Good job offer or not?

[emd123]

I'm finishing fellowship. I've been given the following offer, as the first pain doc in 50+ doc multi-specialty group (mostly primary care; a few non-surgical specialists, no surgeons), essentially an employed position with very limited partnership opportunity . They'll lease or buy c-arm, RF machine, table, lead, etc, and acquire all other start up items at my direction.

The greater of:

300,000 plus malpractice (other benefits by payroll deduction) as base, or

net collections, minus share of office rent, minus 20% billing/admin, minus benefits (health, disability, malpractice, 401k, etc). Procedures will all be done in office (except implants).

After two years, the base goes away and the above formula carries forward.


Good, bad or not enough info?

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[hyperalgesia]

Seems good on the surface.

Just want to know:

Is it in a place you want to be?
After 2 years, if you decide to leave, what are your options? ie. tail coverage, no-compete clause, etc.

 

[Ducttape]

seems good to me too, but....

might be important to get a feel if they expect you to be their prescription machine, or if they are interested in allowing you to practice as the interventionalist, or somewhere in between.

not having any surgeons suggests that they may be more interested in the former.

 

[clubdeac]

Wait so you're saying for the first two yrs you get which ever is greater, 300k or net collections - overhead and expenses etc?? That sounds like an awesome deal! You're guaranteed 300k at the beginning when you're building your practice and then once YOU can produce above that (in 6 mos, 1 yr, 2 yrs) you basically eat what you kill. How could it get any better?? I'd say standard overhead is probably 50% of collections right?

 

[PinchandBurn]

dude-

sounds pretty decent.

Definitely having that guarantted 300k is a great start. Depending on where you train and where exactly you are practicing, dont be shy and ask for a 'sign on bonus' or a 'moving expense'........

 

[emd123]

Seems good on the surface.

Just want to know:

Is it in a place you want to be?
After 2 years, if you decide to leave, what are your options? ie. tail coverage, no-compete clause, etc.

Yes, it's a place I want to be. It's occurrence coverage, no tail needed. The non-compete is 6 miles around 2 sites in a suburban area, which I realize is nothing, really. Within the 6 mile area, however, it's so strict my lawyer thinks its unenforceable in this particular state.

 

[emd123]

seems good to me too, but....

might be important to get a feel if they expect you to be their prescription machine, or if they are interested in allowing you to practice as the interventionalist, or somewhere in between.

not having any surgeons suggests that they may be more interested in the former.

I think it's a "somewhere in between" kind of situation. There's enough established pain guys in the area trying to move to the intervention only route, that I doubt it's feasible early on as the new kid in town. Once I've built some bridges, and a rep as a good pain guy, I think a more intervention focused approach would be more feasible if I wanted to go that route.

 

[emd123]

Wait so you're saying for the first two yrs you get which ever is greater, 300k or net collections - overhead and expenses etc?? That sounds like an awesome deal! You're guaranteed 300k at the beginning when you're building your practice and then once YOU can produce above that (in 6 mos, 1 yr, 2 yrs) you basically eat what you kill. How could it get any better?? I'd say standard overhead is probably 50% of collections right?

I think it is a good deal, BUT, businessmen being businessmen, and contract attorneys being contract attorneys, they did throw in a 100 day " termination without cause provision" which I don't like. Of course, it works both ways and allows me an easy 100-day out, also, but I wonder if they exercised this, could I get caught stuck paying the start up costs back, while they bring in some needle monkey to use the equipment I'm stuck paying back? It could work out great if they help support me creating a well oiled machine and I can generate the funds to pay back the start up quickly and efficiently enough. I think I can keep up on the coding, but I would be at their mercy in regards to billing and collecting for a specialty with all its nuances and changes, that they otherwise haven't billed and coded for yet. I do get the feeling the CEO is pretty well versed on such matters, in general, though. The contract specifies "open books" and would give me the option of having an accountant audit the billing and coding process periodically, at my own expense, of course.

My attorney has suggested a work-RVU system instead. This clearly puts the burden of billing and coding more on them, but certainly, to cover this they might not be willing to pay as much per work RVU if they're taking a little more risk. I almost like taking the "eat what you kill minus overhead" formula and rolling the dice a little bit, although, I suppose there's some risk of not being able to generate my base after 2 years and getting stuck with equipment and start up costs over that amount if the overhead is too high, they can't competently bill and collect, or don't support me well enough for me to generate that base.

Any more thoughts?

(By the way, thanks for the advise SDN bro's.)

 

[Apollyon]

100 days is long, but, fortunately, you get the same amount of time. I'm EM, and my contract wanted 90/30 - me/them, but I negotiated 60/60. My some-time girlfriend is a dentist, and she signed a contract for 90/10 - I'm not kidding. She wouldn't even talk about it with me.

You might ask if that window can be brought down. Just keep it equal.

