How does billing when moonlighting work?

[Stagg737]

So this may have been discussed in a previous thread, but I wasn't really able to find anyone answering my specific question.

From what I've seen on here in a few different sub-forums and threads, residents aren't able to bill for seeing patients until after they they've finished their residency. At the same time, from what I understand, people can start moonlighting as soon as they pass Step 3. So how does this work knowing that when they moonlight they sometimes are working on their own? Do they cover the shift and then whatever they needed to bill for gets signed off by an attending on a later shift? Are they somehow able to bill on these other shifts? Or am I misunderstanding the situation somehow?

Obviously I'm not at that point yet, but I was just curious as I do plan on trying to moonlight in residency.

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[Hakuna Matata]

I believe it may be different once you have your unrestricted license, after you take step 3. Depends on the state as some won't let you until after your second year of residency. But some let you sit for step 3 during pgy-1 and apply for your unrestricted license after passing that at the end of your first year. Then you can begin moonlighting.


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[Brahnold Bloodaxe]

I believe it may be different once you have your unrestricted license, after you take step 3. Depends on the state as some won't let you until after your second year of residency. But some let you sit for step 3 during pgy-1 and apply for your unrestricted license after passing that at the end of your first year. Then you can begin moonlighting.

Hell yeah! That's the states I'll be applying to residency in. Even if I don't feel comfortable enough to pick up EM shifts for $2000 a pop bright and early PGY2 year, there are always those bureaucratic/health screening etc opportunities where all you need is a pulse and a medical license and can still bang out close to $1000 a pop.

 

[Stagg737]

I believe it may be different once you have your unrestricted license, after you take step 3. Depends on the state as some won't let you until after your second year of residency. But some let you sit for step 3 during pgy-1 and apply for your unrestricted license after passing that at the end of your first year. Then you can begin moonlighting.


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So are there pretty significant variations in the law from state to state then? As in, some states let you moonlight as soon as you pass Step 3 while others don't allow moonlighting until after residency?

 

[ACSurgeon]

You can't double dip.

As a resident you're a salaried employee paid by Medicare. Hence, your services are paid for without billing. Cheap labor.

When you moonlight, you're providing services outside of your resident time and thus bill for those services

 

[Hakuna Matata]

So are there pretty significant variations in the law from state to state then? As in, some states let you moonlight as soon as you pass Step 3 while others don't allow moonlighting until after residency?

Yes it depends on the state. I made sure to ask at every residency interview. There was one state that didn't allow moonlighting until your 3rd year so I crossed them off my list!


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[dadaddadaBATMAN]

Hell yeah! That's the states I'll be applying to residency in. Even if I don't feel comfortable enough to pick up EM shifts for $2000 a pop bright and early PGY2 year, there are always those bureaucratic/health screening etc opportunities where all you need is a pulse and a medical license and can still bang out close to $1000 a pop.

You can ask about it when you interview, but most places that I interviewed had moonlighters getting paid about $50-100/hr (closer to the 50 end). It probably varies by field, pgy and location. But you definitely won't be compensated like an attending, because you're not an attending.

The other thing about moonlighting is that it can be high risk from a medico-legal standpoint (depending on where you are). Low pay for high legal risk isn't a great bargain, especially when you have little free time.

I plan to moonlight pgy-3, but it's less about pay than it is about getting out into the "real world" and making my first attending shifts less scary.

 

[hamstergang]

But you definitely won't be compensated like an attending, because you're not an attending.

When you moonlight you are operating as an attending, so you should expect to get paid the same. At least in psych I was paid the same.

 

[dadaddadaBATMAN]

When you moonlight you are operating as an attending, so you should expect to get paid the same. At least in psych I was paid the same.

Interesting. My residency only allows moonlighting in certain conditions (fast track, hospital associated urgent care). I'm guessing it's a combo of location and specialty. Probably shouldn't make/break a rank list, but maybe I should have paid a little more attention

Liability and free time comment still stands though.

 

[Stagg737]

Thanks for the responses! Everyone has been really helpful so far and I really appreciate the lesson.

You can't double dip.

As a resident you're a salaried employee paid by Medicare. Hence, your services are paid for without billing. Cheap labor.

When you moonlight, you're providing services outside of your resident time and thus bill for those services

That makes a lot more sense. I was under the impression that you just couldn't bill at all until you finished residency.

So when someone says you "can't bill at your residency program", they really mean you can't bill and make money off of it, but you do bill patients for the services provided and it is collected by the hospital? Or does someone else just take care of the billing for you altogether while you're in residency (at your program, not moonlighting)? I'm just curious how the hospital/program you're at makes money off of the patients you see as a resident and how that works.

 

[SLC]

Thanks for the responses! Everyone has been really helpful so far and I really appreciate the lesson.



That makes a lot more sense. I was under the impression that you just couldn't bill at all until you finished residency.

So when someone says you "can't bill at your residency program", they really mean you can't bill and make money off of it, but you do bill patients for the services provided and it is collected by the hospital? Or does someone else just take care of the billing for you altogether while you're in residency (at your program, not moonlighting)? I'm just curious how the hospital/program you're at makes money off of the patients you see as a resident and how that works.

The hospital bills, and they do it because an attending consigns all your clinical encounters.

 

[Keona]

We get paid per hour moonlighting. Higher than 60, less than $100 with bonus pay for holidays and some other shifts. I work in urgent car a few shifts a month. The extra money is great and seeing how a non residency location functions is as well.

 

[Raryn]

This is extremely variable from program to program and moonlighting opportunity to moonlighting opportunity.

Internal moonlighting, where most commonly your program just has you pick up an extra shift (ex: covering for a midlevel on a weekend), you typically work under the auspices of an attending and he bills. You'll get paid minimally ($60-80/hr is common). You don't necessarily need a full unrestricted license, just whatever your program requires (because you're still at your training institution). Some programs do offer semi-independent internal shifts, and I'm not sure how those work (none of the places I've been offer this)

External moonlighting, you are working as an independent provider under the auspices of your own license. You bill just like any other licensed physician. This is extremely common in some fields (psychiatry, EM) and more or less unheard of in others (surgical fields). Physician licenses also aren't restricted by specialty, so anyone with a license could moonlight at say... An urgent care... But probably not the best idea if you're a pathologist who hasn't seen a living patient in four years. The pay for external moonlighting is specialty dependent but ranges from $130 to $250++ an HR.

 

[Hakuna Matata]

You can ask about it when you interview, but most places that I interviewed had moonlighters getting paid about $50-100/hr (closer to the 50 end). It probably varies by field, pgy and location. But you definitely won't be compensated like an attending, because you're not an attending.

The other thing about moonlighting is that it can be high risk from a medico-legal standpoint (depending on where you are). Low pay for high legal risk isn't a great bargain, especially when you have little free time.

I plan to moonlight pgy-3, but it's less about pay than it is about getting out into the "real world" and making my first attending shifts less scary.

The pay is highly variable it sounds like. The residency I'm at has significant moonlighting opportunities in various EDs for $150-$220 per hour, along with alternatives to working in the ED like doing H&P's for the hospitalists for closer to $80-$100/hr.


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