Inability to understand RVU language in a contract

[theWUbear]

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I have a contract for a PRN position. The numbers below are modified slightly from what the contract states for privacy reasons. I'm confused as to how to make the numbers fit the total hourly rate I was quoted over the phone.

Over the phone: doctors average $300/hr take home (hourly + RVU)

Contract: Employee shall be paid $110.00 per hour for each clinical hour worked. Employee shall also be paid on an RVU basis that is calculated on each billed patient seen by employee, multiplied by a factor of seventeen dollars ($17.00).

Hospital is a trauma center, docs see 2.0 patients per hour. How do I start with that contract language and estimate my take home to confirm what was told over the phone? Is it too complicated?

 

[cyanide12345678]

You just have to ask them the average number of rvus generated by the average doctor per hour. That's usually going to be around 6-9 rvus per hour for an average doctor, sorry that's a large spread, but most docs will on average be around 3.5-4 rvus per patient.

Doesn't look like you will be anywhere close to 300/hr though

 

[cyanide12345678]

Average RVUs/hr

Hey all, I've searched this topic already and haven't seen any GOOD answers to my question. I'm considering a job that's RVU with a base salary. I've done my research but still have a lot to learn about RVUs as my residency hasn't offered much in regards to this topic. I know all docs...

forums.studentdoctor.net

 

[cyanide12345678]

2019 Medicare Physician Fee Schedule Released - ACEP Now

ACEP Now offers real-time clinical news, news from the American College of Emergency Physicians, and news on practice trends and health care reform for the emergency medicine physician. ACEP Now is an official publication of the American College of Emergency Physicians.

www.acepnow.com

 

[TheSingularity]

You should negotiate for a straight hourly rate as a PRN

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[theWUbear]

This is all really good information. Cyanide - thank you for all that info.

You should negotiate for a straight hourly rate as a PRN

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Singularity, others: you think a 'You Sacks' (the CMG) recruiter would possibly go for negotiating/bite on my request to get the group average amount in straight hourly, at least for the first few months as I get situated at the place? I've only signed one contract so far (my main shop) - when I sent a redlined contract version back to the Envision recruiter she essentially told me "we don't do that"

 

[Brigade4Radiant]

Usually hospitals force the CMG to do the RVU model for metrics. Sometimes you have a doc seeing 1 patient per hour.

 

[DO3]

Someone is not telling the truth. In order to get $300/hr at that RVU rate, you have to see 3+ patients an hour which, at a level 1 trauma center, will be miserable. Sketchy. Run away.

I have a contract for a PRN position. The numbers below are modified slightly from what the contract states for privacy reasons. I'm confused as to how to make the numbers fit the total hourly rate I was quoted over the phone.

Over the phone: doctors average $300/hr take home (hourly + RVU)

Contract: Employee shall be paid $110.00 per hour for each clinical hour worked. Employee shall also be paid on an RVU basis that is calculated on each billed patient seen by employee, multiplied by a factor of seventeen dollars ($17.00).

Hospital is a trauma center, docs see 2.0 patients per hour. How do I start with that contract language and estimate my take home to confirm what was told over the phone? Is it too complicated?

 

[alphaholic06]

This sounds terrible.

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[EctopicFetus]

One of the biggest issues and why it is complex for most residents who receive so incredibly little info on this topic is you have to differentiate wRVUs from total RVUs. I work in a fairly average acuity site. My avg RUV per patient for years has been between 4.3-4.5 per patient.

Main question is work RVUs (wRVUs) vs total RVUs. there is no way to get to 9 wRVUs an hour without seeing way too many patients.
Questions you need to ask
1) Do I get credit for Ekgs (0.24 RVUs per patient)
2) Do we bill for fracture care (high RVU and minimal work, Thanks bone doctors)

At a Level 1, you should have a fair number of procedures plus critical care which will help your numbers. 9 RUVs per hour is about 2pph if you get the total RVUs.

