I am in the process of getting hospital privileges at a hospital and they are basically saying that I wouldn't be an employee instead I would bill directly with insurance and get reimbursed directly. I am not sure about what translates to money wise, what the reimbursement rate is like or process is like. I'm used to getting salary offers. Any one with experience or insight.
Inpatient reimbursements, independent consulting psychiatrist
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I'm not sure about how to see how much you'll get specifically from each insurance panel, but perhaps the hospital has price transparency for how much they charge for each CPT code as they are required to by law. Just look up "[Hospital Name] Price Transparency" on Google. It's likely that you'll have to download a 1-2 GB file and try to make sense of that data as I think this is a ploy to technically have price transparency but make it in a way that's so hard for patients to view that they just give up.
www.cms.gov
I think this is a starting point in negotiating with insurances though so it might not be helpful at all.
Some hospital websites have a searchable "self-generated billing" or "cost estimator" database like UW or Nationwide Children's (both of these are Epic MyChart integrations).
Hospital Price Transparency | CMS
I think this is a starting point in negotiating with insurances though so it might not be helpful at all.
Some hospital websites have a searchable "self-generated billing" or "cost estimator" database like UW or Nationwide Children's (both of these are Epic MyChart integrations).
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One does not just merely walk into Mordor...
Insert that meme here...
Having hospital privileges, to still be independent is okay, and nice. But there are many orcs on this quest ahead of you. There is no guarantee you will have good rates with some of the insurance, most definitely not all. Most Psych units are 50% or more medicare/medicaid. Medicaid is a horrible pain to get enrolled with AND get paid by. AND they will hit you with extra paperwork. So be fully prepared you get paid nothing for seeing medicaid patients. And it usually takes months and months get paid by them.
For private insurance, no guarantee the patients will pay you when they are in their high deductible phase. Your bills get lost in the sea of other bills coming from the hospital, their facility fees, the ED, the internist. Or if this is a psych unit, the hospital bills, and when they see your bill, they are perplexed, why is this doctor sending me a bill?!?!? I already have a bill from the hospital?
So now you MUST have a biller or billing company to send off for your bills. They are midland at best, and you get stuck trying to solve the issues that they fail to do ... i.e. you call the insurance company, you spend 45 minutes on call, you got the answer - but you just wasted 45min of your life, to get paid by medicaid $40.
There is also no guarantee the registration person at the hospital entered in the patients details right. Home address? Name? Insurance? Date of birth? etc. When your biller tries to do their part, uh, doc, we don't have a working phone number or address. The registration details doesn't even list insurance. But then if you some how do try to designate the person as self pay, you then later learn, oh, no they are actually medicaid/medicare and you can't bill them. But LOLZ, you aren't yet enrolled with medicaid! Or, this isn't normal medicare, this is some weird railroad medicare you aren't even enrolled in and you didn't even know existed.
If this is a normal hospital, and you have privileges, read those bylaws! They might be able to put you on call pool and do a consult in middle of night.
Your billers might not have access to THEIR EMR in hospital. So now you have to be the go between to get the notes, the records for the biller to then half heartedly fight the insurance company to show the medical necessity of your services. So it will take time find it, print, or PDF it and upload it to biller system.
Doing your own billing can, and might be more lucrative, a reason why it still exists in some pockets, but you better being entering into this with knowledge and your eyes wide open. Knowing the payer mix and some idea of payer right for Medicaid, Medicare and 2 biggest private insurance payers will help you come up with a blended payer mix formula to estimate your average pay per follow up.
Insert that meme here...
Having hospital privileges, to still be independent is okay, and nice. But there are many orcs on this quest ahead of you. There is no guarantee you will have good rates with some of the insurance, most definitely not all. Most Psych units are 50% or more medicare/medicaid. Medicaid is a horrible pain to get enrolled with AND get paid by. AND they will hit you with extra paperwork. So be fully prepared you get paid nothing for seeing medicaid patients. And it usually takes months and months get paid by them.
For private insurance, no guarantee the patients will pay you when they are in their high deductible phase. Your bills get lost in the sea of other bills coming from the hospital, their facility fees, the ED, the internist. Or if this is a psych unit, the hospital bills, and when they see your bill, they are perplexed, why is this doctor sending me a bill?!?!? I already have a bill from the hospital?