 

[Aether2000]

The average cost of office space for an interventional practice is around 5-8% of the collections; billing fees typically range from 5-8%, purchase amortized or lease fees for equipment and maintenance are around 5-10%, staffing costs vary but range from 5-20%, and benefits are usually 8-15%. Therefore overhead is around 50% It appears this offer may be reasonable but it depends largely on what the office space costs are. A couple of local pain docs that got in bed with a couple of OSS ended up paying $75,000 a month as their office space allocation.
An RVU system is primarily for hospitals and anesthesiologists. It doesn't work well in the real world since these values are very difficult to calculate and would require entry of different work types (eg. follow up visits, initial consults, RVUs for each procedure are different, etc) that would probably make it a no go for the company making the offer. The bottom line is that you do have to produce around twice the collections compared to your income, but with appropriate training of the other specialists on what to refer and marketing within the 50 doctor group, you should be able to tailor a very nice interventional practice. The first year guarantee of $300K is very generous since the overall average income for all anesthesiologists is only $309. It will take around 2 months minimum for credentialing in insurance companies and Medicare and the group may have to eat part or all of the charges for some patients during that time (you are out of network and will be paid a reduced rate or zero by insurers). By 4 months collections should reach 65% of the max you will achieve, and by 7 months you will be at max. Doing the math, with a $300K guarantee, the expectation is that your anticipated collections at max will be at least $800K.
The down side: you don't have any guarantee the guys in the group will refer to you, and they may have long standing referral patterns to other docs. The group may pressure the outliers to do so, but they cannot force them. There is not a partnership offer on the table and therefore your referral to their MRI, PT, back brace, and other ancillary services that will be expected of you may not generate any partnership income for you. Without partnership opportunities, you are working year to year only. Finally, there needs to be some designation on what happens if you depart the practice....ie the residual collectables and billings. It is likely the group will want to retain these but this will leave you with zero income on your departure. This is not uncommon, but you may be able to negotiate a percentage of collections that will continue to flow to you for 6 months after departure from the practice. Best of luck with this job. It appears to be a fair offer.

 

[emd123]

The average cost of office space for an interventional practice is around 5-8% of the collections; billing fees typically range from 5-8%, purchase amortized or lease fees for equipment and maintenance are around 5-10%, staffing costs vary but range from 5-20%, and benefits are usually 8-15%. Therefore overhead is around 50% It appears this offer may be reasonable but it depends largely on what the office space costs are. A couple of local pain docs that got in bed with a couple of OSS ended up paying $75,000 a month as their office space allocation.
An RVU system is primarily for hospitals and anesthesiologists. It doesn't work well in the real world since these values are very difficult to calculate and would require entry of different work types (eg. follow up visits, initial consults, RVUs for each procedure are different, etc) that would probably make it a no go for the company making the offer. The bottom line is that you do have to produce around twice the collections compared to your income, but with appropriate training of the other specialists on what to refer and marketing within the 50 doctor group, you should be able to tailor a very nice interventional practice. The first year guarantee of $300K is very generous since the overall average income for all anesthesiologists is only $309. It will take around 2 months minimum for credentialing in insurance companies and Medicare and the group may have to eat part or all of the charges for some patients during that time (you are out of network and will be paid a reduced rate or zero by insurers). By 4 months collections should reach 65% of the max you will achieve, and by 7 months you will be at max. Doing the math, with a $300K guarantee, the expectation is that your anticipated collections at max will be at least $800K.
The down side: you don't have any guarantee the guys in the group will refer to you, and they may have long standing referral patterns to other docs. The group may pressure the outliers to do so, but they cannot force them. There is not a partnership offer on the table and therefore your referral to their MRI, PT, back brace, and other ancillary services that will be expected of you may not generate any partnership income for you. Without partnership opportunities, you are working year to year only. Finally, there needs to be some designation on what happens if you depart the practice....ie the residual collectables and billings. It is likely the group will want to retain these but this will leave you with zero income on your departure. This is not uncommon, but you may be able to negotiate a percentage of collections that will continue to flow to you for 6 months after departure from the practice. Best of luck with this job. It appears to be a fair offer.

Thanks for the insight. Appreciate it.

 

[Ligament]

Sounds really good to me.

Make sure:
1. They don't want you as a pill mill or dumping ground. Be VERY clear on this.
2. They have the equipment you need, BEFORE you start. Otherwise, you are way behind on your production since you get money from procedures not clinic. This happened to me in a 150 physician group in which I was the first pain doc; I had no c-arm for 6 months and had to send my procedures to the competition for the first 6 months. I lost a butt load of money during this time.
3. The administration CAN essentially force all the group docs to refer to you in reality. Make sure this happens so you get the business.
4. With 50 referring docs, the proper equipment ready to go on day one, you should make good money really fast.
5. Really push for partnership. That is key.
6. Net collections is VERY risky. What is the payor mix? If they take medicaid you aint ever gonna collect anything. Do they have a billing department that has specific training in interventional pain procedures? If not, you will lose a LOT of money because of that. I lost over $100,000 in billings because my billing department at my former employer had no idea what they were doing. Guess what? Even though it was my employers fault, I never got that $100k applied to my production. People got fired over this.