I agree that $300/hr is unlikely. recruiters' main job is to fill the place. they lie, they lie all the time.

Also, yes you cant negotiate a contract with a CMG or a hospital. The contract is to make sure you understand what is going on you have no leverage.

 

[GeneralVeers]

At $17/RVU it's really hard to see how you get to $300/hour. You'd have to be generating > 9RVU/hour to hit that. Maybe they are giving you credit for midlevel charts? That can easily bump it up to 17-19 RVU/hour.

 

[cyanide12345678]

At $17/RVU it's really hard to see how you get to $300/hour. You'd have to be generating > 9RVU/hour to hit that. Maybe they are giving you credit for midlevel charts? That can easily bump it up to 17-19 RVU/hour.

Or the easier explanation is that the recruiter is exaggerating. Maybe one person makes 300/hr, and they are implying that everyone does.

 

[EctopicFetus]

with the $110/hr they are paying you for 3 medicare rate RVUs as a base. Agree that $300/hr is hard to see given this formula. What an amazing profit these guys make.

Assuming you get to 9 RUVs an hour and they collect an average of medicare rates.. thats $36X9. Thats $324/hr.. You on the other hand will get $263. A very sweet $60/hr which is probably a profit of $40-50/hr and they dump the risk on you.

 

[thegenius]

OP what is the answer to some of these questions? What is the average pts per hour they are seeing? What is the average RVU/pt they are seeing?

Are you coming out of residency? Remember it’s common not to be all that efficient out of residency, it takes some time (usually a few years, at least 6 months) to learn to get efficient.

 

[thegenius]

Tell your recruiter the numbers don’t add up. It’s easy:

$110/hr
17 * 2 pts/hr * 4 RVUs/pt = $136
Total $246/hr.

Now I think $246/hr is not bad money, but not even close to $300/hr. And there is a big difference between 2 pts/hr and, say, 2.4 or 2.6/hr.

Ask your recruiter to verify his/her numbers.

 

[Vandalia]

As mentioned above the only way this makes sense is that the RVU calculation is based on RVU rather than wRVU. $17 is low for wRVU, or at least it was. There is also no reasonable way to get to $300/hr if the base is wRVU. However, if it is based on total RVU, then the fee and the quoted hourly rate start to make sense.

That is the question that needs to be asked.

 

[thegenius]

So can someone explain briefly the difference between wRVUs and tRVUs?

I look online and RVU (not work or total) is equal to

Calculating an RVU
An RVU represents the total of three component RVUs, each of which is adjusted based on the geographic location in which a physician practices. The three component RVUs are:

1. Physician work RVU, including the time and clinical skill necessary to treat a patient during an encounter.
2. Practice expense RVU, including labor costs as well as expenses for building space, equipment, and office supplies.
3. Professional liability insurance expense RVU, including the cost of malpractice insurance premiums.

The Centers for Medicare & Medicaid Services (CMS) adds each geographically-adjusted component RVU to arrive at a total RVU for every CPT code. The agency then multiplies the total RVU by the Medicare Conversion Factor, a national value that converts the RVU into a dollar amount. In 2017, the conversion factor is $35.89

So is work RVU just #1 above?
Is total RVU 1+2+3 above?

I’m aware there is a difference between independent physician practice and physicians in hospitals. Are ER docs allowed to bill for all three? Or just the first?

 

[Vandalia]

So can someone explain briefly the difference between wRVUs and tRVUs?

So is work RVU just #1 above?
Is total RVU 1+2+3 above?

Yes. Total RVU is the sum of work, practice expense, and liability RVU. Work RVU is just the first component. All three components have different conversion/payment factors depending on the geographic region.

The total RVU is what actual payment is based on, and is particularly relevant for those who own their own practices. Physician compensation in other practice settings is generally based solely on "Work RVU" to eliminate fluctuations caused for, example, by the large "practice expenses" associated with a particular CPT. This is why when in these threads or an employment agreement/contract people talk about RVU they are almost always talking about wRVU. Except when they aren't.