So now you MUST have a biller or billing company to send off for your bills. They are midland at best, and you get stuck trying to solve the issues that they fail to do ... i.e. you call the insurance company, you spend 45 minutes on call, you got the answer - but you just wasted 45min of your life, to get paid by medicaid $40.
There is also no guarantee the registration person at the hospital entered in the patients details right. Home address? Name? Insurance? Date of birth? etc. When your biller tries to do their part, uh, doc, we don't have a working phone number or address. The registration details doesn't even list insurance. But then if you some how do try to designate the person as self pay, you then later learn, oh, no they are actually medicaid/medicare and you can't bill them. But LOLZ, you aren't yet enrolled with medicaid! Or, this isn't normal medicare, this is some weird railroad medicare you aren't even enrolled in and you didn't even know existed.
If this is a normal hospital, and you have privileges, read those bylaws! They might be able to put you on call pool and do a consult in middle of night.
Your billers might not have access to THEIR EMR in hospital. So now you have to be the go between to get the notes, the records for the biller to then half heartedly fight the insurance company to show the medical necessity of your services. So it will take time find it, print, or PDF it and upload it to biller system.
Doing your own billing can, and might be more lucrative, a reason why it still exists in some pockets, but you better being entering into this with knowledge and your eyes wide open. Knowing the payer mix and some idea of payer right for Medicaid, Medicare and 2 biggest private insurance payers will help you come up with a blended payer mix formula to estimate your average pay per follow up.
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Plus as an individual the insurances are going to pay you dirt. Group practices tend to do better because they can leverage with negotiations.
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Why feel dirty? The concept is simple one, you provided a service and you should get paid.
I really like being able to tell involuntary patients that I am not in any way paid more for keeping them admitted and that the incentive for me is actually to discharge them as quickly as possible to reduce my own workload and that of everyone else on my team. I'm sure at least some of them have internalized it over the years.
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I have arrangements like the OP describes at one hospital I work at, with a small stipend in addition.
If the OP is not established in an area (has an existing OP practice or prior IP work in the area); this position would be a hard pass to do as individual doctor. Even if the OP is established in the area, I would not want to rely on this position for a major source of my income.
If the OP is not established in an area (has an existing OP practice or prior IP work in the area); this position would be a hard pass to do as individual doctor. Even if the OP is established in the area, I would not want to rely on this position for a major source of my income.
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The way that my local group practice makes it fair is to set an assigned amount of points for initial and follow-up and then reimburse the mixed rate for that number of points. That way people aren't incentivized to take only the good paying insurances and discouraged from taking lower reimbursed insurances. The group does the billing though, not the individual psychiatrist...
Or just do what’s right by the patient and if they are sick keep them and treat them. Being a w2 or 1099 should not change that in anyway. I dunno why’d you be even using the “I’m not paid for this with patients or even as a mental model” because in the end you are paid for it no matter the gymnastics you want to do
One of the hospitals I work at this is the model and for that hosptial I prefer it. There is no way they’d pay me as a w2 what I earn as a 1099 through billing insurance companies.
But you need to know something’s about the job before knowing if 1099 v w2 is truly better. One is the average volume of patients your seeing and the turnover IE how many 90792s are you doing a day since those pay quite a bit more. You need an idea of the average payor mix (Medicaids/medicares/private and self funded). Once you know that you can look up what Medicaid pays generally and Medicare and then add to Medicare 20-50% for private and also find out for self funded how do you get paid. Now once you get that info you can have a decent idea of what you can generate. You’ll need a biller unless you want to spend hours (which you might as well see more patients) figuring out how to deal with insurance billing. Also you’re gonna need to factor in your own malpractice, medical etc into this unless you are getting some benefits from elsewhere.
In the end it can for sure be a very good way to do things but you’re gonna need to have a decent volume of patients you can see or have the opportunity for extra coverage say when people are off and a very good supportive ancillary team to make it all possible.