The money you state sounds really good. Doubt you could find much better. The real key is you have an almost captive referall base.

 

[hyperalgesia]

It still sounds good...

I agree as other posters pointed out, the expectations of what a "pain doc does" have to be clear at the outset.

A lot of docs may think "Thank God we're getting a pain doc! Now when I get a drug addict patient, I can give him just enough meds to get him to the pain doc, then he'll take over and appease the patient forever."

If this is the general consensus among the referring docs, you will have a serious problem...

You might just see what the general feeling is about patients who are not appropriate opioid candidates. Do the referring docs understand that some patients will not get what they want?

Also, I would know and discuss the "model" you will use before you get there. Are you gonna completely take over all opioids forever or just until the pt is "stable"? Are you gonna screen the consults for innappropriate pts? I would just make sure you're on the same page.

It sounds promising though, I hope it works out!

 

[onewithpain]

This sounds similar to what I've got. The devil is in the details so read through the contract yourself and pencil in what you want, then take it back for discussion. I didn't have to buy C-arm because we have surgeons who use it, but I did talk them into buying a better one. If its going to belong to the group then it should be paid for by the group. If you pay then its yours. My group fronts everyone the start-up costs and our guarantee amounts to an advance on our eventual income. Your 20% billing/admin is a floating rate for us that varies according to what the group is making and has ranged from 15-22%. I code and send to the biller and they collect. It's all on the computer so I can audit and had to do a lot of screaming to get them to bill the way I code. Since then they have done a couple classes on pain coding. Its still worth it to audit now and then to make sure that they pursue bills that aren't paid (usually because of a biller's error).This area is strong on retirement and I see more MC than private, but even though I will see Medicaid and public aid, they don't cover any procedures so its just a consult and med recs. Many PCPs will try to take advantage and dump difficult patients and so I stopped prescribing early on and now only make recommendations. With 50 referrers you could easily get buried and so let them know that taking over prescriptions would be a full time job for about 6 people. My group got an NP to do it (scary). I have discussed a limited role in prescribing but only if they follow my algorithm and send the patients early rather than waiting until they demand more than 8 Norco/day. If they insist on the 100 day termination without cause then there should be no non-compete at that point. I review my expenses on a regular basis and have been able to keep about 65% of my collections, but I work in ASCs and just collect pro-fees. They are likely referring to someone already but also likely don't know half of what they could refer so plan on educating them. The tendency for busy PCPs is to send the patients to ortho to figure it out. If ortho has their own pain guy then you lose a large portion and a lot of patients get spine surgery for arthritis pain, then are referred to you. Ask them why they want a pain doc, since if you are doing in-office procedures then you are not feeding a facility. This deal has a lot of promise but will be a learning experience for you and the group, therefore the 300,000 to start sounds great. The expenses should be reduced in comparison to starting on your own, by using what the group already has. The ability to negotiate good reimbursement and insure payment may be increased by being in a large group.

 

[emd123]

Several of you have mentioned, "educating referring docs on 'what to refer'". Explain, please.

 

[emd123]

This sounds similar to what I've got. The devil is in the details so read through the contract yourself and pencil in what you want, then take it back for discussion. I didn't have to buy C-arm because we have surgeons who use it, but I did talk them into buying a better one. If its going to belong to the group then it should be paid for by the group. If you pay then its yours. My group fronts everyone the start-up costs and our guarantee amounts to an advance on our eventual income. Your 20% billing/admin is a floating rate for us that varies according to what the group is making and has ranged from 15-22%. I code and send to the biller and they collect. It's all on the computer so I can audit and had to do a lot of screaming to get them to bill the way I code. Since then they have done a couple classes on pain coding. Its still worth it to audit now and then to make sure that they pursue bills that aren't paid (usually because of a biller's error).This area is strong on retirement and I see more MC than private, but even though I will see Medicaid and public aid, they don't cover any procedures so its just a consult and med recs. Many PCPs will try to take advantage and dump difficult patients and so I stopped prescribing early on and now only make recommendations. With 50 referrers you could easily get buried and so let them know that taking over prescriptions would be a full time job for about 6 people. My group got an NP to do it (scary). I have discussed a limited role in prescribing but only if they follow my algorithm and send the patients early rather than waiting until they demand more than 8 Norco/day. If they insist on the 100 day termination without cause then there should be no non-compete at that point. I review my expenses on a regular basis and have been able to keep about 65% of my collections, but I work in ASCs and just collect pro-fees. They are likely referring to someone already but also likely don't know half of what they could refer so plan on educating them. The tendency for busy PCPs is to send the patients to ortho to figure it out. If ortho has their own pain guy then you lose a large portion and a lot of patients get spine surgery for arthritis pain, then are referred to you. Ask them why they want a pain doc, since if you are doing in-office procedures then you are not feeding a facility. This deal has a lot of promise but will be a learning experience for you and the group, therefore the 300,000 to start sounds great. The expenses should be reduced in comparison to starting on your own, by using what the group already has. The ability to negotiate good reimbursement and insure payment may be increased by being in a large group.

