he'd mow the lawns. I was literally making money in my sleep.

That's the first time I understood the difference between being a professional versus a businessman.
Yet, you still went into medicine. What is wrong with us?
 
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For 2021, a 99214 in the office is $132.94 vs a CESI in an ASC pays $110.26. So you can see patient and prescribed gabapentin/more PT for their radiculopathy and get reimbursed $132.94 or shove a needle millimeters from their spinal cord in their neck and get $110.26. Decisions, decisions...
so $22 is "far less"?

from my standpoint, it takes me 7-8 minutes to do an epidural, but 25 minutes to do a 99214 office appointment.

truth be told, we undervalue the time we spend in face to face discussion with patients.

if i were to quantify how much an "encounter" costs me - like how much impact it has on my physical, mental and emotional health and overall impact on my psyche - that 99214 probably takes $300 compared to $100 for the epidural....
 
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so $22 is "far less"?

from my standpoint, it takes me 7-8 minutes to do an epidural, but 25 minutes to do a 99214 office appointment.

truth be told, we undervalue the time we spend in face to face discussion with patients.

if i were to quantify how much an "encounter" costs me - like how much impact it has on my physical, mental and emotional health and overall impact on my psyche - that 99214 probably takes $300 compared to $100 for the epidural....
Time vs risk.
 
so $22 is "far less"?

from my standpoint, it takes me 7-8 minutes to do an epidural, but 25 minutes to do a 99214 office appointment.

truth be told, we undervalue the time we spend in face to face discussion with patients.

if i were to quantify how much an "encounter" costs me - like how much impact it has on my physical, mental and emotional health and overall impact on my psyche - that 99214 probably takes $300 compared to $100 for the epidural....
7-8 minutes in the HOPD? I've never seen less than 45 minute turns in those venues...
 
so $22 is "far less"?

from my standpoint, it takes me 7-8 minutes to do an epidural, but 25 minutes to do a 99214 office appointment.

truth be told, we undervalue the time we spend in face to face discussion with patients.

if i were to quantify how much an "encounter" costs me - like how much impact it has on my physical, mental and emotional health and overall impact on my psyche - that 99214 probably takes $300 compared to $100 for the epidural....
It is far less risk, the clinic visit, but definitely more taxing on the soul if you let it be. The documentation burden and overhead of dealing with insurance/etc is also so much more draining. I'd rather do a blind thoracic epidural with the hanging drop technique than talk to some of these folks about their fibromyalgia complicated by OUD

Still, this is why academic pain fellowships without aggressive interventionalists can thrive and telehealth services such as Dorsal | Proven Treatments for Muscle and Joint Pain make sense

Tons of money in E&M with the payment/documenting changes, as long as you don't mind burning out providers along the way.
 
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so $22 is "far less"?

from my standpoint, it takes me 7-8 minutes to do an epidural, but 25 minutes to do a 99214 office appointment.

truth be told, we undervalue the time we spend in face to face discussion with patients.

if i were to quantify how much an "encounter" costs me - like how much impact it has on my physical, mental and emotional health and overall impact on my psyche - that 99214 probably takes $300 compared to $100 for the epidural....
Yes, I would say $22 is far less when you consider time and risk. Don't forget that we are talking about a CESI in an ASC where there is likely a preop RN/LVN to put in the IV, anesthesia to talk to the patient, then get the patient on the table, let them get their sedation, and all the other crap that comes with doing an injection in an ASC (vs office). Unless you are running two rooms, you're going to be looking at minimum of 15 mins between patients.

Now the 99214, you mention 25 minutes - you CAN spend 25 minutes if you want to justify your level-4 with time-based billing. But 90% of the time, if you are prescribing any medication, you get the level 4 based on E/M. So more like 10 minutes if you are efficient and don't let the patient drone on and on (hopefully a good chunk of these annoying patients get weeded out before they see you).

So again, yes, I say it's a big difference in reimbursement; especially when you consider risk. I don't care how good you are, you never had a complication, you are 100% safe, "I've done 10 thousand CESI's without any problems" blah blah blah. A CESI is more risky than an office visit.
 
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with the new E&M changes 99214 is not that hard to hit. - record burden is much less
 
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with the new E&M changes 99214 is not that hard to hit. - record burden is much less
30 min includes precharting, talking to patient and charting , coordination of care, filling scripts. Not too hard to hit that.
 
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