 

[thegenius]

Yes. Total RVU is the sum of work, practice expense, and liability RVU. Work RVU is just the first component. All three components have different conversion/payment factors depending on the geographic region.

The total RVU is what actual payment is based on, and is particularly relevant for those who own their own practices. Physician compensation in other practice settings is generally based solely on "Work RVU" to eliminate fluctuations caused for, example, by the large "practice expenses" associated with a particular CPT. This is why when in these threads or an employment agreement/contract people talk about RVU they are almost always talking about wRVU. Except when they aren't.

Yes that makes sense. The question is whether billing and coding commonly charges total RVUs, and whether ER docs get total RVU's or wRVUs.

For instance.
Say I see a patient and complete my chart. The billing and coding company says it's worth CPT 99285. 99285 is worth about 4.9 RVUs.

Is that 4.9 wRVU's or totalRVUs?

and if it's equal to totalRVUs, do we know how 4.9 is broken down into #s 1,2,3 above

 

[Vandalia]

Yes that makes sense. The question is whether billing and coding commonly charges total RVUs, and whether ER docs get total RVU's or wRVUs.

For instance.
Say I see a patient and complete my chart. The billing and coding company says it's worth CPT 99285. 99285 is worth about 4.9 RVUs.

Is that 4.9 wRVU's or totalRVUs?

and if it's equal to totalRVUs, do we know how 4.9 is broken down into #s 1,2,3 above

The simple solution would be to ask them directly; as I said for most employment contracts it is wRVU.

You can also look it up online. The AMA has the data but you need to login as a member to access it. You can also generally find it online for specific CPT codes. The ACEP has the most common EM codes:

American College of Emergency Physicians;Top 20 ED Reimbursement Codes

Top 20 ED Reimbursement Codes

www.acep.org

However, I don't know how recently/often these are updated.

For example, for a level III 99283, it breaks down:

Work: 1.34
Practice Expense: 0.29
Liability: 0.12

TOTAL 1.75

So if they are giving you credit for 1.34 it is wRVU. If it is 1.75 it is (total) RVU. If it is 0.9 then you have a problem.

If you look closely, you will notice the ratio between practice expense and liability when compared to work is not consistent. This is one reason most places do compensation based on wRVU and not (total) RVU. Otherwise, some physicians would angle toward work whose value is inflated by these categories. A few bad apples spoil the bunch.

The conversion factor is in the neighborhood of $36, so if it is work RVU you should be getting somewhere in the neighborhood of $36/wRVU as compensation since the other components take care of malpractice insurance and processing expenses. If it is off of total RVU then the rate will be less.

 

[thegenius]

You can also look it up online. The AMA has the data but you need to login as a member to access it. You can also generally find it online for specific CPT codes. The ACEP has the most common EM codes:

American College of Emergency Physicians;Top 20 ED Reimbursement Codes

Top 20 ED Reimbursement Codes

www.acep.org

However, I don't know how recently/often these are updated.

OK...so I've seen how things are done at my work and we get 4.9 for a 99285, 3.32 for 99284, 0.24 for EKG read
so that means we are getting total RVUs at least where I work.

That is good.

 

[theWUbear]

OP what is the answer to some of these questions? What is the average pts per hour they are seeing? What is the average RVU/pt they are seeing?

Are you coming out of residency? Remember it’s common not to be all that efficient out of residency, it takes some time (usually a few years, at least 6 months) to learn to get efficient.

So so grateful for everyone educating me here. Recruiter got back to me with an RVU compensation table. Again, to avoid disclosure of something inappropriately, numbers will be adjusted slightly.

Patients per hour: between 2 and 2.5 (this is my being vague to not put the exact number to multiple sig. figs here)
Average RVU/hr: 11
That's a RVU component of 11*17.5 dollars/rvu = $192
The hourly base was $110/hr
That equals a total compensation of $302/hr

They had stated compensation average of $300.