I believe I will have the ability to do the coding, also on EMR, but what's the best way to oversee the billing and collections? Audit with an accountant periodically? Pick a few charts at random and call the billing department and see what the billing and collection result was?

 

[emd123]

Sounds really good to me.

Make sure:
1. They don't want you as a pill mill or dumping ground. Be VERY clear on this.
2. They have the equipment you need, BEFORE you start. Otherwise, you are way behind on your production since you get money from procedures not clinic. This happened to me in a 150 physician group in which I was the first pain doc; I had no c-arm for 6 months and had to send my procedures to the competition for the first 6 months. I lost a butt load of money during this time.
3. The administration CAN essentially force all the group docs to refer to you in reality. Make sure this happens so you get the business.
4. With 50 referring docs, the proper equipment ready to go on day one, you should make good money really fast.
5. Really push for partnership. That is key.
6. Net collections is VERY risky. What is the payor mix? If they take medicaid you aint ever gonna collect anything. Do they have a billing department that has specific training in interventional pain procedures? If not, you will lose a LOT of money because of that. I lost over $100,000 in billings because my billing department at my former employer had no idea what they were doing. Guess what? Even though it was my employers fault, I never got that $100k applied to my production. People got fired over this.

The money you state sounds really good. Doubt you could find much better. The real key is you have an almost captive referall base.

#6 Decent payor mix. Fair amount of retirees. No Medicaid. Would it be better to insist on $'s per work-RVU?

 

[specepic]

My distilled thoughts about this (and to avoid repeating a lot of the excellent advice above):

- likely you will be busy, it is nice, imo, to be in a captive market, agree on above comments re: dumping/opioid ground. Have a LOA re: this. At my job I was told verbally many times they were anti opioid then when I showed up the PCPs expected o/w. I fixed the situation but remember that anything not in writing may be BS

- I am concerned that you will lose serious $ b/c the onus is not completely on them to bill/collect effectively. Your stress levels about billing/coding/coleectinf will be high. You will be forced (assumung you care about your pay) to constantly nag and follow up. Your pay is based on several factors out of your control. This is less of an issue in a small group where you eventually become a partner. If they want you to be an employee rather than a partner, then pay you via RVU. They can't have it both ways. They want you to assume risk/red tape but not offer ownership. Nice deal for them. e.g. my hosp has a poor payor mix and a charity care program, and not the best billing dept, if I had agreed to collections I would be hosed.

 

[Ducttape]

get your own biller and coder.

if they insist, then get a friendly audit to go over books and make sure things are covered.

from what i know, it seems that $/RVU is easier and safer, and makes you less concerned about insurance and the responsibility of billing. i have a base salary and $/RVU over a base amount, but i do have a high comp and medicaid population. but thats my opinion.

 

[squares]

Does net collections include only physician component or total charges paid by insurance company? I would like to see the total charges since you are footing the bill for everything when you switch to collections model. Same applies if you go to RVU way.

 

[onewithpain]

As far as educating the PCPs, I send out periodic group emails describing conditions that I treat and the algorithm for treating them. Start with common stuff (facets and radiculitis) and then progress to less common (PHN and CRPS). I like to throw in prescribing advice (there was a nice article in Pain Med about opioid rotating). If the docs don't read their email then you may need to talk at a lunch or staff meeting.

I spot check on EMR as time allows. If I am curious I will look myself or have my MA look. I also get weekly billing statements that tell what they billed for me and so I go over those to see that they are billing everything. Early on I found so many mistakes that I had my MA review an entire month. I'm sure that an outside audit would have been faster, ? more thorough, definitely would have cost more. This triggered a meeting with the CEO and a few others and they have gotten much better since then.

See if you can talk to a pain clinic manager in your area and find out what other docs are able to collect. There is one about 3 hours from me who was willing to meet and review what I had and show me other doc's collections (with the names blacked out). Then you can compare that to an RVU based offer.

 

[lobelsteve]

I received patient records from a nearby clinic and the patient got us guided esi and b/l sij every month for the past 5 months. I called my coder and asked her to motify the other office regarding us for esi and 27096 was for fluoro or ct and that the us code in addition to all the others was unsat. I just wanted to call CMS.