But you need to know something’s about the job before knowing if 1099 v w2 is truly better. One is the average volume of patients your seeing and the turnover IE how many 90792s are you doing a day since those pay quite a bit more. You need an idea of the average payor mix (Medicaids/medicares/private and self funded). Once you know that you can look up what Medicaid pays generally and Medicare and then add to Medicare 20-50% for private and also find out for self funded how do you get paid. Now once you get that info you can have a decent idea of what you can generate. You’ll need a biller unless you want to spend hours (which you might as well see more patients) figuring out how to deal with insurance billing. Also you’re gonna need to factor in your own malpractice, medical etc into this unless you are getting some benefits from elsewhere.
In the end it can for sure be a very good way to do things but you’re gonna need to have a decent volume of patients you can see or have the opportunity for extra coverage say when people are off and a very good supportive ancillary team to make it all possible.
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*We call that professionalism.
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some areas are very explicit in their laws for not benefitting from involuntary patients. It does make the idea of working at a UHS hospital seem illegal in DC, for example.
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No one is suggesting not doing what is right by the patient. What is being suggested is that when patients will say that you're just keeping them in the hospital to make more money, it feels good to be able to correctly say that you get paid the same whether they're there or not. I don't know if it's helpful or if patients even believe it, but this is what I believe the other poster is expressing.
My point being the correct answer is “I am keeping you because you mental health needs it.” And if that isn’t the answer it doesn’t matter if you’re a w2 or 1099 you should be discharging the patient.
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You could also tell them that you make less if they stay in the hospital. I think that both statements are inappropriate, as the patient is clearly denying the impact of their symptoms and any discussion of you is a deflection from them. While it may feel good to be able to honestly say your pay has nothing to do with their presence, it's not exactly helpful to the patient.
I do agree that this is a bigger problem than just involuntary care. I mean an orthopedic surgeon is incentivized to do more, possibly unnecessary surgeries if he's paid by the surgery too. The issue is the power imbalance, but geeze does it become starkly contrasted in involuntary care. And yeah, of course everyone tries to do what's right inherently, but your incentives do still matter.
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I actually think its a much bigger deal in surgery. I see docs who are generating 6 figures + more a year as a result of doing unnecessary or not indicated surgery.
Honestly for most IP docs, you get assigned a census, so if I take care of 12 folks, having one drop off and another come on, is the exact same revenue. I do agree incentives matter, but psychiatrists fighting to keep people involuntary for $65/day I think would be at the very lowest of my risks of incentives jeopardizing care in medicine.
Thanks a lot! So for the insurances I am already credentialed with when I see those patients, I just bill them to the insurance. When I worked inpatient I did not usually do the billing at all. What codes are usually used on consult? Is it the same typical codes used outpatient? I will be functioning on a consultation basis for inpatient services and ED. NO actual psychiatry inpatient unit work. I reached out to my insurances and some are saying there are no different contracts for inpatient services.
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Do you currently have your own psychiatric outpatient practice? If so, it shouldn't be that difficult to bill for services at the hospital. In general, you would use the inpatient new patient and follow up codes (some psychiatrists bill for a psych eval rather than a new patient visit). In general, consult codes aren't used anymore. Here's a link for inpatient codes:
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Medicaid really depends on the state, in my state it's pretty great for inpatients depending on the subcontracted plan. Some of the plans are awful though.
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I've spoken with several docs who bill their own on inpatient. It can be a great gig. You want to speak with docs actually working there to learn the local market forces and patterns. The institution will need to give you information on payor mix, voluntary/involuntary, legal requirements (i.e. time to see someone requesting discharge, time to eval someone in seclusion and if it has to be an MD).
But for ER and inpatient consult I really would not want to be billing my own. Those services are majority medicare and medicaid or uninsured unless you are at some private hospital or special situation. Also, you would get zero money if they give you zero consults - but you'd be on the "hook" for free. I would rather get a Base + production for a model or just a straight base with protection built into my contract.
Unless you are doing the ER/inpatient credentialing to round on your own patients, then I would just pass. But talk to an MD who has been doing it there (now or previously) just to understand what the deal is.
But for ER and inpatient consult I really would not want to be billing my own. Those services are majority medicare and medicaid or uninsured unless you are at some private hospital or special situation. Also, you would get zero money if they give you zero consults - but you'd be on the "hook" for free. I would rather get a Base + production for a model or just a straight base with protection built into my contract.
Unless you are doing the ER/inpatient credentialing to round on your own patients, then I would just pass. But talk to an MD who has been doing it there (now or previously) just to understand what the deal is.