Some of you negatively reacted to my original post, saying the numbers don't work out (at least, if using wRVU). Do these numbers cause any concern, or was the missing factor that they may be using total RVU's?

 

[thegenius]

So so grateful for everyone educating me here. Recruiter got back to me with an RVU compensation table. Again, to avoid disclosure of something inappropriately, numbers will be adjusted slightly.

Patients per hour: between 2 and 2.5 (this is my being vague to not put the exact number to multiple sig. figs here)
Average RVU/hr: 11
That's a RVU component of 11*17.5 dollars/rvu = $192
The hourly base was $110/hr
That equals a total compensation of $302/hr

They had stated compensation average of $300.

Some of you negatively reacted to my original post, saying the numbers don't work out (at least, if using wRVU). Do these numbers cause any concern, or was the missing factor that they may be using total RVU's?

Where I work, the average RVU / patient is 4.0, +/- 0.1.

From what I gather from other posts here over the past few years, than number is more or less average around the nation.

So. You can do the math. You are saying their average is 11 RVUs / hr. If you are averaging 2 to 2.5 pts / hr.....

1) you will be seeing sicker patients on average than other ERs. That is one way the RVU / pt can increase. That could be true, however note that seeing sick patients is tiresome and causes substantial fatigue...

2) the average doc there actually sees 2.5 - 2.8 pts / hour. That is doable (although I can’t do that..., you need lots of ER enhancing work protocols like being able to admit without pushback, excellent access to outpatient stuff, a well functioning ER)

If you are super fast and just order tests then maybe thats attainable. If not, assume that you’ll make more like 8-9 RVUs / hr.

My guess is that they probably see more like 2.5 - 2.8 pts / hr. It’s hard to upcode past 4.05 RVUs / patient unless you cheat. Or maybe you’ll be seeing tons of sick patients every day.

 

[EctopicFetus]

Where I work, the average RVU / patient is 4.0, +/- 0.1.

From what I gather from other posts here over the past few years, than number is more or less average around the nation.

So. You can do the math. You are saying their average is 11 RVUs / hr. If you are averaging 2 to 2.5 pts / hr.....

1) you will be seeing sicker patients on average than other ERs. That is one way the RVU / pt can increase. That could be true, however note that seeing sick patients is tiresome and causes substantial fatigue...

2) the average doc there actually sees 2.5 - 2.8 pts / hour. That is doable (although I can’t do that..., you need lots of ER enhancing work protocols like being able to admit without pushback, excellent access to outpatient stuff, a well functioning ER)

If you are super fast and just order tests then maybe thats attainable. If not, assume that you’ll make more like 8-9 RVUs / hr.

My guess is that they probably see more like 2.5 - 2.8 pts / hr. It’s hard to upcode past 4.05 RVUs / patient unless you cheat. Or maybe you’ll be seeing tons of sick patients every day.

This isnt true at all. It depends on what is included. a simple chest pain admit with the EKG is over 5 RVUs. as I said my numbers are about 4.5 RVUs per patient. Our acuity isnt low but we bill for ortho, splints, critical care etc.

I would agree it will be hard to get over 10 RVUs per hour. It is doable but it isnt gonna be relaxing.

The number of RVUs/patient will depend on admit percentage, Critical care, obs, fx care etc.

 

[alphaholic06]

I'm pretty efficient. See about 2.2 patients an hour. 20-25% of that is billed for critical care time and I generate 8-9 RVUs per patient on average.

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[thegenius]

This isnt true at all. It depends on what is included. a simple chest pain admit with the EKG is over 5 RVUs. as I said my numbers are about 4.5 RVUs per patient. Our acuity isnt low but we bill for ortho, splints, critical care etc.

I would agree it will be hard to get over 10 RVUs per hour. It is doable but it isnt gonna be relaxing.