 

[Ducttape]

I received patient records from a nearby clinic and the patient got us guided esi and b/l sij every month for the past 5 months. I called my coder and asked her to motify the other office regarding us for esi and 27096 was for fluoro or ct and that the us code in addition to all the others was unsat. I just wanted to call CMS.

thats interesting, but, um, i dont understand what that has to do with the thread?

 

[lobelsteve]

thats interesting, but, um, i dont understand what that has to do with the thread?

I had my friendly coder/biller contact another office after auditing their chart. Better me/her than CMS.

 

[emd123]

Does net collections include only physician component or total charges paid by insurance company? I would like to see the total charges since you are footing the bill for everything when you switch to collections model. Same applies if you go to RVU way.

I assume it would be the physician "in office" fee. Otherwise, I suppose I don't know what you mean by total charges (charges for meds, etc?)

 

[Ducttape]

depending on how you are set up, the office should bill for a professional (physician) component and, possibly, a facilities fee. As a solo practice, you will probably be set up to get a global fee that is supposed to incorporate both professional component and facility fee.

ill bet your net collections is only the professional component, and does not include facilities fee. If, however, you are paying a secretary, nurse, buying equipment, etc, then you should make sure that you capture everything you "kill"....

 

[squares]

depending on how you are set up, the office should bill for a professional (physician) component and, possibly, a facilities fee. As a solo practice, you will probably be set up to get a global fee that is supposed to incorporate both professional component and facility fee.

ill bet your net collections is only the professional component, and does not include facilities fee. If, however, you are paying a secretary, nurse, buying equipment, etc, then you should make sure that you capture everything you "kill"....

But, why are u guys up @ 2 - 4 AM? Is good old sleep out of fashion?

 

[Ducttape]

But, why are u guys up @ 2 - 4 AM? Is good old sleep out of fashion?

im up at 2 am because the baby(s) are awake...:cry:

 

[onewithpain]

If you work within the group's building but are doing procedures in the office then you should bill the bundled fee. If the group has a procedure room and supplies staff and equipment and materials then you bill the pro fee and they bill the facility. Mke sure.

 

[emd123]

If you work within the group's building but are doing procedures in the office then you should bill the bundled fee. If the group has a procedure room and supplies staff and equipment and materials then you bill the pro fee and they bill the facility. Mke sure.

I would be working in their office building. The procedure room is going in the same building. I don't think it counts as an "ASC" or "hospital" so I supposed I'd bill the "in office" physician charge, right? This is the "bundled fee" correct? Otherwise what is the "pro fee" and facility fee if you are doing procedures in an "office"? I admit, I'm confused at this point.

 

[bedrock]

If you work within the group's building but are doing procedures in the office then you should bill the bundled fee. If the group has a procedure room and supplies staff and equipment and materials then you bill the pro fee and they bill the facility. Mke sure.

Yeah that explanation doesn't make sense.........

There are only 2 ways to bill pain procedures-

1- do procedures in hospital or in an ASC- you can only bill professional fee (unbundled since you personally don't charge them for a facility fee at either location)
2- do procedures in an office, (which means any clinical space besides an ASC or a hospital). You bill a bundled global fee when doing procedures in an office.
That entire global fee should counted toward the revenue you bring to the practice or you're getting screwed and I'd make sure you get what should be coming to you.

Nobody makes good money from just billing the professional fee for procedures, which isn't that much and can be less per hr than office visits. Money is made from procedures in one of three ways.

1- you own a major part of the ASC where you do procedures and make money on the facility fee (from the profit you make on your ASC shares, you don't directly get the facility fees from your specific procedures)
2- you do procedures in hospital and you've negotiated your compensation/RVU rate to be quite high, as you make the hospital a ton of money from facility fees
3- you do procedures in an office and you bill the entire global fee and you also do twice the number of procedures/day as docs in an ASC/hospital because of faster turnover in an office.

 

[emd123]

So many ways to get screwed........................................
..................................................................

 

[squares]

The average cost of office space for an interventional practice is around 5-8% of the collections; billing fees typically range from 5-8%, purchase amortized or lease fees for equipment and maintenance are around 5-10%, staffing costs vary but range from 5-20%, and benefits are usually 8-15%. Therefore overhead is around 50% It appears this offer may be reasonable but it depends largely on what the office space costs are. A couple of local pain docs that got in bed with a couple of OSS ended up paying $75,000 a month as their office space allocation.
An RVU system is primarily for hospitals and anesthesiologists. It doesn't work well in the real world since these values are very difficult to calculate and would require entry of different work types (eg. follow up visits, initial consults, RVUs for each procedure are different, etc) that would probably make it a no go for the company making the offer. The bottom line is that you do have to produce around twice the collections compared to your income, but with appropriate training of the other specialists on what to refer and marketing within the 50 doctor group, you should be able to tailor a very nice interventional practice. The first year guarantee of $300K is very generous since the overall average income for all anesthesiologists is only $309. It will take around 2 months minimum for credentialing in insurance companies and Medicare and the group may have to eat part or all of the charges for some patients during that time (you are out of network and will be paid a reduced rate or zero by insurers). By 4 months collections should reach 65% of the max you will achieve, and by 7 months you will be at max. Doing the math, with a $300K guarantee, the expectation is that your anticipated collections at max will be at least $800K.
The down side: you don't have any guarantee the guys in the group will refer to you, and they may have long standing referral patterns to other docs. The group may pressure the outliers to do so, but they cannot force them. There is not a partnership offer on the table and therefore your referral to their MRI, PT, back brace, and other ancillary services that will be expected of you may not generate any partnership income for you. Without partnership opportunities, you are working year to year only. Finally, there needs to be some designation on what happens if you depart the practice....ie the residual collectables and billings. It is likely the group will want to retain these but this will leave you with zero income on your departure. This is not uncommon, but you may be able to negotiate a percentage of collections that will continue to flow to you for 6 months after departure from the practice. Best of luck with this job. It appears to be a fair offer.

Just for clarification, here is the MGMA data from 2010. Average for anesthesia is 423.

Phys
Med Pracs
Mean
Std. Dev.
25th %tile
Median
75th %tile
90th %tile

Anesthesiology
3,259
166
$419,596
$128,983
$338,287
$423,657
$496,769
$571,819

Anesthesiology: Pain Management
164
54
$488,836
$213,909
$387,128
$401,611
$524,879
$859,777

 

[Ducttape]

essentially, it is dependent on the place of service, and medicare has designated different sites with POS (i kid not) codes.

POS 11 is office setting.

POS 21 is inpatient hospital.

POS 22 is outpatient hospital.

Global fees for POS 11, but not for the other two. But you can get screwed, especially if you are considered an employee.....

Oh and algosdoc, why are RVUs difficult to calculate in the real world? wRVU values are all compiled by Medicare.

I understand that there are different adjustments to the base Medicare RVU for anything, and that can be somewhat difficult to figure out based on the modifiers. But as a whole, it seems that most people who use an RVU system uses a standard modifier that is "consistent" with the insurance mix to calculate pay. So if the group sees 50% medicare and 50% private insurance, the modifier would be a ratio between the two.

the beauty of using an RVU system, as discussed previously, is that the doc doesnt have to worry about his/her own billing, just ensure that the RVUs being posted are appropriate. That takes me 10 minutes a month, after i get all the info from the coders/billers. It is irrespective of collections and AR. I personally think that is a huge headache that someone new to billing would want to avoid.

 

[jsaul]

I don't know why all of you are so worried about "being screwed". It's really simple. If you do procedures in your office you charge the cpt code for the esi with the POS being office. There is no facility fee to worry about. It is just a simple charge for the procedure. I don't know how the employer can "screw" you out of that. It is just like a charge of seeing a new pt or f/.u.

 

[facets]

Ditto, I was going to say, most senior physicians have enough money, have been a new grad out of training with massive debt, and have no interest in "screwing" some young doctor. I am more interested in pointing out the landmines to my juniors, I couldn't sleep if I cheated one. Granted there are some who eat their young, but for the most part we appreciate where you are, we have been there ourselves and hey, you young ones will be the ones taking care of us aging doctors. Believe me after 25 years of bending and twisting while wearing lead, we have back problems. Leave the "screwing" concern for insurance companies, the government and lawyers. Most older docs have nothing but compassion for the young ones. We need to help and protect our own. I don't want an PA/ NP caring for me. Maybe my glasses are a little rosy today, but I really don't think most docs want to take advantage of their juniors. Older docs, chime in-algos?

 

[Ducttape]

I don't know why all of you are so worried about "being screwed". It's really simple. If you do procedures in your office you charge the cpt code for the esi with the POS being office. There is no facility fee to worry about. It is just a simple charge for the procedure. I don't know how the employer can "screw" you out of that. It is just like a charge of seeing a new pt or f/.u.

well, if you want specific examples of how complicated it can get...

If you look at the fees, a procedure that generates a professional fee and a facility fee makes more money than a single global fee, generally speaking. If the office setting has been designated as a POS 22, then you cannot technically bill a global fee but would bill for both. If, however, you are an salaried employee, because you are paid by the "facility", you may not be able to bill a global fee and essentially you can only garner the professional fee for the procedure. Offices that are based in professional buildings that are on or in a hospital may be established as POS 22 instead of POS 11.