The number of RVUs/patient will depend on admit percentage, Critical care, obs, fx care etc.

Isn’t true “at all?” That’s a bit much I think. I’m telling him our numbers. This is averaged out over all patients over a year. This includes simple 99283 stuff to patients with multiple reductions and traumas. Of course the average RVU is dependent on a lot of factors.

If your numbers are 4.5 / RVU then that’s good, congrats. I think that is on the high end among those who post on this board

 

[GeneralVeers]

I'm pretty efficient. See about 2.2 patients an hour. 20-25% of that is billed for critical care time and I generate 8-9 RVUs per patient on average.

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25% critical care time??? How are you not getting flagged by CMS? The best biller in our group of 60+ docs doesn't even hit 5 RVU/pt.

 

[BoardingDoc]

25% critical care time??? How are you not getting flagged by CMS? The best biller in our group of 60+ docs doesn't even hit 5 RVU/pt.

Agree, 25% cc time is WAAAAAY outside the norm. @alphaholic06 is either overestimating, works in an insanely high acuity shop, or is going to have an unpleasant visit in the future.

National average is 8.1%. I don't know the std dev, but I would imagine that 25% is several std devs outside the mean and liable to get you audited.
Source: CMS – 2016 Medicare Utilization Data by Specialty 93 – National: For Claims Processed with 2016 Dates of Service filed by June 30, 2017

 

[EctopicFetus]

I'm pretty efficient. See about 2.2 patients an hour. 20-25% of that is billed for critical care time and I generate 8-9 RVUs per patient on average.

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Gonna call bs.. 8 RVUs per patient is near impossible. DO tell how you get this. Critical care is ~6.2 RVUs. a level 5 is ~4.9. how do you get the extar 3 RVUs per patient. NFW.

 

[EctopicFetus]

Isn’t true “at all?” That’s a bit much I think. I’m telling him our numbers. This is averaged out over all patients over a year. This includes simple 99283 stuff to patients with multiple reductions and traumas. Of course the average RVU is dependent on a lot of factors.

If your numbers are 4.5 / RVU then that’s good, congrats. I think that is on the high end among those who post on this board

My point is the number 4 isnt an average. no one knows. I see plnety of simple stuff. The factor that matters is what are you given credit for. Some places dont bill for splints, fx care etc. Some dont bill for EKGs, some bill for bedside US. All this will change your RVU numbers. 4.0 may be the average and likely is where you work but it isnt some nationally known fact.

 

[EctopicFetus]

Agree, 25% cc time is WAAAAAY outside the norm. @alphaholic06 is either overestimating, works in an insanely high acuity shop, or is going to have an unpleasant visit in the future.

National average is 8.1%. I don't know the std dev, but I would imagine that 25% is several std devs outside the mean and liable to get you audited.
Source: CMS – 2016 Medicare Utilization Data by Specialty 93 – National: For Claims Processed with 2016 Dates of Service filed by June 30, 2017

Keep in mind that that is 8.1% of the medicare crowd who tend to be older and sicker than the other patients in your ED. All that to say most billing companies think a moderalty high acuity ED should be at 8-10%.. 25% is way outside the norm.

 

[deleted109597]

25% critical care time??? How are you not getting flagged by CMS? The best biller in our group of 60+ docs doesn't even hit 5 RVU/pt.

"I only work in the critical care pod at my shop, and have 100% admission rates"

I mean, I've had days where I've had to really, really think about billing critical care time on a patient because I've already billed 6+ hours for the day. But that's once in a blue moon. I've never hit 25% even for a month.

 

[TooMuchResearch]

I've had 1-2 15-20% CC months. They sucked.

"I only work in the critical care pod at my shop, and have 100% admission rates"

I mean, I've had days where I've had to really, really think about billing critical care time on a patient because I've already billed 6+ hours for the day. But that's once in a blue moon. I've never hit 25% even for a month.