On the other hand, if you are an independent contractor with the group, and they are only providing salary backup, you should be able to bill a global fee for your procedures in your office. But big groups such as hospitals do benefit the most when they can charge a separate facility fee, because that is where the most amount of money is generated for each procedure, so it often behooves the group to set it up as a POS 22.

and if you do get global fees, then generally speaking you will probably be expected to pay for things such as staff, overhead, equipment, etc. which makes life a lot more complicated. It also encourages cutting corners like staff in order to save money, when it is often better to spend money on more staff as that improves efficiency and ultimately generates more income.

i know im babbling, but...

 

[Tenesma]

MGMA is not accurate in my region.... and after speaking to a lot of folks MGMA doesn't seem to be all that accurate nationally....

i think 300k starting is quite generous considering the cuts in reimbursements...

 

[emd123]

MGMA is not accurate in my region.... and after speaking to a lot of folks MGMA doesn't seem to be all that accurate nationally....

i think 300k starting is quite generous considering the cuts in reimbursements...

The implication being what? That I'm unlikely to ever net $300,000 and will owe back on that advance or I'll be fired if I can't?
That's the way it's written, not as a salary guarantee, but as an advance on the ultimate collections formula as I described above, much like "onewithpain's" deal above. There's no such thing as a salary guarantee, I realize that. You either generate what you're costing the group, or you're out.

 

[specepic]

The implication being what? That I'm unlikely to ever net $300,000 and will owe back on that advance or I'll be fired if I can't?
That's the way it's written, not as a salary guarantee, but as an advance on the ultimate collections formula as I described above, much like "onewithpain's" deal above. There's no such thing as a salary guarantee, I realize that. You either generate what you're costing the group, or you're out.

There ARE salary guarantees, in fact, a base salary is pretty standard for the first year or two out, and in the setting of being an employee, opposed to an owner or partner, also pretty standard thereafter. The more we discuss this job the less I like it. They want to put all the onus on you.

Let me make it simple: if you are an employee than you should have no responsibility for covering costs of equipment, staff, etc. Also, there should be a very simple and trackable means for determining your productivity and you need to have a guaranteed minimum base salary with at least a two year contract on that. Only if you are a partner should you have to worry about other factors like buying the equipment, overhead vs. pay, etc. They are either taking advantage of you as a new grad, are looking to screw you down the line, or do not know any better (which is unlikely). The terms of the contract and the way they are enforced is not going to improve after you arrive.

 

[facets]

Oy, what is the screwing parania? If you are that worried use your own capital to start your own office and build from scratch. You cannot have it both ways son. You can't put no money up, expect a salary guarentee and expect to profit from every dime over that guarentee. The last office I started lost $500 K the first year and that's just the way it is. It costs a ton of money to buy things you never even thought of until you needed it. Try being in the employees shoes for a minute. I have paid people (usually PA/NP) to read magazines while I tried to build the practice, put every dime that came in into paying them and other employees as well as overhead, then after a year they grumble about working.

 

[specepic]

Oy, what is the screwing parania? If you are that worried use your own capital to start your own office and build from scratch. You cannot have it both ways son. You can't put no money up, expect a salary guarentee and expect to profit from every dime over that guarentee. The last office I started lost $500 K the first year and that's just the way it is. It costs a ton of money to buy things you never even thought of until you needed it. Try being in the employees shoes for a minute. I have paid people (usually PA/NP) to read magazines while I tried to build the practice, put every dime that came in into paying them and other employees as well as overhead, then after a year they grumble about working.

so are you suggesting a new hire front the $ for equipment, get paid only net collections after overhead, and have no opportunity for partnership/ownership/equity? Who in their right mind would take that job?

 

[facets]

No, but he wants a salary guarentee, no up front costs AND a partnership. You can't have it both ways. Either you put up a million up front, lose money for a year, then get full benefits, or you take a salary, get a set amount, lose no money while the practice is being built but "they" may make some money on you after a few years. It's like being married, you lose the ability to date around but gain a partner. Nobody sane expects to get married, have a faithful spouse but retain the ability to have multiple partners while your wife patiently and faithfully sits at home. It's quite frankly, a bratty, immature, unrealistic and entitled attitude. You either or in or out. You put up the money, take the losses and maybe some gain down the road, or you get married, take the certainity of a salary but lose the opportunity dating around- full profits in the near future. Or a mixture of same, an engagement of sorts, you have the ability to buy in. Expecting to lose no money at all, but getting full benefits is as unrealistic as Tiger Woods views on committment and marriage. The arrangemnt has to make sense for both parties and entering a relationship with paranoid attitudes about being "screwed" is a bad way to start. Come on I'm not the only one with years in the trenches-MM?

 

[specepic]

No, but he wants a salary guarentee, no up front costs AND a partnership. You can't have it both ways. Either you put up a million up front, lose money for a year, then get full benefits, or you take a salary, get a set amount, lose no money while the practice is being built but "they" may make some money on you after a few years. It's like being married, you lose the ability to date around but gain a partner. Nobody sane expects to get married, have a faithful spouse but retain the ability to have multiple partners while your wife patiently and faithfully sits at home. It's quite frankly, a bratty, immature, unrealistic and entitled attitude. You either or in or out. You put up the money, take the losses and maybe some gain down the road, or you get married, take the certainity of a salary but lose the opportunity dating around- full profits in the near future. Or a mixture of same, an engagement of sorts, you have the ability to buy in. Expecting to lose no money at all, but getting full benefits is as unrealistic as Tiger Woods views on committment and marriage. The arrangemnt has to make sense for both parties and entering a relationship with paranoid attitudes about being "screwed" is a bad way to start. Come on I'm not the only one with years in the trenches-MM?

BUT, that is not what they are offering him. They want him to cover costs but have told him there is no potential for ownership/partnership EVER. They want him to assume downside while keeping the upside off the table. When joining a group as a new grad I'd say it is standard to have a base guarantee, and if you want to become partner/married two years in then you 'buy in'. He is not talking about opening his own shop. I'm confused why you think this is not standard and is a "bratty, immature, unrealistic and entitled attitude"?

Maybe they aren't trying to screw him at all, but he asked for advice, and good advice covers the worst case scenario that a green new grad may not see/realize. I believe that is what he was looking for.

 

[Tenesma]

i think what facets is saying is that everybody has to pay their dues somehow.... and grads who i have been interviewing in the last five years typically want (generally speaking - i have had some normal/level-headed folk apply as well)
1) 300-400k starting salary - plus bonus based on collections
2) partnership after 1-2 years
3) doesn't want to pay to become a partner
4) wants 8 weeks vacation
5) doesn't want to do inpatient consults
6) doesn't want to take call...

at some point they hve to wake up and smell the coffee.

 

[clubdeac]

i think what facets is saying is that everybody has to pay their dues somehow.... and grads who i have been interviewing in the last five years typically want (generally speaking - i have had some normal/level-headed folk apply as well)
1) 300-400k starting salary - plus bonus based on collections
2) partnership after 1-2 years
3) doesn't want to pay to become a partner
4) wants 8 weeks vacation
5) doesn't want to do inpatient consults
6) doesn't want to take call...

at some point they hve to wake up and smell the coffee.

Tenesma, would you make the new grad you hire pay to become partner if you did all your work in a hospital and essentially had no overhead other than your billing office. That's what one group is asking of me but I'm unsure of what I'm buying when I pay them to become "partner"....

 

[Tenesma]

legally you can only buy in what is fair market value... in a scenario that you are describing it would be the fair market value of the billing office (if they own it and are offering partnership in that part of the practice)... if there is nothing to really "own" except your own collections then the cost of partnership should really be nothing...

 

[emd123]

They do offer limited partnership. It's a large group (50 doc) so equal partnership would be a 2%. After 1 year you get options for a 0.4% stake. It's a "top heavy" group with guys that have been there 20 years. The ability to get a larger stake long term is suggested but not contractually defined (so I won't assume it's likely to happen). It seems to me like a hybrid situation with a significantly larger portion of collections than a pure employee deal, but with more risk than an employee deal, but not nearly the risk or headache (or potential gains) of starting out 100% solo.

 

[emd123]

BUT, that is not what they are offering him. They want him to cover costs but have told him there is no potential for ownership/partnership EVER. They want him to assume downside while keeping the upside off the table. When joining a group as a new grad I'd say it is standard to have a base guarantee, and if you want to become partner/married two years in then you 'buy in'. He is not talking about opening his own shop. I'm confused why you think this is not standard and is a "bratty, immature, unrealistic and entitled attitude"?

Maybe they aren't trying to screw him at all, but he asked for advice, and good advice covers the worst case scenario that a green new grad may not see/realize. I believe that is what he was looking for.

Limited partnership is offered (see above).


On another note, I truly believe even a "guarantee" is in no way a guarantee. No group will keep anyone that loses money for them. If you earn your keep and generate enough to cover your salary and benefits, you are kept. If you don't generate your salary, no group will keep renewing a "guarantee". Your salary is cut or you're let go. No such guarantee exists.

 

[emd123]

Another thing with this group: they don't pay a dividend (or pay bonuses) based on shares of ownership. I can verify this because I personally know someone that's been in the group. Each doc is treated like a single practice with the same net collections minus 20%, minus share of rent, minus benefits "formula". Its basic "eat what you kill". So they pay all shareholders like equal partners except 5% of the overhead is a fee they they take. I think this is fair, knowing I wouldn't have most of the headaches of actually running every facet of the practice. There's significant upside if you can hold your own, and better return on collections than with a basic employee formula. If you need a guarantee that you can't fund after a 2 year upstart period, they won't keep taking losses on you, and I suppose there's risk in that. It's not perfect, but that's what contract lawyers are for.